Management of Endometrial Cancer
Georgios Androutsopoulos1*, Georgios Decavalas1
1.Department of Obstetrics and Gynecology, University of Patras, Medical School, Rion, Greece.
Department of Obstetrics and Gynecology,
University of Patras, Medical School,
Article Type: Editorial
Received: October 01, 2013; Published: October 25, 2013
Citation: Androutsopoulos G, Decavalas G. (2013). Management of Endometrial Cancer, Int J Translation Community Dis, 01(01), 01-03. doi: dx.doi.org/10.19070/2333-8385-130001e
Copyright: Androutsopoulos G© 2013. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Endometrial cancer (EC) is the most common malignancy of the female genital tract.1 It occurs primarily in postmenopausal women [1,2]. Overall, about 2.64% of women develop EC during their lifetime . In those patients, the most common presenting symptom is abnormal uterine bleeding .
Based on clinical and pathological features, sporadic EC is classified into 2 types [3, 4]. Type I EC, represents the majority of sporadic EC cases (70-80%) [3,4]. It is usually well differentiated and endometrioid in histology [3, 4]. Type II EC, represents the minority of sporadic EC cases (10-20%) [3, 4]. It is poorly differentiated and usually papillary serous or clear cell in histology [3, 4].
Systematic surgical staging is the baseline therapy, for most patients with EC [2, 5-9]. Moreover, that therapeutic approach allows a more clear decision for stage related postoperative adjuvant therapy .
In those patients, systematic surgical staging includes: total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy and complete resection of all disease . Especially in patients with type II EC, systematic surgical staging requires additional omentectomy and biopsy of any suspected lesion . Pelvic washings are no longer part of FIGO surgical staging system for EC, but may be reported separately .
Appropriate surgical staging provides prognostic and therapeutic benefits for women with EC [2, 8]. It facilitates targeted therapy that maximize survival and minimize the morbidity of overtreatment (radiation injury) and the effects of undertreatment (recurrent disease, increased mortality) .
Pelvic and para-aortic lymphadenectomy is essential for surgical staging in patients with EC [5, 8]. It has diagnostic and prognostic value [5, 11]. It defines accurately the extent of disease and determines the prognosis of EC patients [5, 11]. Undoubtedly, it is the only way to identify EC patients with stage IIIc disease [8, 9, 12, 13]. Also, it provides a rationale for the need, type and extent of postoperative adjuvant treatment [5, 11, 14].
Additionally, pelvic and para-aortic lymphadenectomy seems to have a therapeutic effect in patients with EC [15-17]. It is associated with improved survival in patients with type II EC and in patients with advanced stage disease [2, 15, 16, 18, 19]. However it has no effect on survival in patients with early stage type I EC.[2, 20, 21].
It seems that pelvic and para-aortic lymphadenectomy can be safely omitted in patients with early stage well differentiated type I EC [8, 20-23]. However pelvic and para-aortic lymphadenectomy should be performed in all patients with advanced stage type I EC or with type II EC [18, 24, 25]. Also in any case of doubt, lymphadenectomy should be performed rather than abandoned .
The extension of pelvic and para-aortic lymph node dissection (more than 14 lymph nodes) is an independent risk factor for postoperative complications [20, 23,26]. Moreover in elderly patients and in patients with relevant comorbidities (obesity, diabetes, coronary artery disease), morbidity must be carefully weighed against any survival advantage [8, 27, 28].
Traditionally, systematic surgical staging in EC patients performed through a laparotomy [29, 30]. However in EC patients with early stage disease, it may be performed with minimally invasive techniques (laparoscopy, robotic-assisted surgery) [2, 29-32]. Minimally invasive surgery associated with smaller incisions, shorter hospital stay, quicker recovery and lower risk of complications (blood loss, wound infection, herniation and ileus) [8, 29-32]. Moreover, it offers many advantages especially in overweight and elderly patients [8, 29-33]. Compared with laparotomy, it is associated with similar overall and disease-free survival [29, 30]. However, there are relatively small differences in recurrence rates [29, 30].
Especially in EC patients at increased risk for recurrence or with advanced stage disease, required a more aggressive management with postoperative adjuvant radiotherapy and/or chemotherapy [2, 5,7, 24].
Postoperative adjuvant radiotherapy includes external pelvic radiotherapy and/or brachytherapy. Vaginal brachytherapy in EC patients with early stage disease, reduces the risk of local recurrences but has no impact on overall survival . However, it is well tolerated and associated with less side effects than external pelvic radiotherapy . It is the adjuvant treatment of choice for high-intermediate risk EC patients [34, 35].
External pelvic radiotherapy in EC patients with early stage disease, also reduces the risk of local recurrences but has no impact on overall survival [8, 34, 36, 37].
Also, it is associated with significant morbidity and a reduction in quality of life [34, 36]. It is used only in high risk EC patients or at advanced stage disease [35,38].
Adjuvant chemotherapy is the mainstay of treatment for EC patients with locally advanced or metastatic disease [2, 5, 39]. The most active chemotherapeutic agents are: taxanes, anthracyclines and platinum compounds [39, 40]. Although adjuvant chemotherapy achieve high response rates, it has only modest effect in progression free survival and overall survival .
Recent years, molecular targeted therapies have still shown modest effect in unselected EC patients . They usually target the inhibition of EGFR, VEGFR and PI3K/PTEN/AKT/mTOR signal pathways . Perhaps they may be clinically active as adjuvant therapy in well-defined subgroups of type II EC patients with EGFR and ErbB-2 overexpression [43, 44].
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