Professional Documents
Culture Documents
Guidelines For Management of Endometrial Carcinoma
Guidelines For Management of Endometrial Carcinoma
Carcinoma
Dr Veena P
Additional Professor
Dept of OG, JIPMER
8th July 2017
Incidence
*Ganesh Balasubramanian, S Sushama, B Rasika, et al. Hospital-based Study of Endometrial Cancer Survival
in Mumbai, India. Asian Pacific J Cancer Prev, 2013. 14 (2), 977-980
Early
menarche &
Late
menopause
Tamoxifen HRT
Risk
factors
Obesity,
Lynch II
DM, HTN
Nulliparity &
PCOS
Tamoxifen
• In standard doses used in adjuvant treatment of breast cancer, it is known to cause
endometrial hyperplasia and polyps, invasive endometrial carcinoma and uterine sarcoma
• Causes sub-epithelial stromal hypertrophy, which gives a false impression of thick
endometrium on ultrasonography Poor correlation between endometrial thickness and
abnormal pathology so evaluate only women with AUB
• Risk of developing endometrial carcinoma is estimated to be only 1.26 for 1000 patient
years after 5 years of tamoxifen intake
• ATLAS ACOG tamoxifen use may be extended to 10 years
Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of estrogen receptor-positive
breast cancer: ATLAS, a randomized trial. The Lancet, Volume 381, 2013
Protective factors
• Oral contraceptive pills: 1 year of use confers 30-50% reduced risk
• Risk reduction is up to 10-20 yrs
• Progestin component has chemo protective role
• Progesterone IUCDs confers long term protection
• Earlier age of menopause
• Smoking
Type I tumors Type II tumors
• 80% of endometrial carcinomas • 10 to 20% of endometrial carcinomas, but
• Estrogen-dependent account for more than 50% of all endometrial
• Usually preceded by atypical cancer deaths
complex endometrial hyperplasia • Not clearly associated with estrogen stimulation
• Tumors of endometrioid histology
• A precursor lesion is rarely identified
that are grade 1 or 2, mucinous
carcinoma • Include grade 3 endometrioid tumors, serous,
• Favorable prognosis clear cell, undifferentiated, MMMTs
• Poor prognosis – behave like ovarian cancers
Clinical scenarios
1. 55 year old obese woman, P2L2, known DM & HTN, presented with PMB.
EB is reported as Endometrioid Adeno Ca Gr 2
2. 35 year old nulliparous woman undergoing treatment for infertility, presented with HMB
and found to have Endometrioid Adeno Ca Gr 1 on EB
3. 65 year old k/c/o CAD, uncontrolled HTN and DM diagnosed to have Endometrioid
Adeno Ca on EB done for PMB
4. 50 year old, TAH BSO done for HMB found to have endometrial Ca on final HPR
5. Post surgical staging for endometrial cancer, woman develops menopausal symptoms
6. A woman treated for early endometrial cancer with surgery alone presents with vaginal
bleeding after 14 months of surgery
1. 55 year old Obese woman, P2L2, known diabetic and hypertensive,
presented with PMB EB is reported as Endometrioid Adeno Ca Gr 2
Outline
• Initial evaluation
• Surgical staging
• MIS
• Vaginal hysterectomy
• Risk stratification
• Adjuvant therapy
• Follow up
Initial evaluation of endometrial cancer (NCCN 2017 and ESMO-ESGO-
ESTRO 2015)
Recommended Optional
Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium [published
erratum appears in Int J Gynaecol Obstet 2010;108:176]. Int J Gynaecol Obstet 2009;105:103–4
Surgical treatment
Stage I
• Includes abdominal exploration, peritoneal cytology, type 1 hysterectomy, bilateral
salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy
• Omentectomy in type 2 tumors
• Indications for pelvic and para-aortic lymph node dissection
• Tumor histology clear cell, serous, squamous, or grade 2-3 endometrioid
• Myometrial invasion > 50%
• Isthmus-cervix extension
• Tumor size > 2 cm
• Extra-uterine disease
“Extent of surgery should be adapted to
the medical condition of the patient”
Surgical treatment
• Stage II
• Radical hysterectomy with BSO and retroperitoneal lymphadenectomy
• ESMO-ESGO-ESTRO 2015: no need of radical hysterectomy* (Level 4 evidence, Strength of
recommendation: B)
• Stage III
• Operable: Maximal surgical cytoreduction with a good performance status
• Inoperable: (stage 3B): Primary radiation Extra-fascial hysterectomy
• Stage IV
• IV A: Anterior and posterior pelvic exenteration
• IV B: Systemic therapeutic approach with palliative surgery
*Takano M, Ochi H, Takei Y et al. Surgery for endometrial cancers with suspected cervical involvement:
is radical hysterectomy needed (a GOTIC study)? Br J Cancer 2013; 109: 1760–1765
MIS
Colombo et al. ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer. Annals of Oncology 0: 1–26,
2015
Vaginal hysterectomy
Colombo et al. ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer. Annals of Oncology 0: 1–26, 2015
Adjuvant treatment
*If negative prognostic factors (age>60 years, LVSI and tumor size>2 cm) EBRT and
add chemotherapy if LVSI+ in type 1 and in all type 2 tumors
Colombo et al. ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer. Annals of Oncology 0: 1–26, 2015
EBRT and Vaginal brachytherapy
Stage II
If grade 1–2 tumour, myometrial invasion<50%, negative LVSI
and complete surgical staging: Vaginal brachytherapy alone
Sequential radiotherapy
Stage III–IV
Gotlieb WH, Beiner ME, Shalmon B, et al. Outcome of fertility-sparing treatment with progestins in young patients with
endometrial cancer. Obstetrics and Gynecology. Oct 2003;102(4):718–25.
3. 65 year old k/c/o CAD, uncontrolled HTN and DM diagnosed to have
endometrioid adeno ca on EB done for PMB
Medically unfit patients
• About 1/4th of patients treated for early endometrial cancer develop recurrent disease
• More than half of the recurrences develop within 2 years and about 3/4th occur within 3
years of initial treatment
• Asymptomatic, vaginal bleeding, pelvic pain, hemoptysis, anorexia, nausea & vomiting,
seizures, jaundice
Treatment of recurrence
• For central pelvic recurrence, the treatment of choice is surgery or radiation therapy,
while for lateral pelvic recurrences it is radiation therapy + chemotherapy
• High rates of local control: complete response (CR) and a 5-year survival of 50%
• Hormonal therapy or cytotoxic chemotherapy
• Hormonal therapy is recommended for endometrioid histologies with ER/PR +ve
and involves mainly the use of progestational agents, tamoxifen and aromatase
inhibitors
• Cytotoxic chemotherapy: anthracyclines, platins and taxanes most active
agents. The standard of care is six cycles of 3-weekly carboplatin and paclitaxel
Targeted therapy
• PI3Kinase/mTOR and angiogenesis inhibitors are the most promising classes of drugs
to investigate in advanced/recurrent endometrial cancer and further biomarker-driven
studies are warranted
• Studies are under way and as of now, none of these agents has been approved for
clinical use
Summary of Recommendations and Conclusions
Level A (based on good and consistent scientific evidence)
• Office EB is reliable and accurate
• Routine preoperative assessment with imaging is not necessary
• The initial management comprehensive surgical staging (total hysterectomy, BSO,
and pelvic and para-aortic lymphadenectomy, and the collection of peritoneal cytology)
• MIS standard surgical approach for comprehensive surgical staging
• Adjuvant radiation increases RFS but does not increase OS
• Chemotherapy for advanced endometrial cancer improves patient outcomes
• Vaginal brachytherapy is enough in intermediate risk disease
Summary of Recommendations and Conclusions