Fig. 36.1
Management of incompletely staged endometrial carcinoma (Adapted from the NCCN guidelines [4])
Women with incompletely staged clear-cell or papillary serous carcinomas of the endometrium should undergo restaging with peritoneal cytology, excision of enlarged pelvic and para-aortic lymph nodes, omental biopsy or omentectomy, biopsies from peritoneal surfaces, and removal of any gross disease. This should be followed by chemotherapy with or without tumor directed radiotherapy. In women who have only undergone hysterectomy, where endometrial carcinoma was diagnosed on postoperative histopathology, it is indeed advisable to go for restaging to remove both the adnexa which may be involved in 5 % cases, as well as remove any suspicious pelvic and para-aortic lymph nodes and other disease in the same sitting. Adjuvant treatment then follows the algorithms for completely staged endometrial cancer depending upon the stage and risk factors.
Conclusions
Surgical staging in endometrial cancer enables appropriate tailoring of adjuvant treatment modalities that benefit high-risk women only. Previously, a full pelvic and para-aortic lymphadenectomy was recommended for staging of endometrial cancer. However, early stage cancers with well- or moderately differentiated histology may not benefit from lymphadenectomy. Hence, the recent NCCN guidelines recommend a selective and tailored lymphadenectomy to benefit high-risk cases and avoid overtreatment in low-risk cases.
Even in the United States, only 30–40 % cases are completely staged [19], the rates of lymphadenectomy understandably higher with gynecologic oncologists than general gynecologists. Management of incompletely staged cases should include a histopathological review to determine the uterine risk factors, radiological imaging, and then appropriate adjuvant treatment according to the findings. Many of these women will require restaging to address the lymph nodes, and laparoscopic and robotic surgery is increasingly being used for the same, providing the advantages of minimally invasive surgery and the same overall survival rates as those with laparotomy.
Key Points
1.
Eighty percent of endometrial cancers are diagnosed in stages I and II. The rate of pelvic and para-aortic lymph node metastases increases with the grade of endometrial lesion and the depth of myometrial invasion.
2.
Women with nodal disease have a 3 to 5 year survival rate of 50–75 % with increased rates of nodal and distant recurrences compared to 80–95 % survival rate in those without nodal disease who mostly present with vaginal cuff relapses.
3.
The management of endometrial cancer is surgical staging – total extra-fascial hysterectomy and bilateral salpingo-oophorectomy, collection of peritoneal washings, excision of suspicious or enlarged lymph nodes in pelvic and para-aortic regions (bilateral pelvic lymph node dissection and para-aortic lymph node dissection in high-risk cases like deeply invasive lesions, high-grade histology, and serous and clear-cell adenocarcinomas), and biopsy or excision of extrauterine lesions suspicious of tumor.
4.
Previously, a full pelvic and para-aortic lymphadenectomy was recommended for all women, but now, a more selective and tailored lymphadenectomy is recommended by the National Comprehensive Cancer Network (NCCN) panel to avoid overtreatment.
5.
Women with low-risk uterine factors and negative nodes have low risk of recurrence and death with or without adjuvant pelvic radiation.
6.
In women with incompletely staged endometrial cancer, a histopathological review of the hysterectomy specimen is essential to determine the grade and stage of the lesion and high-risk intrauterine factors like positive lymphovascular space invasion, tumor size more than 2 cm, and lower uterine involvement. A radiological imaging – CECT scan of the chest, abdomen, and pelvis or a PET-CT – is advised to look for nodal and any other metastatic disease.
7.
Depending upon the grade and stage of the endometrial lesion and findings on postoperative imaging, women with incompletely staged disease may be put on observation or undergo surgical restaging (and then adjuvant treatment according to the final histopathology and stage after restaging) or pelvic radiation. Surgical restaging can be done laparoscopically or via robotic surgery, where available.
