Optimizing The Management Of Endometrial Cancer

Endometrial cancer is the disease of affluent, Obese, Low Parity, Postmenopausal women. It is being the most Common Genital Malignancy of Western countries. In United States about 41,200 new cases occur every year. In India the incidence of endometrial cancer is on the rise mainly because of the changes in the lifestyle. In population based cancer registry of Delhi, the incidence of endometrial cancer is 4.3/ 100,000 women per year (ICMR) reflecting the similar changing trend among the other cancers of Breast and Ovary amongst Indian women.

In approximately 75% of the patients, the disease is confined to the uterus at the time of diagnosis. Majority of these women present with the irregular or postmenopausal vaginal bleeding.Exposure to unopposed oestrogen, HRT, Obesity, Anovulatory Cycles, Oestrogen Secreting Tumors and Tamoxifen use, are the risk factors for the endometrial cancer. The reported survival in low risk early stage disease approaches more than 95% but in high risk group of early stage disease, it drops down to even less than 50%. Thus it is imperative to identify the high risk factors and tailor the extent of surgical staging and the adjuvant treatment appropriately in order to provide the best opportunity for long term survival.

Histological confirmation and information on endometrial biopsy is sufficient for the treatment planning with proper metastatic work up. Reported false negative rate of office endometrial biopsy is 10 % hence fractional curettage must be considered in symptomatic patients with negative endometrial biopsy.

Endometrial Cancer is staged as per FIGO Staging. In 1970 the staging of endometrial cancer was clinical .In 1998 surgical staging for endometrial cancer was adopted based on the fact that in 15 to 20 % of the patients the clinical staging was inaccurate and did not reflect the accurate extent of the disease. On the other hand the surgical staging identified the accurate extent of the disease with multiple prognostic factors in the presence of the full pathological review.

Abeler V et al (1992) in a multivariate analysis showed the superiority of surgical pathological staging over clinical staging.Stage being the most important Independent prognostic factor.

Thus it is important for us to define the accurate stage of the disease for providing the optimal treatment to the patient. We are concerned with the treatment related morbidity too in addition to the survival and thus the quality of life issues. With proper surgical staging we will be able to identify low risk group of patients who will not require adjuvant radiation therapy thus can avoid morbidity of the combined treatment.

Total hysterectomy & bilateral salpingo-oopherectomy is the main stay of the treatment. The Surgical staging includes Peritoneal Washing, Biopsy of abnormal peritoneal surface, Pelvic Lymphadenectomy and Para -aortic Lymphadenectomy. Infracolic omentectomy is carried out in select group of patients. It is important to identify the subset of patients requiring the proper surgical staging. Patients for surgical staging are selected by assessing Uterine Risk Factors, which can be known preoperatively or assessed intraoperatively.

The information on Histological Subtypes and Histologic Grade is available preoperatively and intraoperative assessment of the hysterectomy specimen will provide the information on Myometrial Invasion, Isthmus-cervix extension and tumor size assessment which in fact will require the facility of frozen section requiring institution based management of these patients.

The patients requiring surgical staging are:

a)       High Risk uterus confined disease patients, IC, Grade III, Any Invasion, Histology Papillary Serous, Clear Cell, Undifferentiated, Adeno-squamous Carcinoma Endometrium.

b)       All patients of suspected cervical involvement and extra uterine spread of the disease.

Following proper surgical staging the accurate stage of the disease and the poor prognostic factors within the stage will define the nature and extent of the adjuvant treatment of Intravaginal Brachytherapy, Pelvic Radiation therapy, or required extended field radiation therapy is required. The chemotherapy of Platinum and Adriamycin / Paclitaxel is considered. Though, the treatment of advanced stage endometrial cancer is yet to be established.