The mainstay of treatment for Stage I disease is hysterectomy and bilateral salpingo-oophorectomy. This should be performed through a vertical incision and peritoneal washings should be taken at the start of the operation. The role of lymphadenectomy remains to be defined. In North America, lymphadenectomy is preferred to stage the disease and, if the nodes are free of disease, adjuvant radiotherapy is avoided. In the UK, the traditional approach has been to determine the level of risk of nodal metastasis by uterine pathology and, in high-risk cases, to prescribe adjuvant radiation. The MRC is conducting a randomized trial of lymphadenectomy in endometrial cancer.
If the cervix is known to be involved pre-operatively, a radical hysterectomy should be performed. Occasionally the patient will present with a frozen pelvis that requires a non-surgical approach. Some surgeons are advocating laparoscopic lymphadenectomy together with a laparoscopically-assisted vaginal hysterectomy but, as yet, this is an unproven procedure.
Radiotherapy Radiotherapy has two roles in endometrial cancer. The usual indication is adjuvant therapy following hysterectomy but, less commonly it may be required as primary treatment for women unfit to undergo surgery, usually through a combination of co-morbidity and marked obesity. It may also be required for advanced disease where residual tumour remains following surgery or where the tumour was inoperable from the outset or for local recurrence.
Adjuvant radiotherapy is generally delivered with external-beam irradiation of a planned volume (usually four fields) to around 50 Gy over four weeks. Vault brachytherapy reduces the risk of vault recurrence in Stage II disease.
Although currently given to 40-50% of cases treated in the UK, the value of adjuvant radiotherapy is not certain. While early trials have demonstrated that loco-regional control is improved by irradiation, there is no evidence that radiotherapy improves survival, and it does carry a risk of radiation damage to bowel and bladder. The current MRC trial randomizes women with regards to adjuvant radiotherapy for high-risk disease, with the aim of answering this question.
Chemotherapy Chemotherapy alone has relatively little to offer in endometrial carcinoma. Combinations such as cisplatin and doxorubicin have some activity but response rates are low. Progestagens, which have been widely prescribed in the past, have never been shown to be of significant benefit and should not be prescribed as adjuvant long-term therapy.
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