Current Treatment Options in Patients with Endometrial Cancer
Department of Obstetrics and Gynecology, Medical School, University of Patras, Rion, Greece
- *Corresponding Author:
- Georgios Androutsopoulos, MD
Lecturer, Department of Obstetrics and Gynecology
Medical School, University of Patras, Rion 26500, Greece
E-mail: [email protected]
Received date: December 12, 2012; Accepted date: December 12, 2012; Published date: December 14, 2012
Citation: Androutsopoulos G (2012) Current Treatment Options in Patients with Endometrial Cancer. J Community Med Health Educ 2:e113. doi: 10.4172/2161-0711.1000e113
Copyright: © 2012 Androutsopoulos G. 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.
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Endometrial cancer (EC) is the most common malignancy of the female genital tract and occurs primarily in postmenopausal women . Overall, about 2% to 3% of women develop EC during their lifetime . The most common symptom present in patients with EC is abnormal uterine bleeding .
Based on clinical and pathological features, EC is classified into 2 types . Type I EC, represents the majority of sporadic EC cases (70-80%), is usually well differentiated and endometrioid in histology . Type II EC, represents the minority of sporadic EC cases (10- 20%), is poorly differentiated and usually papillary serous or clear cell in histology .
Surgery is the primary treatment for patients with EC [2,4]. Systematic surgical staging for most of them is the baseline therapy and allows clear decision for stage related postoperative adjuvant therapy .
In patients with EC, systematic surgical staging includes: total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy and complete resection of all diseases. Especially in patients with type II EC, systematic surgical staging includes 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 [2,5]. It facilitates targeted therapy to maximize survival and to minimize the effects of under treatment (recurrent disease, increased mortality) and potential morbidity associated with overtreatment (radiation injury) .
Pelvic and para-aortic lymphadenectomy is essential for surgical staging in patients with EC [4,5]. It has diagnostic and therapeutic value [4,8]. It can be used to deine accurately the extent of disease and determine the prognosis of EC patients . As 15% to 20% of EC patients harbor para-aortic disease alone, the need for complete pelvic and para-aortic lymphadenectomy cannot be ignored [5,9,10]. Undoubtedly, it is the only way to identify stage IIIC patients with EC . Also, it provides a rationale for the need, type and extent of postoperative adjuvant treatment [4,8,11].
Additionally, pelvic and para-aortic lymphadenectomy seems to have a therapeutic effect in women with EC [12-14]. It is associated with improved survival, in patients with type II EC and in patients with advanced stage disease [2,12,13,15,16]. However, it has no effect on survival, in patients with early stage type I EC [2,17,18].
The extension of pelvic and para-aortic lymph node dissection (more than 14 lymph nodes) is an independent risk factor for postoperative complications [17,19,20]. Also in elderly EC patients and in EC patients with relevant co-morbidities (obesity, diabetes, coronary artery disease), morbidity must be carefully weighed against any survival advantage [5,21,22].
It seems that pelvic and para-aortic lymphadenectomy can be safely omitted in patients with early stage well differentiated type I EC [5,7,18,20,23]. However it is obvious that pelvic and para-aortic lymphadenectomy should be performed in patients with advanced stage type I EC, as well as in all patients with type II EC [15,24,25]. Also in any case of doubt, lymphadenectomy should be performed rather than abandoned .
Traditionally, systematic surgical staging in EC patients is performed through a laparotomy [26,27]. However in EC patients with early stage disease, it may be performed with minimally invasive techniques (laparoscopy, robotic-assisted surgery) [2,26-29].
Laparoscopic approach in early stage EC offer many advantages especially in overweight and elderly patients [5,26-29]. It is associated with smaller incisions, shorter hospital stay, quicker recovery and lower risk of complications (blood loss, wound infection, herniation and ileus) [5,26-29]. Compared with laparotomy, it is associated with similar overall and disease-free survival [26,27]. However, there are relatively small differences in recurrence rates [26,27].
Minimally invasive surgery is an accepted integral surgical tool in the treatment of early stage EC [27,30]. Beginning with laparoscopy and continuing with robotic-assisted surgery, the surgeon may be able to achieve the goal of a systematic surgical staging, with reduced surgical morbidity [21,26,28,29].
In EC patients at increased risk for recurrence or with advanced stage disease, more aggressive management with postoperative adjuvant radiotherapy and/or chemotherapy is required . Postoperative adjuvant radiotherapy includes external pelvic radiotherapy and/or brachytherapy.
External pelvic radiotherapy in EC patients with early stage disease reduces the risk of local recurrences but has no impact on overall survival [5,31-33]. Also, it is associated with significant morbidity and a reduction in quality of life [31,33]. It is used only in high risk EC patients or at advanced stage disease [34,35].
Vaginal brachytherapy in EC patients with early stage disease also 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 [33,34].
Adjuvant chemotherapy is the mainstay of treatment for EC patients with locally advanced or metastatic disease [24,36]. The most active chemotherapeutic agents are: taxanes, anthracyclines and platinum compounds [36,37]. Although they achieve high response rates, they have only modest effect in progression free survival and overall survival .
However, the combination of adjuvant chemotherapy and radiotherapy is promising in high risk EC patients and at advanced stage disease [36,38]. It seems that combination is more effective than radiotherapy alone .
Molecular targeted therapies have still shown modest effect in unselected EC patients . They usually target the inhibition of EGFR, VEGFR and PI3K/PTEN/Akt/m TOR signals pathways . Perhaps they may be clinically active as adjuvant therapy in welldefined subgroups of type II EC patients with EGFR and ErbB-2 over expression .
Conflict of Interest
I declare that I have no conflict of interest.
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