ENDOMETRIAL CARCINOMA ,TREATMENT OPTIONS BY STAGE

DERIVED FROM AMERICAN CANCER SOCIETY

Endometrial cancer is often diagnosed when a woman who is having symptoms has an endometrial biopsy or D&C. Tests, such as ultrasound and CT scan, may be done to look for signs that the cancer has spread to lymph nodes or tissues outside of the uterus. Even when these tests show no signs of cancer spread, surgery is needed to stage the cancer. In this operation, the uterus, fallopian tubes, and ovaries are removed (total hysterectomy bilateral salpingo-oophorectomy -- TH/BSO). Lymph nodes from the pelvis and around the aorta are also removed (a pelvic and para-aortic lymph node dissection) and examined for cancer spread. Pelvic washings are obtained. If tests done before surgery show signs that the cancer has spread outside of the uterus, a different surgery may be planned.
Stage I
An endometrial cancer is stage I if the cancer is limited to the body of the uterus and has not spread to lymph nodes or distant sites. If the tumor is endometrioid, standard treatment includes surgery to remove and stage the cancer (see above). The tissues removed at surgery are examined under a microscope in a lab to see how far the cancer has spread. This decides what stage the cancer is in. Treatment after surgery depends upon stage. Surgery and other treatment often differ for cancers that aren't endometrioid - this will be discussed later in this section.
Treatment after complete staging
Stage IA endometrioid cancers are only in the endometrium and have not grown into the myometrium. These cancers most often do not need any further treatment after surgery. If the tumor is grade 3, the doctor may recommend vaginal brachytherapy (VB). Pelvic radiation may be given as well in rare circumstances.
In Stage IB, the cancer has grown less than halfway into the myometrium. Many of these can be observed without further treatment after surgery. For high grade tumors, doctors are more likely to recommend radiation after surgery. Either VB, pelvic radiation, or both can be used.
In stage IC, the cancer has grown more than halfway through the myometrium. After surgery the patient may be watched without further treatment or offered some form of radiation treatment. Either VB, pelvic radiation, or both can be used.
High-grade cancers, such as papillary serous carcinoma or clear cell carcinoma, are more likely to have spread outside of the uterus at the time of diagnosis. Patients with these types of tumors do not do as well as those with lower grade tumors. The surgery may be more extensive if the biopsy done before surgery showed a high-grade cancer, In addition to the TH/BSO and the pelvic and para-aortic lymph node dissections, the omentum is often removed and peritoneal biopsies may be obtained. After surgery, both chemotherapy and radiation therapy are often given to help keep the cancer from coming back. The chemotherapy usually includes the drugs cisplatin and doxorubicin. Sometimes paclitaxel is given as well.
Someone with a uterine carcinosarcoma often has the same type of surgery that is used for high-grade endometrial carcinoma. After surgery, radiation, chemotherapy, or both may be used. The chemotherapy often includes the drugs cisplatin and ifosfamide, sometimes along with paclitaxel.
Patients not staged with surgery
As stated above, standard treatment for endometrial cancer includes surgery to remove and stage the cancer. In some cases, however, the doctor may treat based on the clinical stage (see the section about staging for more details) and radiologic testing.
If the cancer seen on endometrial biopsy or D&C is grade 1 and it looks like the cancer is only in the uterus, the cancer is said to be clinical stage I, grade 1. Because few of these cancers have already spread, some doctors do not feel that full surgical staging is always needed. Often a TH/BSO will be done first. As soon as the uterus is removed, it will be examined to see how deep and far the cancer may have spread. If the cancer is only in the upper two thirds of the body of the uterus and hasn't grown more than halfway through the muscle layer of the uterus, the chance that the cancer has spread is very low. In these cases, the surgeon may not do a LND but instead may remove only a few lymph nodes or none at all. If any of the lymph nodes contains cancer it means that the cancer is stage IIIC and further treatment is needed (treatment of stage IIIC is discussed later). If no lymph nodes were removed (or if there were no cancer cells in the nodes that were removed), treatment after surgery could include observation without further treatment or radiation.
Women who cannot have surgery because of other medical problems are often treated with radiation alone.
Progestin therapy is sometimes used to treat stage I, grade 1 EC in young women with who still want to have children. Progestin treatment can cause the cancer to shrink or even go away for some time, giving the woman a chance to get pregnant. This approach is experimental and can be risky. In some cases, it does not work and the cancer keeps growing. Sometimes the tumor gets smaller or goes away for a while, but then comes back again. Not having surgery right away may give the cancer time to spread outside the uterus. A second opinion from a gynecologic oncologist and pathologist (to confirm the grade of the cancer) before starting progestin therapy is important. Patients need to understand that this is not a standard treatment and may increase risk.
Doctors are more likely to remove some lymph nodes when the biopsy shows that the cancer is a higher grade (2 or 3). If the cancer has spread deeper than half the thickness of the wall of the uterus, then the pelvic and para-aortic lymph nodes are usually sampled.
If the cancer comes back after surgery, it usually does so in the vagina. Many doctors recommend vaginal brachytherapy to prevent this from happening. Others recommend external beam radiation to the whole pelvic area. Certain features make it more likely that the cancer will come back after surgery, such as higher grade, spread to the lower third or outer half of the uterus, growth into lymph or blood vessels, larger tumor size, and patient age over 60. Radiation therapy is often given to reduce the risk of cancer coming back in the vagina or pelvis for cancers with one or more of these features. In patients without these risk factors the chance that the cancer will come back is small and radiation may not be given after surgery. Although giving radiation right after surgery reduces the chance of the cancer growing back in the pelvis, it does not help women live longer than if the radiation is only given when the cancer comes back. There may be less worry if the radiation is given right away, but fewer women will receive radiation if they wait until the cancer returns.
Stage II
When a cancer is stage II, it has spread to the cervix but still has not grown outside of the uterus.
Stage IIA cancers have spread among the gland cells of the cervix, but have not grown into the supporting connective tissue. Most often, the patient first has surgery -- hysterectomy and bilateral salpingo-oophorectomy (BSO), with pelvic and para-aortic lymph node dissection. After surgery, the patient may require no further treatment, or the doctor may recommend radiation therapy with vaginal brachytherapy, pelvic radiation treatments, or both. Treatment after surgery depends on how far the cancer has grown into the muscle layer of the uterus (the myometrium) and the grade of the tumor.
Stage IIB cancers are growing into (invading) the connective tissue of the cervix. One treatment option is to have surgery first, then radiation therapy. The surgery would include a hysterectomy (discussed in the section about treatment), bilateral salpingo-oophorectomy (BSO), and pelvic and para-aortic lymph node dissection (LND). Vaginal brachytherapy and pelvic radiation treatments are given after the patient has recovered from surgery. The other option is radiation therapy first, followed by a simple hysterectomy, BSO, and LND.
The lymph nodes that have been removed are checked for cancer cells. If lymph nodes show cancer, then the cancer is not really a stage II - it is a stage IIIC.
In some cases, a woman with early stage endometrial cancer might be too frail or ill from other diseases to safely have surgery. These women are treated with radiation therapy alone.
For women with high-grade cancers, such as papillary serous carcinoma or clear cell carcinoma, the surgery may include omenetectomy and peritoneal biopsies in addition to the TH/BSO, pelvic and para-aortic lymph node dissections, and pelvic washings. After surgery, chemotherapy, radiation therapy, or both may be given to help keep the cancer from coming back. The chemotherapy usually includes the drugs cisplatin and doxorubicin. Sometimes paclitaxel is given as well.
Someone with a Stage II uterine carcinosarcoma often has the same type of surgery that is used for a high-grade cancer. After surgery, radiation, chemotherapy, or both may be used. The chemotherapy often includes the drugs cisplatin and ifosfamide, sometimes along with paclitaxel.
Stage III
Stage III cancers have spread outside of the uterus.
If the surgeon thinks that all visible cancer can be removed, a hysterectomy with bilateral salpingo-oophorectomy (BSO) is done. Sometimes patients with stage III cancers require a radical hysterectomy. A pelvic and para-aortic lymph node dissection may also occur. Pelvic washings will be obtained and the omentum may be removed. Some doctors will try to remove any remaining cancer (debulking), but doing this hasn't been proven to help patients live longer.
If the surgeon feels that it is not possible to remove all visible cancer, radiation therapy may be given before surgery to remove the cancer. Radiation therapy may shrink the tumor enough to make surgery an option.
Stage IIIA: If the cancer looks like it hasn't spread outside of the uterus, but the pelvic washings show cancer cells, it is stage IIIA. For small, low-grade cancers, no other treatment may be needed after surgery. If the cancer is grade 3, the doctor may recommend further treatment with radiation.
A cancer is also considered stage IIIA when it has spread to other tissues in the pelvis like the fallopian tubes, the ovaries, and the omentum. When this occurs, treatment after surgery may include chemotherapy, radiation, or a combination of both. Radiation is given to the pelvis or to both the abdomen and the pelvis. Sometimes vaginal brachytherapy is used as well.
Stage IIIB: In this stage, the cancer has spread to the vagina. After surgery, stage IIIB may be treated with radiation, with or without chemotherapy.
Stage IIIC: When the cancer has spread to the lymph nodes in the pelvis or around the aorta, it is stage IIIC. Treatment includes surgery, followed by chemotherapy and radiation.
For women with high-grade cancers, such as papillary serous carcinoma or clear cell carcinoma, the surgery may include omenetectomy and peritoneal biopsies in addition to the TH/BSO, pelvic and para-aortic lymph node dissections, and pelvic washings. After surgery, chemotherapy, radiation therapy, or both may be given to help keep the cancer from coming back. The chemotherapy usually includes the drugs cisplatin and doxorubicin. Sometimes paclitaxel is given as well.
Someone with a Stage III uterine carcinosarcoma often has the same type of surgery that is used for a high-grade cancer. After surgery, radiation, chemotherapy, or both may be used. The chemotherapy often includes the drugs cisplatin and ifosfamide, sometimes along with paclitaxel.
Stage IV
Stage IVA: These cancers have grown into the bladder or bowel.
Stage IVB: These cancers have spread to lymph nodes outside of the pelvis or para-aortic area. This stage also includes cancers that have spread to the liver, lungs, or other organs.
The patient may have the best chance if all the cancer that is seen can be removed and biopsies of the abdomen do not show cancer cells. This may be possible if the cancer has only spread to lymph nodes in the abdomen and pelvis. In most cases of stage IV endometrial cancer, the extensive spread of the cancer makes a surgical cure nearly impossible. A hysterectomy and bilateral salpingo-oophorectomy may still be done to prevent excessive bleeding. Radiation therapy may also be used for this reason. When the cancer has spread to other parts of the body, hormone therapy may be used. Drugs used for hormone therapy include progestins and tamoxifen. Aromatase inhibitors may also be useful and are being studied. High-grade cancers and those without detectable progesterone receptors are less likely to respond to hormone therapy.
Combinations of chemotherapy drugs may help for a time in some women with advanced endometrial cancer. The drugs used most often are doxorubicin (Adriamycin), paclitaxel (Taxol), and either cisplatin or carboplatin.. These drugs are often used together in combination. Stage IV carcinosarcoma is often treated with chemotherapy. Cisplatin, ifosfamide, and paclitaxel are the drugs most often used. Women with stage IV endometrial cancer should consider taking part in clinical trials of chemotherapy or other new treatments.
Recurrent endometrial cancer
When a cancer has gone away with treatment, but then comes back later, it is called recurrent. Treatment depends on the amount and location of the cancer. If the recurrent cancer is only in the pelvis, radiation therapy may provide a cure. Women with more extensive recurrences are treated like those with stage IV endometrial cancer. Either hormone therapy or chemotherapy is recommended. Low-grade cancers containing progesterone receptors are more likely to respond well to hormone therapy. Higher-grade cancers and those without detectable receptors are less likely to shrink during hormone therapy, but may respond to chemotherapy. Clinical trials of new treatments are another option.
If patients have other medical conditions that make them unable to have surgery, radiation therapy alone or combined with hormonal therapy is generally used. The outlook for these patients is not as good as those who are able to have surgery.
Last Revised: 07/26/2008