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Management when a Hysteroscopic or D&C Biopsy is Reported as Grade 1 AC of the Endometrium

10/1/2014 - Anitra D. Beasley, MD

Mentor:  Laurie S. Swaim, MD

Editor:  Paula J. Hillard, MD

REVISED PEARL - July 2016

Surgery is the cornerstone of treatment for endometrial carcinoma except for select premenopausal patients desiring fertility, and patients with significant medical comorbidities.  In patients with known grade 1 adenocarcinoma, standard therapy includes a total hysterectomy, bilateral salpingo-oophorectomy, pelvic washings for cytology, and lymphadenectomy.  In patients with stage 1a, grade 1 disease, no further therapy is indicated.  Patients with greater than 50% myometrial invasion or cervical extension should also have complete surgical staging, including hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, and pelvic and para-aortic lymphadenectomy. 

Traditionally, surgical staging has been performed by laparotomy.  However, laparoscopic or robotic staging can be performed, depending on the skill of the surgeon.  Some patients may additionally require adjuvant radiation therapy.    

Vaginal hysterectomy alone is generally considered to be suboptimal treatment in patients with endometrial carcinoma as it does not allow for evaluation of the abdomen and lymph nodes.  However, vaginal hysterectomy with concurrent bilateral salpingo-oophorectomy may be considered for patients in whom abdominal and laparoscopic procedures are contraindicated.  Additionally, while radiation therapy alone produces inferior results when compared to surgical management, it can be used as primary therapy in patients with significant medical comorbidities.  Progestin therapy may be considered in patients who are not able to tolerate either surgery or radiation therapy.

With a thorough evaluation, young premenopausal women who desire future fertility may be candidates for medical management.  They should have low-risk disease (grade 1 or 2, limited to the uterus) and be willing to adhere to progestin therapy and surveillance.  While the optimal treatment duration and surveillance is unknown, endometrial biopsy every three months is a common approach to monitor response.  When offering conservative management, it is important to remember that women who are thought to have low-risk disease may actually have more aggressive Disease.  In addition, there is a risk of disease progression despite medical therapy.  Even in cases without recurrence, definitive treatment is recommended following childbearing, as these women tend to have ongoing risk factors for endometrial cancer.

Further Reading:

Endometrial cancer. Practice Bulletin No. 149. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1006–26.

Hacker NF and Friedlander M. "Uterine Cancer." in Berek & Hacker's Gynecologic Oncology. Ed. Berek JS and Hacker NF. 6th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015.

National Cancer Institute: PDQ® Endometrial Cancer Treatment. Bethesda, MD: National Cancer Institute. Last modified 04/23/2014. Available at: http://cancer.gov/cancertopics/pdq/treatment/endometrial/HealthProfessional. Accessed 6/25/2016.

Initial approval 10/2014;  Minor Revisions 7/2016

 

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