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10/1/2014

Management of Grade 1 Adenocarcinoma of the Endometrium

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, sentinel lymph node sampling, and possibly lymphadenectomy.  Patients with grade 1 endometrioid lesions with less than 50% myometrial invasion and tumor size of 2 cm or less seem to be at low risk of lymph node metastases and may not require a systematic lymphadenectomy. Patients with greater than 50% myometrial invasion or cervical extension should have complete surgical staging. In patients with stage 1a, grade 1 disease, no further therapy is indicated. 

Traditionally, surgical staging has been performed by laparotomy. However, advances in minimally invasive surgery have made it the preferred approach for endometrial cancer surgical staging.  Some patients may additionally require adjuvant radiation therapy. Consultation with a surgeon experienced in the management of endometrial cancer, such as a Gynecologic Oncologist, is advised.

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 the risks of abdominal or laparoscopic procedures ourweigh the risks of a vaginal approach.  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.

Young women who desire future fertility may be candidates for medical management. Potential candidates should have low-risk disease (grade 1 or 2, limited to the uterus), be willing to adhere to progestin therapy and surveillance, and understand the risk of progressive disease.  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 appear to have low-risk disease may actually have more aggressive disease.  Disease may progress despite medical therapy.  Even in cases without recurrence, hysterectomy is recommended following completion of childbearing.

 

Further Reading:

American College of Obstetricians and Gynecologists. Practice Bulletin No. 149: Endometrial cancer. Obstet Gynecol. 2015 Apr;125(4):1006-26. doi: 10.1097/01.AOG.0000462977.61229.de.

Hacker NF and Friedlander M., Uterine Cancer., 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. As of 8/8/17. Available at time of publication at: https://www.cancer.gov/types/uterine/hp/endometrial-treatment-pdq/

Initial approval October 2014. Minor Revision July 2016. Revised January 2018. Reaffirmed July 2019; Reaffirmed March 2021. Reaffirmed September 2022

 

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