Summary of recommendations

From Cancer Guidelines Wiki

Summary of recommendations

Endometrial cancer

Multidisciplinary care

Is there benefit for multidisciplinary care of women with low and high-risk apparent early stage endometrial cancer?

Recommendation Grade
All patients with endometrial cancer should have the benefit of multidisciplinary team management, which includes review of pathology and relevant imaging, and presentation of their case at a multidisciplinary team conference. C
Practice point(s)
It is recommended that all patients should have access to subspecialist (gynaecological oncologist) care in the management of their gynaecological cancer.
Patients may benefit from multidisciplinary team approach at a number of points during their care, including: changes in major treatment modality (surgery, radiotherapy, chemotherapy) post-treatment survivorship care and decisions regarding palliative care.

Is there benefit for multidisciplinary care of women with low and high-risk apparent early stage endometrial cancer?

Recommendation Grade
All patients with endometrial cancer should have the benefit of multidisciplinary team management, which includes review of pathology and relevant imaging, and presentation of their case at a multidisciplinary team conference. C
Practice point(s)
It is recommended that all patients should have access to subspecialist (gynaecological oncologist) care in the management of their gynaecological cancer.
Patients may benefit from multidisciplinary team approach at a number of points during their care, including: changes in major treatment modality (surgery, radiotherapy, chemotherapy) post-treatment survivorship care and decisions regarding palliative care.

Pre-operative investigations

What is the role of preoperative imaging for low and high risk apparent early stage endometrial cancer?

Recommendation Grade
Preoperative MRI may assist in the assessment of patients wishing to retain fertility. D
Routine ‘predictive’ preoperative imaging with abdomino-pelvic CT scan is NOT indicated in clinically early stage endometrial cancer where the tumour appears to be confined to the uterine body and is of low grade (1-2) endometrioid histological type. C
Preoperative abdomino-pelvic CT scan is indicated in patients who have symptoms, signs or blood tests suggestive of metastatic disease or high-grade or high-risk histologic type of endometrial carcinoma. C
Preoperative MRI may be helpful when there is clinical suspicion of cervical involvement as confirmation will guide surgical management. B
Preoperative ‘predictive’ imaging may be useful in patients who are not suited to full surgical staging and may assist in ‘staging’ and planning management. C
Practice point(s)
In Australia and elsewhere there is a trend toward a laparoscopic surgical approach to endometrial cancer, thus reducing the opportunity for full visual exploration and palpation of the peritoneal cavity and aortic and pelvic retroperitoneal nodes (see section on Hysterectomy). In patients in whom a laparoscopic approach is planned, it may be useful to perform a CT scan of abdomen and pelvis to exclude gross pelvic organ abnormality, or retroperitoneal nodal enlargement.

Is there a benefit to a histopathological review of currettings or biopsy prior to treatment in low and high risk apparent early stage endometrial cancer

Recommendation Grade
Pre-operative review of uterine curettings or endometrial biopsies by a specialist gynaecological pathologist is recommended to assist in the accurate tailoring of treatment. C

Surgery

What is the evidence based surgical approach for hysterectomy in low and high risk apparent early stage endometrial cancer

Recommendation Grade
Laparoscopic approach to the management of endometrial cancer can be considered by appropriately trained surgeons, as it has been found to be feasible and surgically safe with reduced post-operative complications and length of stay. Data on the oncological safety are still awaited. B

What is the evidence based surgical approach for bilateral salpingo–oophorectomy in premenopausal women with low and high risk apparent early stage endometrial cancer

Recommendation Grade
Consideration should be given to retaining ovaries in young women less than 45 years of age with endometrial cancer whose ovaries appear normal at operation and have no adverse risk factors. C
Patients with Lynch Syndrome should be counselled that their ovaries should be removed at the time of hysterectomy given the high lifetime risk of developing ovarian cancer. C

What is the evidence based surgical approach for lymphadenectomy in low and high risk apparent early stage endometrial cancer

Recommendation Grade
A simple hysterectomy and bilateral salpingo-oophorectomy may be considered optimal surgery for patients with apparent stage 1A Grade 1 or Grade 2 endometrioid adenocarcinoma of the uterus. B
Pelvic lymphadenectomy may be carried out in surgically fit patients with grade 3 endometrioid adenocarcinoma, deeply invasive (more than 50% myoinvasion) grade 1 and grade 2 tumours, cervical involvement, palpably enlarged nodes, or endometrioid tumours greater than 2cm, for accurate staging and appropriate planning and tailoring of adjuvant therapy. B
A para-aortic lymphadenectomy may be considered in selected groups of patients with positive pelvic nodes, palpably enlarged para-aortic nodes, tumour involvement of the cervix, or adnexal disease for accurate staging and appropriate planning and tailoring of adjuvant therapy. C
Practice point(s)
While lymphadenectomy is part of the current FIGO 2009 surgical staging for endometrial cancer, it is important for clinicians to consider the benefits, limitations and morbidity of the procedure in the absence of compelling evidence for any survival advantage related to full surgical staging. This is of particular importance in patients who are at lower risk of nodal metastasis.

What is the role of intra-operative assessment of the uterus in low and high risk apparent early stage endometrial cancer

Recommendation Grade
Caution should be exercised in relying on intra-operative assessment of depth of invasion, involvement of cervix and histological grade as a means to determine extent of surgical staging C
Patients with high grade, histologically aggressive or large tumours are unlikely to benefit from intra-operative assessment. D
Practice point(s)
Intra-operative assessment may be used to identify those patients with (apparent) low-stage and low-grade endometrioid adenocarcinomas who have adverse prognostic features identified only at operation.

Adjuvant therapy

After hysterectomy, what is the role of radiotherapy (external beam, brachytherapy) in the management of early stage high risk endometrial cancer

Recommendation Grade
Patients with apparent stage 2 tumours, combined use of EBRT and VBT is recommended. In those patients with stage 2 (full surgical staging), VBT alone can be considered. D
Adjuvant radiation can be offered to those stage 1 patients with risk factors in order to improve local control. B
In selected at-risk patients, use of VBT alone over pelvic EBRT can be considered to reduce toxicity. B
It is reasonable to follow the PORTEC-2 dosing guidelines for adjuvant brachytherapy. The equivalent VBT dose should be limited to below 60 Gy/2 Gy per fraction. D
The addition of EBRT to VBT in higher risk patients with early stage disease can be considered in order to improve local control. For combined VBT and pelvic EBRT, PORTEC-3 Guidelines can be used to guide radiotherapy dosing. C

After hysterectomy, what is the role of chemotherapy (concurrent/concomitant, sequential, sandwich, chemoradiation) in the management of early stage high risk endometrial cancer

Recommendation Grade
Patients with completely resected stage I-III high-risk disease can be counselled that the use of adjuvant chemotherapy in addition to radiotherapy may improve progression-free survival rates compared to the use of adjuvant radiotherapy alone, particularly if their histology is endometrioid.
There is no evidence that overall survival is improved. These patients should be encouraged to consider enrolment into clinical trials addressing this question.
B
Patients with uterine papillary serous cancer (UPSC) or clear cell (CC) uterine cancer should be counselled that there is only low level evidence that adjuvant chemotherapy may have any impact on survival. D
Patients treated with sequential adjuvant chemotherapy and radiotherapy may receive the full course of chemotherapy either before or after radiotherapy, or given as part of a sandwich regimen.
Acceptable chemotherapy regimens include cisplatin and doxorubicin or carboplatin and paclitaxel.
C
The use of chemotherapy should be considered for patients with stage IV disease or those with stage III disease plus residual disease at the completion of surgery. Pelvic radiotherapy should also be considered to reduce the risk of pelvic relapse, except perhaps in patients with widespread distant disease. B

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