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Surgery of uterine cancer

Stage I

Surgery is the primary treatment for uterine cancer. At the beginning of the operation, a thorough inspection of the abdomen is done, and abdominal rinse fluid is collected for cytological evaluation, possibly after abdominal lavage. 

  • With a tumor confined to the uterus, a total abdominal hysterectomy and bilateral salpingo-oophorectomy are performed. If there is invasion of the cervix (stage II), a radical hysterectomy is performed. An alternative for stage II uterine cancer is a regular hysterectomy followed by radiation treatment. 
  • In cases of serous-papillary and clear-cell tumors, an omentectomy and lymph node extirpation is always performed.
  • LND is performed in many cases of endometrial cancer and is determined by histology, grade, pre-operative factors, frozen section results and patient comorbidities.

Postoperative treatment 

  • Endometrioid tumors in stage I grade 1–2 are categorized in the low-risk group. The frequency of recurrence is 5–7% (21). Recurrences are most commonly localized to the vagina or pelvis, and can be treated with radiation with good results (15). At Oslo University Hospital, it is recommended not to give adjuvant treatment to this patient group.
  • Endometrioid tumors in stage Ib grade 1–2 as well as stage Ia grade 3 are categorized as moderate risk group. The frequency of recurrence is about 10%. Recurrences are most commonly localized to the vagina or pelvis and are treated with radiation therapy achieving good results (15). An effect has not been found on survival by adjuvant radiation therapy of these two groups of patients (16). At Oslo University Hospital, it is not recommended to give adjuvant radiation therapy to this patient group.
  • Endometrioid tumors in stage Ib grade 3 are considered high risk with a recurrence rate of about 25%. Recurrences are partly localized to the pelvis and partly outside the pelvis. Adjuvant radiation to the pelvis reduces the frequency of local recurrences, but do not increase survival. A recent Cochrane analysis showed marginally improved survival by adjuvant chemotherapy.  
  • Serous papillary as well as clear cell tumors have a high risk for recurrence in both stage Ia and Ib. Adjuvant radiation to the pelvis reduces the frequency of local recurrences, but do not increase survival.
  • Adjuvant treatment with progestagens has no documented effect.

Postoperative chemotherapy with 6 courses of carboplatin and paclitaxel is offered to:

  • Patients with tumors of grade 3 and invasion of the myometrium of 50% or more
  • All patients with type 2 tumors
  • All patients with carcinosarcoma

Lymph node staging

The risk for lymph node metastasis is about 5% in the low risk group, about 10% in the moderate risk group, and 25% or higher in the high risk group (13).

Lymph node staging in endometrial cancer is controversial and has not been shown to increase survival in 2 randomized studies. At the Norwegian Radium hospital, pelvic and paraaortal lymph node staging is performed in all patients in the high risk group and in patients with stage Ib, grade 2 or 3 as well as in patients with carcinosarcoma.

Stage II

In the case of visible macroscopic tumor tissue on the cervix, the possibility of cervical cancer must be considered. MRI is usually helpful for differential diagnoses. For stage II confirmed preoperatively, we recommend a radical hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymph node staging.

Postoperative treatment

External radiation treatment to the pelvis is recommended for stage II in case a simple hysterectomy is performed.

All patients with stage II are offered postoperative chemotherapy with 6 courses of carboplatin and paclitaxel.

Stage III–IV

This is a heterogenous group of tumors where the primary examinations have confirmed metastasis outside the uterus in some cases, while for others, this is first confirmed by the histological evaluation after surgery for assumed stage I cancer. 

If there is spreading to the pelvis, it was previously recommended to give radiation before surgery. Recent studies (19) show, however, that chemotherapy is more effective than radiation for advanced endometrial cancer. It is therefore recommended to remove the tumor by surgery followed by chemotherapy. An alternative is neoadjuvant chemotherapy followed by surgery.

If the tumor can be completely removed by surgery based on a thorough preoperative evaluation, we choose primary surgery first, otherwise, we consider to give neoadjuvant chemotherapy.

Aftercare

  • Stage IIIa: Chemotherapy after surgery
  • Stage IIIb with parametrial infiltration: Neoadjuvant chemotherapy followed by surgery will usually be given. Supplemental radiation will be considered. Treatment often consists of surgery. The extent of chemotherapy combined with radiation therapy is evaluated individually.
  • Stage IIIb with vaginal metastasis: Individualized treatment. Surgery with full resection if possible followed by chemo. Radiation is an option in case of unresectable tumor.
  • Stage IIIc: If the lymph nodes are considered removable by surgery, the treatment is initiated by surgery and followed by chemotherapy.
  • Stage IV: If there is invasion of the bladder or rectum as well as confirmed distant metastases (liver, lungs, or bone) treatment is assessed individually. Treatment often begins with chemotherapy if the patient's general health condition is acceptable. Further treatment in the form of surgery or radiation will depend on the effect of the chemotherapy on the tumor and the disease profile. For hormone receptor-positive tumors, hormone treatment may also be considered.

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