1. preoperative grade 2 or 3

2. preoperative high-risk histology including papillary serous, clear cell or MMMT

3. clinically advanced stage endometrial cancer

B (Secondary Surgery)
Ic, G3 or IIa, G3 plus ≥ 50% myometrial invasion without lymph node dissection: recommend secondary pelvic lymphadenectomy

2) Radiation - Endometrioid Type

Table 2 - Based on FIGO 2009 Staging

Surgicaly staged - node negative 

Node Positive (IIIC): This subgroup of patients will be referred for considered of chemotherapy. Radiation to pelvis +/- PAN will be considered after the completion of chemotherapy.

Unstaged

Unstaged patients with LVSI are considered “high risk” and P+V radiation is recommended.

Special scenarios: Pap serous and clear cell: recommendations based on full surgical staging.

O=observation
V=vault brachytherapy
P=pelvic radiation
PAN=Para-aortic nodes

3) Chemotherapy

Table 3

(M–: no myometrial invasion; M+: myometrial invasion)

* Consider using hormones instead for stage IVb grade 1 as incurable

Grade 1 tumors have a response rate up to 30% whereas it is 9% for Grade 3. For the incurable grade 1 patient Tamoxifen 20 mg od or Megace 160 mg po od or Provera 300 mg po od are reasonable first choices before chemotherapy.

** deeply invasive within uterus

Chemotherapy Protocols

Carboplatin/paclitaxel (GOENDCAT) is the recommended protocol based upon the superiority of taxane-platin containing regimens over platinum-anthracycline regimens and lesser toxicity of carboplatin-paclitaxel compared to cisplatin/adriamycin/paclitaxel.

Special Histologies/Situations

1. Small Cell Carcinomas
Rare tumour in endometrium. See cervix protocol (SMCC2)

2. Isolated pelvic relapse: refer to BCCA as cure possible.

References

1. Fleming; JCO 22:2159, 2004
2. Weber; PASCO 22 22:543, 2003
3. Hoskins; JCO 19:4048, 2001
4. Carey MS, Gyn Oncol 101-158, 2006

4) Estrogen Replacement Therapy

In spite of the fact that endometrial tumours that develop on HRT tend to be very well differentiated and minimally invasive, with a generally good prognosis, the known association with estrogen use causes concern when women with endometrial carcinoma request hormone replacement.

Many of these patients are asymptomatic. There is a small proportion of patients who suffer from extreme vasomotor symptoms. Unfortunately, alternatives to estrogen often meet with only limited success. In many patients symptom control is not satisfactorily achieved with the use of clonidine or progesterone.

For women symptomatic secondary to estrogen lack or at risk for significant osteoporosis, hormone replacement is of value. Thorough discussion of the pros and cons of replacement is required for each individual.