Another method of management of clinical stage II endometrial cancer that is gaining favor is an initial surgical approach followed by radiation. This method is based on the difficulty in establishing the preoperative diagnosis of cervical involvement in the absence of a gross cervical tumor, the evidence that radiation is equally effective when given after hysterectomy, and the high incidence of extrapelvic disease when the cervix is involved. Exploratory laparotomy with an extrafascial or modified radical hysterectomy, bilateral salpingo-oophorectomy, peritoneal washings for cytology, and resection of grossly enlarged lymph nodes are performed. These procedures are followed by appropriate pelvic or extended-field external and intravaginal radiation, depending on the results of surgical staging. Excellent results were reported using this treatment scheme (329–331).
Clinical Stages III and IV Clinical stage III disease accounts for about 7% to 10% of all endometrial carcinomas (335–340). Patients usually have clinical evidence of disease spread to the parametria, pelvic sidewall, or adnexal structures; less frequently, there is spread to the vagina or pelvic peritoneum. Treatment for stage III endometrial carcinoma must be individualized, but initial operative evaluation and treatment should be considered because of the high risk for occult lymph node metastases and intraperitoneal spread when disease is known to extend outside of the uterus into the pelvis. In the presence of an adnexal mass, the initial impetus for surgery is to determine the nature of the mass. Surgery is performed to determine the extent of disease and to remove the bulk of the disease if possible. This procedure should include peritoneal washings for cytologic examination, para-aortic and pelvic lymphadenectomy, biopsy or excision of any suspicious areas within the peritoneal cavity, and omentectomy and peritoneal biopsies. Except in patients with bulky parametrial disease, total abdominal hysterectomy and bilateral salpingo-oophorectomy should be performed. The goal of surgery is eradication of all macroscopic disease because this finding is of major prognostic importance in the management of patients with clinical stage III disease. Postoperative therapy can be tailored to the extent of disease.
Results of therapy depend on the extent and nature of disease. A 5-year survival rate of 54% was reported for all patients with stage III disease; however, the survival was 80% when only adnexal metastases were present, compared with 15% when other extrauterine pelvic structures were involved (335). Patients with surgical–pathologic stage III disease have a much better survival rate (40%) than those with clinical stage III disease (16%) (326). Patients who are treated with combined surgery and radiation fare better than patients who receive radiation therapy alone (340).
Stage IV endometrial adenocarcinoma, in which tumor invades the bladder or rectum or extends outside the pelvis, makes up about 3% of cases (340–344). Treatment of stage IV disease is patient dependent but usually involves a combination of surgery, radiation therapy, and systemic hormonal therapy or chemotherapy. One objective of surgery and radiation therapy is to achieve local disease control in the pelvis to provide palliative relief of bleeding, discharge, and complications involving the bladder and rectum. In one report, control of pelvic disease was achieved in 28% of 72 patients with stage IV disease treated with radiation alone or in combination with surgery, progestins, or both (342). Several reports noted a positive impact of cytoreductive surgery on survival, the median survival being about threetimes greater with optimal cytoreduction (18 to 34 months vs. 8 to 11 months, respectively) (342–344). Pelvic exenteration may be considered in the very rare patient in whom disease is limited to the bladder, rectum, or both (345,346).