Serum CA125 measurement was suggested for posttreatment surveillance of endometrial cancer (392–394). Elevated CA125 levels were documented in patients with recurrent tumor, and these levels correlated with the clinical course of disease. However, CA125 levels may be normal in the presence of small recurrences, making the utility of CA125 measurements for follow-up of patients after treatment of early-stage disease suspect. Determinations of CA125 should be obtained in patients with elevated levels at the time of diagnosis or with known extrauterine disease.
Twenty-five percent of women with endometrial cancer are premenopausal and 5% are under the age of 40, indicating that interest in ovarian preservation or postoperative estrogen replacement is not uncommon (395). Isolated investigations suggest that premenopausal women have a much higher likelihood (23%) of a synchronous ovarian cancer (396). If both ovaries appear grossly normal, the risk of adnexal malignancy decreases to less than 1% (397).Careful inspection of the adnexa is imperative when ovarian preservation is considered (23,396–398).
Most endometrial cancers are associated with excess estrogen exposure, calling into question the appropriateness of estrogen therapy for premenopausal patients with endometrial cancer following hysterectomy and bilateral salpingo-oophorectomy. In 1986, Creasman et al. and others reported that estrogen therapy appeared safe with no documented increase in the risk of recurrence following surgical treatment for endometrial carcinoma (397,399,400). Some investigations reported higher intercurrent death rates, such as from myocardial infarction, in the group in which estrogen was withheld (397,401). A randomized, double-blind, placebo-controlled study was designed to determine whether estrogen replacement increased rates of disease recurrence in women with stage I or II endometrial cancer. This investigation closed early because of a fall off in accrual after the findings of the Women’s Health Initiative were made public in 2002. At the time of closure, the enrollment of over 1,200 patients in the study was insufficient, given the exceptionally low recurrence rate is this low-risk group (399). Although the safety of estrogen therapy in patients with endometrial cancer was not verified with level 1evidence, this investigation provided sufficient reassurance to justify the practice of offering estrogen therapy to patients with low-grade, FIGO 2009 stage IA disease in the absence of other contraindications. The American College of Obstetricians and Gynecologists issued a committee opinion recommending that providers should take into consideration prognostic indicators such as depth of invasion, grade, and stage when deciding to administer estrogen therapy to these patients (402).
For women who decline systemic estrogen replacement, symptoms of vaginal dryness and dyspareunia may be judiciously treated with topical estrogen alone. Symptomatic relief of hot ﬂashes can be achieved by prescribing progestins such a medroxyprogesterone acetate, 10 mg orally daily or 150 mg intramuscularly every 3 months, or nonhormonal agents such as Bellergal, clonidine, and venlafaxine.
Uterine sarcomas are relatively rare tumors of mesodermal origin. They constitute 2% to 6% of uterine malignancies (403–405). There is an increased incidence of uterine sarcomas after radiation therapy to the pelvis for either carcinoma of the cervix or a benign condition. The relative risk of uterine sarcoma after pelvic radiotherapy is estimated to be 5.38, with an interval of 10 to 20 years (405). Uterine sarcomas are, in general, the most malignant group of uterine tumors and differ from endometrial cancers with regard to diagnosis, clinical behavior, pattern of spread, and management.