The Japanese GOG randomized patients to pelvic radiotherapy versus platinum-based chemotherapy in patients with stage IB to IIIC endometrial cancer and myometrial invasion greater than 50%. Assessment of para-aortic nodal status was performed in only 29% of cases. The investigators found no differences between the twoexperimental arms in terms of progression-free survival and overall survival. A subgroup analysis of 120 patients with either (i) stage IB tumor and age greater than 70 years or grade 3 endometrioid adenocarcinoma or (ii) stage II or IIIA tumor (positive cytologic findings) showed that chemotherapy was associated with significantly improved disease-free and overall survival rates (317). The benefits achieved with combined chemoradiation, identification of the best chemotherapeutic regimen, and the identification of subgroups of patients who may benefit from these treatments deserves further investigation.
Clinical Stage II Endometrial cancer involving the cervix either contiguously or by lymphatic spread has a poorer prognosis than disease confined to the corpus (267,278,318–334). Preoperative assessment of cervical involvement is difficult. Endocervical curettage has relatively high false-positive (50% to 80%) and false-negative rates. Histologic proof of cancer infiltration of the cervix or presence of obvious tumor on the cervix is the only reliable means of diagnosing cervical involvement, although ultrasonography, hysteroscopy, or MRI may show cervical invasion.
The relatively small number of true stage II cases in reported series and the lack of randomized, prospective studies preclude formulation of a definitive treatment plan. Three areas must be addressed in any treatment plan: 1.
For optimal results, the uterus should be removed in all patients.
2.
Because the incidence of pelvic lymph node metastases is about 36% in stage II endometrial cancer, any treatment protocol should include treatment of these lymph nodes.
3.
Because the incidence of disease spread outside the pelvis to the para-aortic lymph nodes, adnexal structures, and upper abdomen is higher than in stage I disease, attention should be directed to evaluating and treating extrapelvic disease.
Two approaches usually were used in the treatment of clinical stage II disease: 1.
Radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic and paraaortic lymphadenectomy 2.
An initial radical surgical approach to treatment of clinical stage II endometrial cancer has the advantage of collecting accurate surgical–pathologic information. Conversely, many patients with endometrial cancer are elderly and obese and have medical problems that make this approach unsuitable. Reported results are no better than those with combined radiation and less radical surgical therapy (267). The use of radical hysterectomy may be limited to patients with anatomic problems that prevent optimum dosimetry or other conditions that conﬂict with the use of radiation therapy.
The most common, traditional approach to the management of clinical stage II endometrial cancer is to use external and intracavitary radiation followed by extrafascial hysterectomy.
This combined approach resulted in 5-year survival rates of 60% to 80%, with severe gastrointestinal or urologic complications occurring in about 10% of patients (319–327). Patients who have medically inoperable disease are usually treated with external-beam radiation and one or two intracavitary insertions. Compared with combined radiation and surgery, the results with radiation alone are diminished, but about 50% of patients are long-term survivors (279) (Table 35.9).