Surgical Treatment An algorithm for the management of patients with clinical stage I and II endometrial cancer is presented in Figure 35.6. The most common current protocol for surgical management of endometrial cancer includes peritoneal cytology, hysterectomy and bilateral salpingo-oophorectomy, and surgical staging.In patients with nonendometrioid cancer, omentectomy along with appendectomy and peritoneal biopsies may be performed. The need to perform lymphadenectomy is based on the type of endometrial cancer, the grade of the tumor, the tumor size and extent of myometrial invasion determined during the surgery, and the presence of extrauterine disease. Bilateral pelvic and para-aortic lymphadenectomy is performed if the patient has any of the following factors:evidence of extrauterine disease, tumor that is FIGO grade 3, nonendometrioidtype endometrial cancer, or evidence of tumor invasion more than 50% of the thickness of the myometrium.In the absence of these risk factors only bilateral pelvic lymphadenectomy is performed, if the tumor size is greater than 2cm; para-aortic lymphadenectomy would be performed only if pelvic lymph nodes were positive (Fig. 35.7). Lymphadenectomy is omitted altogether for patients without the above risk factors, absence of cervical involvement, and tumor size less than2cm. The decision to administer postoperative radiation, chemotherapy, or both is predicated on the final results of pathological examination of the surgical specimen and cytology, according to previously described criteria (243).
Figure 35.7 Radical pelvic sidewall resection. Photo taken of a patient with a left pelvic sidewall recurrence following resection of psoas muscle and bony ilium. Structures from lower to upper aspect of the photo (medial to lateral) include ureter, internal and external iliac artery, common iliac vein, lumbosacral trunk, obturator nerve (sacrificed), and femoral nerve. The cut edge of the psoas muscle is seen at left. (Provided by Sean C. Dowdy, MD, Mayo Clinic.)
Hysterectomy with bilateral salpingo-oophorectomy represents the first step in the treatment of endometrial cancer. The most debated issue in endometrial cancer management concerns the utility of lymph node dissection. This topic is extensively discussed in the “Surgical Staging” section of this chapter.
Vaginal hysterectomy may be considered for selected patients who are extremely obese and have a poor medical status or for patients with extensive uterovaginal prolapse. Vaginal hysterectomy with bilateral salpingo-oophorectomy may be considered adequate treatment for patients with low risk tumors (endometrioid, grade 1 or 2, <50% myometrial invasion, and tumor diameter <2 cm; Fig. 35.7. Vaginal hysterectomy is particularly suitable for patients who are at lowrisk for extrauterine spread of disease (i.e., those with clinical stage I, well-differentiated tumors). In one report, a 94% survival rate was found in 56 patients with clinical stage I endometrial carcinoma treated by vaginal hysterectomy, with or without postoperative radiotherapy (mostly brachytherapy). Three-fourths of these patients had grade 1 lesions (244). Others reported similar good results (245–247). Vaginal hysterectomy is preferable to radiation therapy alone, but should be reserved for specific patients.