Endometrial cancer management guidelines updated: assorting the uncertainties! -----2

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11–13 December 2014 in Milan, Italy.

These guidelines were published in an article by Colombo N et al in January issue of Annals of Oncology. 

These guidelines were developed based on 12 questions identified by the expert panel. 

The first question was addressed in part 1: Which surveillance should be used for asymptomatic women?

The second question is: What work-up and management scheme should be undertaken for fertility-preserving therapy in patients with atypical hyperplasia (AH)/endometrial intraepithelial neoplasia (EIN) and grade 1 endometrioid endometrial cancer (EEC)?

 

It’s rare that young women of childbearing age will be diagnosed with EC, with only 4% of all patients being younger than 40 years of age. 

Younger women also have a better prognosis, being at early and low grade stage of disease when diagnosed. The standard approach in women of childbearing age is hysterectomy and bilateral salpingo-oophorectomy with or without lymphadenectomy. This procedure has a very good survival ( 93% at 5 years) but results in permanent loss of reproductive capacity. 

The conservative management consist of medical therapy with progestins (oral or local) for premalignant and grade 1 EC.

Recommendation 2.1: Patients with AH/EIN or grade 1 EEC requesting fertility-preserving therapy must be referred to specialised centres. Level of evidence: V, Strength of recommendation: A

Recommendation 2.2: In these patients, D&C with or without hysteroscopy must be performed .Level of evidence: IV, Strength of recommendation: A 

Recommendation 2.3: AH/EIN or grade 1 EEC must be confirmed/diagnosed by a specialist gynaecopathologist .Level of evidence: IV,Strength of recommendation: A

Recommendation 2.4: Pelvic MRI should be performed to exclude overt myometrial invasion and adnexal involvement. Expert ultrasound can be considered as an alternative.Level of evidence: III, Strength of recommendation: B

Recommendation 2.5: Patients must be informed that fertility-sparing treatment is a non-standard treatment and the pros and cons must be discussed. Patients should be willing to accept close follow-up and be informed of the need for future hysterectomy.Level of evidence: V,Strength of recommendation: A

Recommendation 2.6: For patients undergoing fertility-preserving therapy, MPA (400–600 mg/day) or MA (160–320 mg/day) is the recommended treatment. However, treatment with LNG-IUD with or without GnRH analogues can also be considered.Level of evidence: IV,Strength of recommendation: B

Recommendation 2.7: In order to assess response, D&C, hysteroscopy and imaging at 6 months must be performed. If no response is achieved after 6 months, standard surgical treatment should be performed. Level of evidence: IV,Strength of recommendation: B

Recommendation 2.8: In case of complete response, conception must be encouraged and referral to a fertility clinic is recommended.Level of evidence: IV, Strength of recommendation: B

Recommendation 2.9: Maintenance treatment should be considered in responders who wish to delay pregnancy.Level of evidence: IV,Strength of recommendation: B

Recommendation 2.10: Patients not undergoing hysterectomy should be re-evaluated clinically every 6 months.Level of evidence: IV,Strength of recommendation: B

Recommendation 2.11: After completion of childbearing, a hysterectomy and salpingo-oophorectomy should be recommended. The preservation of the ovaries can be considered depending on age and genetic risk factors. Level of evidence: IV, Strength of recommendation: B 

Pregnancy is protective for endometrial cancer and the pooled pregnancy rate in a recent metaanalysis was 28%, which reached 39% when assisted reproductive technology was used.
  

To be continued…..

References:

Colombo N,Creutzberg CL, Amant F et al. ESMO-ESGO-ESTRO consensus conference on endometrial cancer: diagnosis, treatment and follow-up. Ann Oncol 2016; 27: 16–41.