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Current therapy of patients with endometrial carcinoma

A critical review

Derzeitige Therapie von Patientinnen mit Endometriumkarzinomen

Eine kritische Übersicht

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Abstract

Magnetic resonance imaging (MRI), 18-FDG positron emission tomography (18FDG PET-CT), and computed tomography (CT) have demonstrated disappointing detectability of lymph node metastases in endometrial cancer. The treatment of choice in patients with endometrial cancer is hysterectomy and bilateral salpingoophorectomy. Above all, obese patients with comorbidity have benefited the most from laparoscopically assisted approaches. For inoperable patients in FIGO stage I/II, radiation remains an alternative to hysterectomy. The role of pelvic and paraaortic lymphadenectomy is the most controversial issue in endometrial carcinoma treatment. The current spectrum of treatment ranges from no lymphadenectomy, exclusive pelvic or additional inframesentric paraaortic sampling, or complete pelvic to infrarenal paraaortic lymphadenectomy. The sentinel concept in patients with endometrial carcinoma is far from being introduced into routine clinical practice. Without a lymphadenectomy, decision making for adjuvant therapy remains a challenge, because no information is available from lymph node status and the reliability of pathologic grading is poor. For patients after hysterectomy with a low risk of local relapse (stage I/II without additional risk factors), vaginal brachytherapy is sufficient to prevent vaginal relapses. Adjuvant external beam irradiation (EBRT) in stage I/II demonstrated improved local control which impacted overall survival only in patients with high-risk features (higher age, grading myometrial infiltration). Stage IIIC patients seem to benefit from EBRT with regard to overall survival. In patients at high risk of progression (grade 3, MI > 50%, FIGO IIIC, unfavorable histology), multimodal treatment should be considered. The optimal substances and sequences are under investigation.

Zusammenfassung

Die Bildgebung mittels Magnetresonanztomographie (MRT), 18-FDG-Positronen-Emissionstomographie (18FDG-PET-CT) oder Computertomographie (CT) ist unsicher in der Beurteilung der Lymphknoten bei Endometriumkarzinomen. Die Therapie der Wahl von Patientinnen mit Endometriumkarzinomen ist die Hysterektomie und bilaterale Salpingoophorektomie. Vor allem komorbide, alte, adipöse Patientinnen profitieren von laparoskopisch assistierten Operationsverfahren. Für inoperable Patientinnen im FIGO-Stadium I/II stellt die primäre Bestrahlung eine onkologisch valide Alternative zur Hysterektomie dar. Die Rolle der pelvinen und paraaortalen Lymphadenektomie ist derzeit das am meisten kontrovers diskutierte Thema bei der Behandlung von Endometriumkarzinomen. Das derzeitige Therapiespektrum reicht von keiner Lymphadenektomie, einem alleinigen pelvinen oder zusätzlichen inframesentrischen paraaortalen Sampling bis zur kompletten pelvinen oder infrarenalen paraaortalen Lymphadenektomie. Das Sentinelkonzept bei Patientinnen mit Endometriumkarzinom ist derzeit weit davon entfernt, in die klinische Routine eingeführt werden zu können. Wird auf die Lymphadenektomie verzichtet, ist eine Therapieentscheidung für Patientinnen nach Hysterektomie schwierig, da keine Information zum Risikostatus vorhanden und die Reliabilität des pathologischen Gradings unbefriedigend ist. Für Patientinnen nach Hysterektomie im FIGO-Stadium I und II ohne zusätzliche Risikofaktoren ist die vaginale Brachytherapie (VBT) ausreichend zur Prophylaxe vaginaler Rezidive. Verbesserte lokale Kontrollraten konnten mit der adjuvanten perkutanen Bestrahlung (EBRT) im Stadium I/II erzielt werden, die jedoch nur bei Patientinnen mit Risikofaktoren (Alter, Grading, Myometriuminfiltration) einen positiven Einfluss auf das Gesamtüberleben hatte. Patientinnen im Stadium IIIC scheinen von der EBRT auch „quo ad vitam“ zu profitieren. Für Patientinnen mit hohem Progressionsrisiko (G3, MI  > 50%, FIGO IIIC, ungünstige Histologie) sollte eine multimodale Therapie erwogen werden. Die optimalen Substanzen und Sequenzen sind Gegenstand von Studien.

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  1. Department of Radiooncology, Charité University Medicine, Charité – Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany

    S. Marnitz

  2. Department of Gynecology, Charité University Medicine, Berlin, Germany

    C. Köhler

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Marnitz, S., Köhler, C. Current therapy of patients with endometrial carcinoma. Strahlenther Onkol 188, 12–20 (2012). https://doi.org/10.1007/s00066-011-0004-0

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