B20. Endometrial cancer; FIGO classification and therapy
FIGO classification
The International Federation of Gynaecology and Obstetrics (FIGO) classifications are similar to the TNM, but slightly different. FIGO classifications are preferred in gynaecology.
| Stage | Description |
|---|---|
| 0 | Carcinoma in situ |
| I | Tumour is localised to the corpus |
| II | Tumour reaches the cervix |
| III | Tumour infiltrates the neighbouring tissues (adnexa, vagina, lymph nodes) |
| IVa | Tumour infiltrates the bladder or rectum |
| IVb | Distant metastasis |
(There are substages of I, II, and III, but I’ve excluded them for simplicity)
General concepts of treatment
MRI or CT is important in staging the tumour, to evaluate the local and distant spread. The complete staging can only be performed after total hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy.
Unless contraindicated, surgical therapy should always be part of the therapy of endometrial cancer. If surgery is contraindicated, primary combined irradiation, brachytherapy, and teletherapy are necessary.
Preoperative and/or postoperative irradiation may be performed as well.
Surgical therapy
Total hysterectomy with bilateral salpingo-oophorectomy is the mainstay of surgical treatment. It is curative in early stages and improves prognosis in later stages. It also allows the proper surgical staging. Laparoscopy is preferred over laparotomy.
Pelvic and para-aortic lymph nodes are removed in case of middle risk and high risk stages, generally IIIc and above.
If presurgical evaluation shows possible spreading to the cervix (stage II), a radical hysterectomy is performed instead. Radical hysterectomy means the en bloc removal of the uterus, cervix, upper vagina, and parametrium.
Irradiation therapy
The plan to irradiate must be made on an individual basis, depending on the stage of cancer and the state of the patient. Two types of irradiation are used, teletherapy and brachytherapy.
Teletherapy may use LINAC, CT 3D planning, IGRT, IMRT.
Brachytherapy, also called intracavitary therapy, may be HDR-Al, LDR, or HDR.
If surgery is contraindicated or the patient refuses surgery, we may use definitive radiotherapy. This entails both teletherapy and brachytherapy.
In case of if stage IVb or recurring cancer, palliative irradiation may be used to stop bleeding and decrease pain.
Chemotherapy
Chemotherapy may be used in recurring cancer or as adjuvant therapy. Paclitaxel + carboplatin is used.
Follow-up after treatment
- Physical examination
- Every 3 months in the first year
- Every 4 months in the second year
- Then less and less frequently until 1 time per year
- Imaging
- Chest x-ray
- MRI/CT/transvaginal ultrasound
- CA-125 detection