Endometrial Cancer. Part 8
For patient’s that have grade II to grade III, they need a total abdominal hysterectomy, they need pelvic and periaortic lymph node sampling and they need peritoneal washings, particularly if they are a grade II, sometimes they can be bounced to a grade III, if they are grade III, they should definitely get peritoneal pelvic lymph nodes simply because they are at the risk, that is anywhere from 20 to 60% of having positive nodes and this is going to help tailor your treatment, and if you are dealing with a patient who is elderly and may not tolerate radiation, this may be very critical information to help you manage this patient postoperatively.
For people who have advanced stage II endometrial cancer, which means there is involvement of the cervix, if the cervix is not grossly involved, meaning there is only endocervical involvement and you have picked this up on a fractional D&C, these patient’s can still undergo a total abdominal hysterectomy, bilateral salpingo-oophorectomy plus your pelvic and periaortic lymph node dissection, send it to pathology and decide if this patient needs postop treatment or not. Most likely she is going to need postoperative radiation therapy because she has at least endocervical involvement. Some GYN oncologists were proposed to a radical hysterectomy for endocervical involvement and therefore necessity for adjunctive radiation therapy. This can be tough in patient’s who have endometrial cancer because #1, these patient’s tend to be elderly and doing radical hysterectomies in the elderly, although it is a completely acceptable treatment for a stage II disease, you are going to leave them with bladder atony and difficulty with their bowels, so it’s a tough surgery to put these patient’s through, plus a lot of them are morbidly obese, and therefore not a surgical candidate to undergo a radical hysterectomy. If the cervix is grossly involved, meaning there is no way you can get out, it’s 4 or 5 cm, what we usually do is treat with external beam radiation followed by one inter cavitary implant followed by an extra fascial hysterectomy following the surgery, and then for huge, large unresectable tumors, anything goes, you use a combination of chemotherapy, plus radiation, plus some surgery to give the patient the optimal palliative result.
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For patient’s who have recurrent or advanced endometrial cancer, there is chemotherapy and progestins. The most active chemotherapeutic agent for endometrial cancer to date has been Adriamycin, it has been proposed to have a 35 to 40% response rate. Now response rate means that if you take patient’s who have a measurable lesion, and given them Adriamycin , it does not mean that 40% of them will have a complete response, that means there will be some shrinkage of tumor. The response rates for Adriamycin last anywhere from seven months. The most active regimen that has been deemed by the gynecologic oncology group looked at single agent Adriamycin versus Adriamycin plus cisplatinum and there was a slightly higher response rate with a combination of cisplatinum and Adriamycin, so that is felt to be the gold standard for endometrial cancer and all the other trials are looking at that.