Hormone replacement therapy. In the absence of specific medical contraindications, hormone replacement therapy (HRT) frequently is offered to premenopausal patients undergoing bilateral salpingo-oophorectomy and is usually continued for postmenopausal patients after surgery. In patients with endometrial cancer, there is a concern that exogenous estrogen may stimulate “dormant” cancer cells and increase the likelihood of recurrent disease.
To date, no randomized studies have adequately addressed this issue. An ongoing GOG trial is randomizing early-stage patients to receive estrogen or placebo postoperatively to determine rates of recurrence. Patient accrual is still under way. Several reports have found that early-stage patients who initiate or resume estrogen replacement therapy do not have a higher incidence of recurrent disease. In fact, 3 studies have shown a lower incidence of recurrence in these patients.22-24 Should additional studies confirm these early findings, future clinical and laboratory investigations will be needed to delineate possible explanations.
Laparoscopy. The role of laparoscopy in the surgical management of endometrial cancer is being explored by the GOG in a prospective, randomized trial. The concerns over laparoscopy relate to the adequacy of the nodal sampling, which often is performed in patients who are obese and/or have other comorbid conditions. Ultimately, the prospective trial will determine the adequacy of laparoscopy, as well as its potential benefits, in relation to the standard laparotomy.
Frequency of nodal metastases among risk factors
|RISK FACTOR||NO. OF PATIENTS||PELVIC NODES (%)||AORTIC NODES (%)|
|1 Well||180||5 (3%)||3 (2%)|
|2 Moderate||288||25 (9%)||14 (5%)|
|3 Poor||153||28 (18%)||17 (11%)|
|Endometrial||87||1 (1%)||1 (1%)|
|Superficial||279||15 (5%)||8 (3%)|
|Middle||116||7 (6%)||1 (1%)|
|Deep||139||35 (25%)||24 (17%)|
|Data from Creasman WT, Morrow CP, Bundy BN, et al. Surgical pathologic spread patterns of endometrial cancer. A Gynecologic Oncology Group study. Cancer. 1987;60:2035-2041.|
Although the mortality rate has declined more than 50% since 1940, endometrial malignancies remain a significant cause of cancer deaths. Fortunately, most cases are diagnosed before the disease has spread outside the uterus. Surgical staging is integral to the management of early-stage disease, and preoperative intracavitary radiation has fallen out of favor. The extent of lymph-node sampling, the appropriate adjuvant therapy, and the advisability of laparoscopic management vary from case to case and remain fairly controversial. Another unresolved issue is the use of HRT in patients with endometrial cancer.
Dr. Barakat reports no financial relationship with any companies whose products are mentioned in this article.