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Monitoring
For patients who underwent fertility-sparing treatments, recurrence rates are 30-40%. The treatment response should be assessed using D and C, hysteroscopy, and imaging studies on the 6th month following completion of therapy. Conception with continued follow-up every 6 months should be encouraged if with complete treatment response at the 6th month post-treatment; maintenance progestin-based treatment should also be considered. For patients with persistent disease due to treatment failure after 6 months of initial therapy, pelvic MRI is recommended, especially for those considering further fertility-sparing regimens. Patients on progestin-based treatment should be monitored every 3-6 months, with D and C, endometrial biopsy, hysteroscopy, and imaging. Re-evaluation every 6 months should be imposed on patients who did not undergo hysterectomy. Progesterone receptor (PgR) may be used to predict disease remission. Patients with a good response to treatment should be referred to fertility clinics. For patients who underwent fertility-sparing treatments, extrafascial hysterectomy and bilateral salpingo-oophorectomy with staging is recommended for the following: After childbirth; the presence of disease progression in biopsies; and persistent endometrial cancer after 6-12 months of progestin-based therapy. Patients with FIGO stage III-IV disease who chose non-fertility-sparing treatments should be re-evaluated using chest/abdominal/pelvic CT every 6 months for the first 3 years after therapy, and every 6-12 months for the next 2 years. Other imaging modalities may be considered in patients with possible disease progression, new masses on PE, or new pelvic, abdominal or lung symptoms during follow-up.
Prognosis
The prognostic factors in the evaluation of endometrial cancer include: Age; International Federation of Gynecology and Obstetrics (FIGO) stage; depth of myometrial invasion; tumor differentiation grade; tumor type; hormone receptor status; and lymphovascular space invasion (LVSI).
Complications
Recurrent Endometrial Cancer
The diagnostic tests to consider for recurrent endometrial cancer include: Whole body PET/CT if considering surgery or locoregional therapy; abdominal/pelvic/chest CT scan depending on the patient’s symptoms and PE evaluation; and pelvic MRI may be considered in patients who refused to undergo hysterectomy.
Management
Radiotherapy may be considered in patients with localized vaginal relapse post-surgery. External beam radiotherapy with or without brachytherapy with or without systemic therapy is recommended for patients with no history of radiotherapy. If with history of brachytherapy, surgical resection with exploration with or without intraoperative radiotherapy or external beam radiotherapy with or without brachytherapy and with or without systemic therapy is recommended. If previously given external beam radiotherapy, the following may be considered: Surgical resection with exploration with or without intraoperative radiotherapy; systemic therapy with or without palliative external beam radiotherapy; and vaginal brachytherapy with or without systemic therapy. Radical re-irradiation using stereotactic body radiotherapy, permanent seed implants, or proton therapy may be considered if surgical management is not feasible.
External beam radiotherapy with or without systemic therapy may be considered for patients with pelvic or para-aortic or common iliac node recurrence at high risk for systemic relapse. Systemic therapy with or without external beam radiotherapy may be considered for patients with upper abdominal/peritoneal disease relapse with microscopic residual disease. External beam radiotherapy with or without systemic therapy with or without vaginal brachytherapy may be considered for patients with disease confined to the vagina or paravaginal soft tissue. Surgical resection and/or external beam radiotherapy, or ablative therapy or systemic therapy may be considered in patients with isolated metastases.
Hormone therapy with systemic therapy is recommended for patients with low-grade, asymptomatic and HR-positive disseminated metastases. Systemic therapy with or without palliative therapy is recommended for patients with higher grade or large-volume disseminated metastases.
Please refer to the Pharmacological Therapy section for the list of recommended agents.
Cytoreduction therapy improves survival rate and helps reduce recurrence in patients with intra-abdominal disease. Surgery may be considered only if cytoreduction without residual disease is possible. Exenteration may be considered in patients with locally advanced disease and those with isolated central local relapse with clear margins post-radiotherapy.