Therapy. Uterine cancer
Simple hysterectomy and bilateral salpingo-oophorectomy remain the hallmarks of therapy for corpus cancer. After complete surgical staging, if disease is limited to the uterus, most patients need no further therapy. The one exception is patients with a poorly differentiated, deeply invasive cancer. Nonrandomized studies controlled for prognostic factors suggest that pelvic radiation in this group may prevent both local and distant recurrence. In all other instances, radiation therapy did not appear to be of benefit. In the only prospective, randomized study comparing radiation with no radiation, it appeared that radiation decreased local recurrence but overall survival was the same.
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The role of brachytherapy postoperatively does not appear to be efficacious in most surgical stage I cancers because vaginal vault recurrence appears to be no more than 1-2%, irrespective of whether the patient receives radiation. Fortunately, most adenocarcinomas of the endometrium are surgical stage I, and most of those are adequately treated with surgery only.
When disease is present outside of the uterus, there is no general agreement as to optimal therapy. Unfortunately, prospective, randomized studies have not been done, and the clinician’s experience, both published and unpublished, affects the therapeutic recommendation. The question that has been raised is whether surgical staging is only diagnostic and therefore has no impact on survival. Data are now appearing in the literature suggesting that lymphadenectomy can be therapeutic to a greater degree than simple hysterectomy and bilateral salpingo-oophorectomy patients with true stage II disease has not been investigated in any depth. Again, most oncologists would probably treat these patients with postoperative radiation, although some have suggested that surgery may be definitive, particularly for those with stage IIA cancers. The role of radical hysterectomy in patients with clinical stage II disease has essentially been discarded from our armamentarium. In patients with surgical stage III and IV disease, treatment is usually individualized and combination therapy with surgery and radiation is common. The use of chemotherapy and hormones both in adjuvant and therapeutic modes in patients with advanced disease has not proved to be efficacious. Multiple regimens have been attempted, but response rates remain suboptimal.
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Recurrent disease historically has been treated in many different ways. If a local recurrence appears in the vaginal vault, surgery alone or in combination with radiation therapy has saved many of these patients. If recurrence is in the lower vagina, success has been limited. For metastatic disease, progestins have been primarily used; reports have noted an objective response in about one third of patients. More recent data suggest that the response rate is 15-20%. Original grade of tumor, length of time from primary treatment to recurrence, and hormone receptor status of the original tumor all appear to be indicative of the patient’s response to progestin. Several cytotoxic agents have been used with objective responses noted. The most experience has been with adriamycin and cyclophosphamide, cisplatin with or without adriamycin, and more recently paclitaxel. Unfortunately, when there is a response, it is relatively short lived. The ideal single or combination regimen for recurrent endometrial cancer has not yet been identified.