Robert Thompson, MD
Associate Professor, Department of Radiation Oncology, and Hospital Services
Chief, University of Nebraska Medical Center, Omaha, Nebraska
Dr. Grigsby does an excellent job of summarizing the
accepted, stage-by-stage treatment recommendations as well as the controversies
surrounding the treatment of endometrial carcinoma. This review is both
important and timely, as we have seen the incidence of endometrial cancer
increase over the past few years to the point where it is now the most common
gynecologic malignancy.
Surgical Staging Controversy
Controversies surround the initial surgical management of endometrial cancer,
specifically in regard to the extent of surgical staging recommended. Especially
pertinent is Dr. Grigsby’s discussion of the management of apparent
early-stage endometrial cancer patients who have not undergone surgical staging.
Although some authors advocate surgical staging with lymph node dissection as
the standard of care,[1] some question the necessity and rationale for more
aggressive lymph node dissection in a patient population for which the resulting
data provide only prognostic information and only indirectly influence survival
(via decisions regarding adjuvant therapy).[2] Nonetheless, the current FIGO
staging system for endometrial cancer is defined as a surgical staging system
rather than a clinical staging system (as it was described before the 1988
revision).[3]
Our practice reflects what Dr. Grigsby describes as the most common treatment
approach for endometrial cancer in the United States. That is, most of our
patients with apparent early-stage disease are referred postoperatively to be
considered for radiation therapy without undergoing complete surgical staging.
Data from a prospective randomized trial of adjuvant postoperative radiation
therapy can be used to develop treatment guidelines in this context. The
Gynecologic Oncology Group’s GOG-99 trial surgically staged all patients and
used only external-beam irradiation without brachytherapy.[4] Given the absence
of complete surgical staging data for the majority of our patients, we are often
faced with the prospect of making decisions regarding adjuvant treatment without
the benefit of guidelines developed from recent trials that use data only from
surgically staged patient populations.
Further Guidance
