Prognosefaktoren und Prognose des Endometriumkarzinoms

Endometrial cancer can be classified into two types according to histopathological and endocrinological parameters. Type II carcinomas of the endometrium (clear cell and serous carcinoma) have a significantly worse prognosis than type I carcinoma (estrogen/progesteron receptor positive). They are more like ovarian carcinomas and are treated as such. Other prognostic factors such as tumour size, including depth of invasion, lymphatic and distant metastasis, and less significant prognostic factors such as age, parity, metabolic diseases and genetic aberrations all influence the relapse rate and survival of patients. New molecular biological and molecular genetic prognostic factors provide a possible opportunity for developing new diagnostic and therapeutic options which may lead to a better prognosis.     

Epidemiologie,Risikofaktoren und Genetik des Endometriumkarzinoms

In April 2018 the first German interdisciplinary S3 guidelines for the diagnosis, treatment, and follow-up of patients with endometrial cancer were published. This article is a summary of Chapter 3: “Epidemiology and risk factors, prevention of endometrial cancer” and Chapter 10: “Hereditary endometrial cancer”. It is a clinically oriented abbreviated version of these chapters. The statements and recommendations regarding the epidemiology and established risk factors of endometrial cancer are presented. In addition, the diagnosis and management of hereditary forms of endometrial cancer are discussed.     

Rezidivtherapie des Ovarialkarzinoms

Despite optimal primary oncologic management most patients with advanced ovarian cancer develop a recurrence with a subsequent shift from the therapeutic intention to a palliative approach. Symptom control and quality of life gain in importance as treatment goals and further management is primarily influenced by the response to the preceding platinum-based chemotherapy. Two main subgroups can be distinguished with platinum-resistant (recurrence less than 6 months after last platinum-based chemotherapy) and platinum-sensitive disease (recurrence more than 6 months after last platinum-based chemotherapy). In cases of platinum-resistant recurrence the initial concept of cytoreductive surgery in combination with platinum-based combination chemotherapy apparently failed and many patients still have to recover from persisting side effects of the previous therapy. Therefore, mono-chemotherapy was up till now the therapy of choice for this patient cohort. In contrast, patients with platinum-sensitive recurrence usually receive another platinum-based chemotherapy. According to recently published data some patients with recurrent disease might additionally benefit from antiangiogenic therapy by the addition of bevacizumab. In selected cases of platinum-sensitive recurrence secondary cytoreductive surgery appears to be an option although a prognostic impact of this procedure has not yet been proven through prospective randomized studies. In this review recent developments in the oncologic management of recurrent ovarian cancer are discussed and current evidence considering therapeutic approaches is highlighted to give a concise overview of clinically relevant therapeutic aspects.     

Endokrine Therapie des Endometriumkarzinoms und seiner Präkanzerosen

Endometrial cancer is, apart from breast cancer, the most common gynecologic malignancy in western industrialized countries with a mortality rate of ca 20–25%. Estrogen-associated endometrial cancer (type 1) has a favourable prognosis, but the non-estrogen-related type 2 tends to have a poor outcome. Endometrial hyperplasias without atypia can be safely treated with endocrine interventions. Conservative treatment of atypical endometrial hyperplasias should be reserved for women who wish to preserve their fertility, provided a thorough histological follow-up is possible. The cornerstone of the treatment of invasive endometrial cancer is radical surgery including complete pelvic and para-aortic lymphonodectomy in tumors larger than stage 1a or with other risk factors. The routine use of adjuvant teletherapy is not indicated when correct surgical staging has been performed. There are no evidence based recommendations for adjuvant hormonal or chemotherapy. In patients with disseminated endometrial cancer, endocrine therapy is a reasonable initial approach. Palliative chemotherapy is indicated after the failure of an endocrine treatment, in patients with receptor-negative tumors, or when life-threatening tumor manifestations require a fast response.     

Epidemiologie des Endometriumkarzinoms

Cancer of the uterine corpus is the fourth most common cancer among women in Western Europe with approximately 11,400 newly diagnosed patients in Germany each year. In a comparatively high proportion diagnosis can be established at an early stage of the disease. Expected cure rates are therefore high and survival is mainly determined by comorbidity. Exposure to excessive endogenous or exogenous estrogens has been recognized as a major etiologic factor accounting for 65–80% of cases. The risk associated with estrogenic hormone replacement therapy can be reduced significantly by addition of progesterone. Besides hormone replacement therapy and tamoxifen use, various medical conditions including obesity, diabetes, and the PCO syndrome have been linked to the disease and are considered as targets for preventive intervention.     

Management des Endometriumkarzinoms

Cancer of the endometrium is the second most common gynecologic cancer among women in western countries. Primary surgery is the most important procedure in diagnosis (staging) and therapy (selection criteria for adjuvant treatment) in the management of endometrial cancer. Despite lacking data in the literature different aspects of surgical technique and adjuvant therapy are part of the clinical routine. For instance, although intracavitary and external-beam irradiation have been used to treat endometrial carcinomas for almost a century, the influence of adjuvant irradiation on the survival rate of patients with endometrial carcinomas has never been clearly determined. There is also not one prospective randomised trial which has demonstrated the benefit of a radical hysterectomy in stage II. This article dicusses the risk-based treatment recommendations and presents new trends in the therapy of endometrial cancer.     

Operative Therapie des Endometriumkarzinoms

The recommended therapy of endometrial cancer is surgery. It is important for diagnostic as well as for therapeutic reasons. The histological work-up gives information about the therapeutic options and the prognosis. The clinical staging that was performed until 1988 is not recommended anymore. In addition to abdominal hysterectomy with resection of the ovaries, systematic pelvic and paraaortic lymphadenectomy is necessary. For stage pT1a and pT1b G1-G2 lymphadenectomy is not mandatory. The oncological outcome shows poorer results for primary radiation compared with surgical therapy. It should be taken into consideration as a therapy option for patients with additional diseases making surgery impossible. The sentinel method as an effective and safe diagnostic tool must be proven by further studies.     

Endokrine Therapie des Endometriumkarzinoms

Endometrial cancer originates from the endometrium which is hormone dependent. In addition, many endometrial cancers express receptors for progestagens and/or estrogens, therefore, endocrine therapy for this malignancy has been studied for many decades. High dose progestagens are the backbone of fertility sparing conservative treatment of atypical endometrial hyperplasia and of very early stages of well differentiated endometrial cancers in women wishing to preserve child bearing capability. In many studies it has been shown that adjuvant therapy with high dose progestagens after primary surgical treatment is of no benefit. In the palliative situation, when recurrent tumor and/or metastases are no longer amenable to surgery and/or radiotherapy, patients with grade 1 or 2 tumors or with expression of progesterone and/or estrogen receptors should be treated with high dose progestagens if tumor manifestations are not life-threatening. If tumors first respond to this endocrine therapy and then become resistant, a second endocrine therapy using either tamoxifen or fulvestrant (off-label use!) can be considered.     

Adjuvante Therapie des Endometriumkarzinoms

FIGO I/II endometrial carcinoma has a good prognosis after hysterectomy with bilateral extirpation of the appendages and lymphadenectomy, which is particularly important in cases with unfavourable prognostic factors. Adjuvant chemotherapy with eight cycles of doxorubicin and cisplatin leads to better survival in stage III and IV compared to adjuvant, percutaneous radiotherapy. Small retrospective studies suggest an advantage for adjuvant chemotherapy in stage I/II with unfavourable prognostic factors, however, randomized studies are still required. Serous and clear cell carcinoma require a thorough, systematic surgical therapy. Retrospective work also indicates the value of adjuvant chemotherapy for this particular histological form, although this is not sufficient to provide a valid statement on a regime for adjuvant therapy.     

Operative Therapie des Endometriumkarzinoms

In April 2018, a new German S3 guideline supported by the Leitlinienprogramm Onkologie (Guideline Program—Oncology) on diagnosis, treatment, and aftercare of endometrial cancer was published. Based on current systematic literature reviews, consensus recommendations were established by an interdisciplinary multiprofessional group. Compared to prior versions of this guideline, adaptions have been made regarding routine radical hysterectomy for stage 2 cancer, the differential indications for systematic pelvic and periaortic lymph node dissection as well as mode of peritoneal access. Further aspects are the use of sentinel lymph node dissection and the surgical approach for advanced stages and carcinosarcomas.     

Adjuvante Therapie des Endometriumkarzinoms

In April 2018, the first German interdisciplinary S3 guideline for diagnosis, treatment, and follow-up of patients with endometrial cancer was published. The current article is a summary of chapters 7, “Radiotherapy of endometrial cancer” and 8, “Adjuvant medical treatment of endometrial cancer”, providing readers with a clinically orientated short version. The recommendations for postoperative brachytherapy and external beam radiotherapy as well as for adjuvant progestagen and chemotherapy for type I and II endometrial cancers, including carcinosarcomas, are given.     

Vaginosonographische Darstellung des Endometriumkarzinoms

Ohne Zusammenfassung     

Palliativmedizin und Hospiz

Ohne Zusammenfassung     

Strahlentherapie des Endometriumkarzinoms: S3-Leitlinie 2018 und neue Studiendaten

Die Gynäkologie - Die vaginale Brachytherapie und die perkutane Strahlentherapie sind wichtige Elemente multimodaler Behandlungskonzepte des Endometriumkarzinoms. Aktuelle Empfehlungen der...     

Prävention des Endometriumkarzinoms

To prevent malignant diseases, various strategies are reasonable: screening, avoidance of risk factors, detection and knowledge of preinvasive lesions, screening of special populations with risk factors, and application of protective factors. Screening asymptomatic women for endometrial cancer is generally not warranted. Oral combined contraceptives show significant protective effects; however, their use for preventive measures is limited. For these reasons, understanding of risk factors (hyperestrogenism, polycystic ovary syndrome, chronic anovulation, tamoxifen, obesity, hereditary nonpolyposis colorectal cancer) is important. Awareness of early symptoms (bleeding disturbances, postmenopausal bleeding), diagnosis, and treatment of endometrial hyperplasia is important for preventive reasons and is discussed in detail.