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Endometrial cancer

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of endometrial cancer are prepared by our editorial team based on guidelines from the American Society for Radiation Oncology (ASTRO 2022), the European Society of Medical Oncology (ESMO 2022), the European Society for Radiotherapy and Oncology (ESTRO/ESP/ESGO 2021), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2018), the U.S. Preventive ...
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Screening and diagnosis

Indications for screening: as per USPSTF 2017 guidelines, insufficient evidence to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult females.
I
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  • Indications for testing

Classification and risk stratification

Surgical staging: as per ACOG/SGO 2015 guidelines, perform comprehensive surgical staging with total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and the collection of peritoneal cytology in patients with endometrial cancer. Make exceptions to this approach only after consultation with a practitioner specializing in the treatment of endometrial cancer, such as a gynecologic oncologist.
A
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Diagnostic investigations

Initial evaluation: as per SOGC 2018 guidelines, elicit a complete focused history and perform a physical examination in patients with suspected endometrial cancer. Pay attention to predisposing factors for excess estrogen stimulation of the endometrium, such as a long history of anovulation, obesity, menstrual irregularity, or long-term use of unopposed estrogen or tamoxifen.
B
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Diagnostic procedures

Hysteroscopy: as per SOGC 2018 guidelines, consider performing a hysteroscopic examination in patients with persistent uterine bleeding with benign endometrial sampling or insufficient endometrial sampling after ultrasound.
C

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  • Biopsy and histopathology

  • Molecular testing

Medical management

Setting of care
As per ESGO/ESP/ESTRO 2021 guidelines:
Plan staging and treatment on a multidisciplinary basis (generally at a tumor board meeting, composed according to local guidelines) and based on the comprehensive and precise knowledge of prognostic and predictive factors for outcomes, morbidity, and QoL.
B
Treat patients in a specialized center by a dedicated team of specialists in the diagnosis and management of gynecological cancers, especially in high-risk and/or advanced-stage diseases.
B

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  • Management of local/locoregional disease (total hysterectomy)

  • Management of local/locoregional disease (lymph node excision and surgical restaging)

  • Management of local/locoregional disease (ovarian preservation)

  • Management of local/locoregional disease (adjuvant therapy)

  • Management of local/locoregional disease (systemic therapy)

  • Management of local/locoregional disease (medically unfit patients)

  • Management of local/locoregional disease (fertility preservation)

  • Management of local/locoregional disease (estrogen therapy)

  • Management of advanced/metastatic disease

Therapeutic procedures

Technical considerations for radiotherapy: as per ASTRO 2022 guidelines, deliver intensity-modulated radiotherapy to reduce acute and late toxicity in patients with endometrial carcinoma undergoing adjuvant EBRT.
B
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Perioperative care

Preoperative staging
As per ESMO 2022 guidelines:
Include the following in the preoperative work-up:
clinical and gynecological examination
transvaginal ultrasound, pelvic MRI
CBC, liver and renal function profiles
B
Consider obtaining additional imaging (such as thoracic and abdominal CT and/or FDG-PET-CT) in patients at high risk of extrapelvic disease.
C

Specific circumstances

Patients with Lynch syndrome: as per ESGO/ESP/ESTRO 2021 guidelines, obtain MMR immunohistochemistry (plus analysis of MLH1 promotor methylation status in case of immunohistochemical loss of MLH1/PMS2 expression) or MSI tests in all endometrial carcinomas, irrespective of histologic subtype of the tumor, to identify patients with Lynch syndrome and triage for germline mutational analysis.
B
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Patient education

General counseling: as per ESGO/ESP/ESTRO 2021 guidelines, counsel patients about the suggested diagnostic and treatment plan and potential alternatives, including risks and benefits of all options.
B

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  • Genetic counseling

Follow-up and surveillance

Follow-up: as per ESMO 2022 guidelines, perform physical and gynecological examinations every 6 months for the first 2 years and then yearly until 5 years in patients with low-risk endometrial cancer
B
consider arranging phone follow-ups as an alternative to hospital-based follow-up consultations in low-risk patients.
B
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  • Management of recurrent disease