Surgical management of early stage endometrial cancer

Endometrial cancer (EC) is the sixth most commonly diagnosed cancer and the 14th leading cause of cancer death in women worldwide, with 320 000 estimated new cases and 76 000 deaths every year. It occurs in women predominantly after menopause. The estimated agestandardized incidence rates (ASRs) vary from one to 30 cases per 100 000 women across countries globally, with the highest rates found in countries with a very high Human Development Index, where almost two-thirds of all cases occur. Low rates are observed in several Sub- Saharan African, Middle-Eastern, and South-Central Asian countries. The diagnosis of EC requires histopathological confirmation and is made according to the World Health Organization (WHO) pathological classification. About 80% of ECs are of endometrioid type. EC is a surgically staged disease. Surgical intervention is the treatment of patients with EC. The type of surgery and postoperative therapy depends on the stage and other clinical-pathological risk factors. The abdominal laparotomy approach, vaginal, laparoscopic and robotic-assisted methods are option for the surgical treatment of EC. This chapter discusses these different treatment options. With a rising incidence of obesity, the number of patients with EC will also inevitably increase. However, surgical intervention in obese patients is more challenging. Laparotomy as a standard therapy in EC patients stage I and II should be reserved for selective cases. Laparoscopic assisted surgery for this disease is ontologically adequate and offers many benefits for the patients. Robotic assisted surgery has been proven to be cost effective with low morbidity in the treatment of EC. The current controversial issues of treatment are performing lymphadenectomy (LND) in different stages of this disease. Most recurrences of EC will occur within the first 3 years after treatment and 3- to 4-monthly evaluations are recommended. Follow-up intervals of 6 months are recommended during the fourth and fifth years, and annually thereafter. No impact on survival of a routine follow-up strategy has been demonstrated. Most cases of EC are diagnosed in postmenopausal women, approximately 20-25% of cases are premenopausal and a further 5% of patients are diagnosed at younger 40 years of age. The current standard for the management of early EC, includes total hysterectomy, however this option is not an acceptable for young women who wishes to preserve their fertility. Hence, fertility-sparing management of early well-differentiated endometrioid adenocarcinoma of the uterus is warranted.