Treatment of Endometrial Cancer (uterine Cancer)

Endometrial cancer is a tumor of the uterine mucous membrane. In most cases, it is adenocarcinoma. They are classified according to the grade of malignancy, from the first to the third – the highest. Neoplasms of 1 and 2 grade of malignancy refer to endometrial cancer of the first type. It develops more often in elderly people, has a better prognosis, grows slowly, and rarely recurs after treatment. Grade 3 adenocarcinoma is considered type 2 endometrial cancer. It often develops at a younger age, proliferates, metastasizes early, and is not associated with the level of sex hormones. This type of cancer requires aggressive treatment. The latest methods of radiation therapy and drug therapy, as well as minimally invasive laparoscopic operations, are used abroad to combat this disease.

Content

1. Diagnostics
2. Surgery
3. Operations on the lymph nodes
4. Radiation therapy
5. Drug therapy
6. Why is it better to undergo treatment abroad
7. Treatment in Europe with Booking Health

Diagnostics

Diagnostics usually begin with an ultrasound examination. It is carried out transabdominally (through the abdomen) and transvaginally (through the vagina). The second type of the examination is more informative. The possible presence of a tumor is indicated by a thickening of the endometrium or the appearance of tumor nodes.

To confirm the diagnosis, an endometrial biopsy is performed. This is a non-traumatic outpatient procedure. The doctor receives samples for cytological examination.

A more accurate diagnostic method is dilatation and curettage. The doctor scrapes the uterine cavity to obtain more endometrial tissue for examination in the laboratory. In developed countries, the procedure is carried out under the guidance of a hysteroscopy. In this case, it becomes safer than the traditional "blind" examination.

Hysteroscopy is an endoscopic method for diagnosing a disease. The doctor can examine the uterine cavity from the inside. Both hysteroscopy and curettage of the uterus are performed under anesthesia.

To assess the extension of the tumor process, the following tests are used:

• Ultrasound examination and MRI of the pelvic and abdominal organs
• Computed tomography or chest X-ray
• Brain MRI
• Positron emission tomography (PET) for suspected distant metastasis
• Cystoscopy, Proctoscopy – examination of the bladder and rectum with an endoscopic instrument
• Blood test for CA-125 tumor marker – to assess the risk of distant metastasis

Surgery

A surgical intervention provides the best treatment results. Most women undergo surgical removal of the uterus with appendages, parauterine tissue and lymph nodes.

Hysterectomy is the most common operation for endometrial cancer. It assumes the removal of the uterus and appendages, including the fallopian tubes and ovaries. The procedure can be performed through vaginal, laparoscopic or laparoscopic access. Hysterectomy can be performed in different scopes, depending on the size and grade of the tumor. Along with the uterus, the surrounding tissue is often removed.

Vaginal access is rarely used for the removal of malignant uterine tumors. At the same time, this type of operation is the most sparing. Therefore, it is sometimes resorted to if other treatment methods are too risky for a woman because of her poor health.

Laparoscopic access has gradually become the mainstay in developed countries. The operation is performed through a short abdominal incision. It is less traumatic when compared to open surgeries, provides a quick recovery, minimal risk of complications, and a short hospital stay. The aesthetic result is improved, as smaller scars remain on the abdomen.

Robot-assisted surgeries are even safer for health but are carried out only in specialized centers. The doctor controls the robot-assisted surgical system remotely, using a console. The advantages of this approach: more degrees of freedom, minimal risk of complications due to the human factor and less blood loss. The doctor can get to the furthest corners of the pelvis, remove more lymph nodes, and get better oncological results.

Laparotomy is considered a classic treatment method for endometrial cancer. These are traditional interventions through a large incision in the abdomen. It is the gold standard in countries with poor medical care and is also used in developed countries in the advanced stages of cancer.

Peritoneal lavage is performed intraoperatively to clarify the stage of cancer. Doctors check to see if the tumor has extended to the peritoneum. They take swabs from the peritoneum and then examine them for cancer cells. The extension of cancer in the peritoneum affects the choice of treatment options after surgery to remove the tumor.

Cytoreductive surgeries are performed for advanced stages of endometrial cancer if tumor foci have appeared in the abdominal cavity. This operation is performed through large abdominal incisions. The surgeon removes all tumors that he can find. As a result, the survival rate of patients increases and conditions are created for the follow-up control of cancer with the help of drugs and radiation therapy.

Operations on the lymph nodes

Dissection of the pelvic and para-aortic lymph nodes is a phase in treating endometrial cancer. This is not a separate operation, and the lymph nodes are removed simultaneously with the uterus. The exception is when the uterus is removed through the vagina. Then additional incisions are required in the abdomen to remove the lymph nodes. This stage of the operation can be performed laparoscopically.

Sentinel node mapping is an intraoperative diagnostic procedure that is performed in countries with a high level of medicine. It is used in the advanced stages of endometrial cancer. For many patients, sentinel lymph node mapping reduces the health consequences of cancer treatment. Lymph node dissection often causes complications, and mapping allows the doctors to avoid this stage of the operation in many cases.

In the initial stage, they are still removed even if there are no signs of metastases in the lymph nodes. This is necessary to detect possible metastases. Histological examination can detect them, while CT, MRI and other imaging methods "see" only enlarged nodes. However, metastases can be of minimal size and can be located even in non-enlarged lymph nodes.

The sentinel lymph nodes are the first to receive lymph from the tumor. If metastases appear somewhere, then first of all here. If there are no metastatic foci in the sentinel lymph nodes, then they are absent in other nodes. Therefore, there is no need to remove them.

To find out which lymph nodes are sentinel, doctors inject blue or green contrast agents into the area of ​​the tumor. They check which nodes are accumulating the dye. They are removed and examined. If there are no metastases, lymph node dissection is not performed, which allows the woman to avoid complications associated with it. If metastases are detected, lymph node dissection is performed in a standard scope.

Radiation therapy

Radiation therapy for the treatment of women with endometrial cancer involves the use of one of two radiation options:

• Brachytherapy
• External beam radiation therapy

A combination of these methods is possible.

External beam radiation therapy is most often used after surgery to reduce the risk of recurrence. The radiation helps the doctors to destroy the remaining cancer cells. Radiation therapy is started 4-6 weeks after surgery.

External beam radiation therapy is less commonly performed before surgery. Such an approach is sometimes used for advanced tumors. It is reduced in size, which makes total removal possible.

Brachytherapy involves contact irradiation of the tumor. It can be vaginal and interstitial. According to the intensity of radiation, brachytherapy is divided into low-energy and high-energy.

Advantages over remote irradiation:

• Better radiation dose distribution
• Lower risk of recurrence
• Less risk of side effects from the bladder and rectum since the beams do not pass through these tissues on their way to the target.

Disadvantages:

• Lymph nodes cannot be irradiated (a combination with external beam radiation therapy is required, if necessary)
• Higher risk of vaginal stenosis (narrowing due to scarring)

The most common indication for brachytherapy is adjuvant treatment to reduce the risk of cancer recurrence. Without radiation after surgery, the tumor will recur with a probability of 15%. Brachytherapy reduces this risk to 1%.

Vaginal brachytherapy is an outpatient procedure that does not require invasive intervention. Doctors insert a cylinder into the vagina, inside which radioactive material is placed for a short time. This is how high-energy brachytherapy works. Low-energy radiation is less commonly used and lasts for several days. The woman spends this time in the hospital.

Other indications for brachytherapy:

• Tumor recurrence from the vaginal stump
• Preoperative treatment to reduce the tumor size
• Control of inoperable tumor
• Palliative treatment option for advanced cancer

Drug therapy

The following methods of drug therapy are used in uterine cancer:

• Chemotherapy
• Hormone therapy
• Targeted therapy
• Immunotherapy

Chemotherapy is used in the following cases:

• Recurrence after primary treatment
• Type 2 endometrial cancer (high grade)
• 3-4 stage of the disease

As a rule, chemotherapy is carried out with two or more drugs if the woman's state of health allows the doctors to carry out such treatment. The regimen includes platinum-based drugs.

Chemotherapy can be used as part of "sandwich therapy". It involves several cycles of drug therapy, then radiation therapy and chemotherapy again. In this combination, cancer treatment works better, but the therapy has a greater effect on health and is less well tolerated by patients.

Hormone therapy is used for hormone-positive stage 3-4 cancer. It may include progestins, antiestrogen, luteinizing hormone-releasing hormone agonists, and aromatase inhibitors. The effectiveness of the various options is comparable.

Targeted therapy is carried out in the following cases:

• Uterine cancer recurrence
• A high degree of malignancy
• 4-rd stage of the disease

The drugs of the following pharmacological groups are used.

Kinase inhibitors are often combined with immunotherapy and are used as second-line therapy for uterine cancer. The drug is taken once a day in capsules. Possible side effects include diarrhea, fatigue, muscle pain, and high blood pressure.

Angiogenesis inhibitors are monoclonal antibodies against the VEGF protein. It provides the growth of blood vessels necessary for the tumor supply. Since the cancer cells do not receive enough blood supply after using this drug, they divide more slowly and the progression of the cancer slows down. Angiogenesis inhibitors are combined with chemotherapy as part of the first-line therapy or used alone when standard cytostatic therapy is ineffective.

mTOR inhibitors block a protein that stimulates the division of cancer cells. The drugs of this group are used in the advanced stages and in recurrent tumors. They are successfully combined with chemotherapy and hormone therapy.

Immunotherapy is carried out with PD-1 inhibitors. They are classified as immune checkpoint inhibitors. These drugs do not directly damage cancer cells but stimulate an antitumor immune response. PD-1 inhibitors are used for high levels of microsatellite instability (MSI-H), defects in the mismatch repair gene (dMMR), and high tumor mutation burden (TMB-H). Immunotherapy is often combined with kinase inhibitors. It is usually a second-line cancer therapy.

Why is it better to undergo treatment abroad

The highest level of medical care awaits you abroad. The advantages of treatment in developed countries are:

• Minimally invasive laparoscopic surgery removes the uterus instead of traumatic operations through a large abdominal incision.
• Some centers carry out safe and high-tech robot-assisted operations.
• Doctors perform sentinel lymph node mapping during surgery for early-stage endometrial cancer, which allows many women to avoid lymph dissection and concomitant complications.
• If possible, doctors save the ovaries (in women under 45, in the initial stages, if there is no damage to the oncological outcome of treatment).
• Successful operations are carried out even in the initial stages of endometrial cancer, which has extended through the peritoneum.
• High-precision options for external beam radiation therapy are used as they are less damaging to the surrounding tissues of the tumor.
• Brachytherapy is used to prevent recurrence after surgery or to destroy a recurrent tumor.
• In the advanced stages of cancer, modern methods of drug therapy are used: these are not only chemotherapy and hormonal therapy but also targeted therapy and immunotherapy.

Treatment in Europe with Booking Health

To undergo endometrial cancer treatment in one of the European hospitals, you are welcome to use the Booking Health services. On our website, you can find the cost of treatment and compare prices in different clinics in order to book a medical care program at a favorable price. Treatment in Europe will be easier and faster for you, and the cost of treatment will be reduced.

Please leave a request on the Booking Health website. Our specialist will contact you and consult about treatment in Europe. Booking Health will fully arrange your trip to another country. We will provide you with the following benefits:

• We will select the best European hospital whose doctors specialize in the treatment of endometrial cancer.
• We will help you overcome the language barrier and establish contact with the doctor in the European hospital.
• We will reduce the waiting period for the medical care program. You will receive treatment on the most suitable dates.
• We will reduce the prices. The cost of treatment in Europe will be reduced due to the lack of overpricing and additional coefficients for foreign patients.
• We will solve any organizational issues: we will prepare the documents, meet you abroad and take you to the hospital, book a hotel, and provide an interpreter.
• We will elaborate on the medical care program and translate medical documents. You will not have to undergo previously performed diagnostic procedures.
• We will help you to keep in touch with doctors after treatment in Europe.
• We organize additional examinations and treatment in a European hospital.
• We will buy medicines in another country and forward them to your native country.
• The world's leading doctors will take care of your health. The Booking Health specialists will help you reduce the cost of treatment, organize your trip to a European hospital, and you can fully focus on restoring your health.

The world's leading doctors will take care of your health. The Booking Health specialists will help you reduce the cost of treatment, organize your trip to a European hospital, and you can fully focus on restoring your health.

Authors:

The article was edited by medical experts, board certified doctors Dr. Vadim Zhiliuk and Dr. Sergey Pashchenko. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

Our editorial policy, which details our commitment to accuracy and transparency, is available here. Click this link to review our policies.

Sources:

National Cancer Institute

Cancer Support Community

Cancer. Net