Carcinoma endometrial: estadiamento e tratamento cirúrgico

Abstract

Introduction: Uterine cancer is the most common gynecological malignancy in high-income countries and the second most common in low- and middle-income countries (after cervical cancer). Endometrial adenocarcinoma is the most prevalent histopathological subtype. Its cardinal symptom is abnormal uterine bleeding, and there may be patients with normal findings on cervical cytology. Most are diagnosed when the disease is confined to the uterus, with a 90% 5-year survival rate. The main risk factor is excess endogenous or exogenous estrogen, unopposed by progestin. Lynch syndrome (hereditary non-polyposis colon cancer) is a genetic risk factor; The pathogenesis in these cases is germline mutation in DNA mismatch repair genes. Objectives: to discuss the staging of endometrial cancer, its surgical treatment and its prognostic factors. Methodology: Literature review based on articles from the Scielo, PubMed and VHL databases, from January to March 2024, with the descriptors in English “endometrial carcinoma”, “surgical treatment”, “diagnosis” and “staging”. Complete articles from the last five years (2019-2024) were included, with a total of 30 studies. After reading, studies with other criteria were excluded, choosing 05 full articles. Results and discussion: Before treatment, patients with endometrial carcinoma (EC) should have a complete evaluation, including history (including screening for hereditary susceptibility to cancers, physical examination, and endometrial sampling, to establish the diagnosis of EC. thorax imaging should be performed as part of the initial evaluation to exclude pulmonary metastases. Abdominal and pelvic imaging is rarely performed in patients with nonaggressive SCCs, but is often used to exclude metastases from aggressive SCCs. Bilateral oophorectomy (BSO) and lymphadenectomy. For staging EC in patients with disease apparently confined to the uterus (based on physical examination, with or without pelvic imaging) who are candidates for surgery and in whom it is expected that the procedure can be completed without conversion to laparotomy, we recommend minimally invasive surgery (MIS; laparoscopy or robotic surgery) instead of laparotomy. Conventional total laparoscopic hysterectomy with BSO is the preferred option for most patients, with the use of robotic surgery if this makes MIS possible in patients who have a high risk of conversion to laparotomy (e.g., patients with obesity). For patients with clinically apparent extension of EC to the cervix, management may include (1) radical hysterectomy with postoperative radiotherapy based on pathologic factors, (2) extrafascial hysterectomy with postoperative radiation, or (3) primary radiotherapy followed by of extrafascial hysterectomy. In patients who have clinical or radiographic evidence of metastatic disease, surgery is typically performed to establish a definitive diagnosis, to palliate symptoms and signs of disease, and/or to improve oncologic outcomes. In general, these procedures are performed via laparotomy through a midline incision. Cytoreduction is performed in some patients. The approach to lymph node assessment in patients with EC is a subject of debate and no option has emerged as superior based on available data. Options for lymph node management retroperitenal (in the absence of grossly metastatic disease) include no lymph node dissection (LND), systematic LND only if the risk of lymph node metastasis exceeds a certain threshold, routine sentinel lymph node dissection (SLND) after lymphatic mapping, or systematic LND in all patients. Patients should be counseled about options and engaged with the surgeon in shared decision-making about the approach to lymphadenectomy. Conclusion: Medical stay may be an appropriate option for patients who cannot tolerate surgery or who desire fertility preservation. Assessment in these patients includes medical history, physical examination for uterine size and mobility and evidence of metastatic disease, endometrial sampling, and pelvic and abdominal imaging.