Submit manuscript...
eISSN: 2377-4304

Obstetrics & Gynecology International Journal

Correspondence:

Received: January 01, 1970 | Published: ,

Citation: DOI:

Download PDF

Editorial

Nowadays, synchronous primary cancers represent a very rare clinical entity.1‒9 Especially in patients with malignancies of the female genital tract, only 0.5‒1.7% of them harbour synchronous primary cancers.10‒15 Among them, synchronous primary endometrial and ovarian cancers (SPEOC) is the most common combination of cancers of the female genital tract.1,6,10,11,13 They usually develop in young, obese, premenopausal and nulliparous women and the average age at diagnosis is approximately 50 years.10,15‒21 Those patients are commonly 10 ‒ 20 years younger than patients with single primary endometrial or ovarian cancer.11,18,19,21,22

To begin with, most international scientific societies (ACOG, FIGO and ESMO) recommend the systematic surgical staging as the initial treatment approach in patients with malignancies of the female genital tract.3,4,7,8,10,11,13,17‒20,23‒30 In particular, the systematic surgical staging in those patients with SPEOC includes: total abdominal hysterectomy with bilateral salpingo‒oophorectomy, total omentectomy, appendectomy, pelvic and para‒aortic lymphadenectomy, complete resection of all disease, biopsies of any suspicious lesions and pelvic washings.3‒8,11,13,17‒19,23,24,27,21

The systematic surgical staging in patients with SPEOC can be accomplished either with laparotomy or laparoscopy. Laparotomy is the preferable treatment approach for systematic surgical staging especially in patients with advanced stage disease. Minimally invasive techniques (laparoscopy and robotic‒assisted surgery) offer essential advantages mainly in overweight and elderly patients (smaller incisions, better visualization, shorter hospital stay, less postoperative pain, quick recovery and low risk for postoperative complications). However, they are significantly more difficult and time consuming and require advanced surgical skills. This is the reason why, minimally invasive techniques are less popular and are mainly implemented in patients with early stage disease.3‒8,11,13,17‒19,23,24,27,31  

It is interesting to note, that pelvic and para‒aortic lymphadenectomy plays a crucial role in the systematic surgical staging of patients with SPEOC. Moreover pelvic and para‒aortic lymphadenectomy represents the only way to diagnose patients with stage III disease.3‒8,27,31 The radical extent of pelvic and para‒aortic lymph node dissection (more than 14 lymph nodes) in patients with SPEOC, increases significantly the risk for postoperative complications.3‒8,23‒25,32,34 Consequently, in elderly patients and in patients with comorbidities (obesity, diabetes mellitus and coronary artery disease), the surgeon should carefully weigh the increased morbidity with any survival advantage.3‒8,26,35,36

On the other hand, according to the recommendations of the international scientific societies (ACOG, FIGO and ESMO), postoperative adjuvant treatment (radiotherapy and/or chemotherapy) plays an equally important role in patients with malignancies of the female genital tract and either increased risk for recurrence or at advanced disease stage.3,4,7,8,10,11,13,17‒20,23‒29 However, in patients with SPEOC, postoperative adjuvant treatment has a controversial role.17,20,37 In this light, postoperative adjuvant treatment should be individualized based on the risk of recurrence of each individual primary cancer.3‒8,37,38 Additionally, the postoperative adjuvant treatment of each primary cancer should not affect the postoperative adjuvant treatment of the other neoplasm.3‒8,10,13,18‒20,22‒24,37,39‒42

The postoperative adjuvant radiotherapy in patients with SPEOC includes vaginal brachytherapy and external radiotherapy.3‒8,23‒25 Vaginal brachytherapy is the adjuvant treatment of choice for intermediate risk endometrial cancer (EC) patients (stage IA grade 3 endometrioid type EC, stage IB grade 1‒2 endometrioid type EC).3‒8,28,43‒48 It is well tolerated and minimizes the risk of local recurrences but has no impact on overall survival.43,45,47,49 Moreover, it is associated with well‒tolerated side effects and improved quality of life.3‒8,43,45,47,49 Especially for intermediate risk EC patients, vaginal brachytherapy and external pelvic radiotherapy are equivalent in achieving local control of the disease.28,43‒46

Likewise, external pelvic radiotherapy represents the adjuvant treatment of choice in high risk EC patients (stage IB grade 3 endometrioid type EC, stage I non‒endometrioid type EC).3‒8,28,44,46,49 It is not well tolerated, being associated with significant morbidity and impairment in the quality of life.3‒8,43,50 Despite the fact that external pelvic radiotherapy reduces the risk for local recurrences, it has no impact on overall survival.3‒8,43,45,47,50,51

In contrast, postoperative adjuvant chemotherapy is the adjuvant treatment of choice in patients with SPEOC and advanced stage disease.3‒8,38 The most common used chemotherapeutic agents in patients with SPEOC, are taxanes, anthracyclines and platinum compounds. The administration of postoperative adjuvant chemotherapy achieves high response rates in patients with SPEOC.3‒8,18,20 Nowadays, the postoperative combination of adjuvant radiotherapy with adjuvant chemotherapy shows promising results, especially in high risk or at advanced stage SPEOC patients. The combined application of adjuvant radiotherapy and adjuvant chemotherapy reduces the risk of relapse or death and increases overall survival in SPEOC patients.3‒8,18,20,28,44,46,49

In conclusion, the systematic surgical staging plays a crucial role in the treatment of SPEOC and offers many diagnostic, prognostic and therapeutic advantages.3‒8,10,11,13,17‒20,23,24,26 Additionally, it allows more sound and objective decisions on the necessity of postoperative adjuvant treatment in patients with SPEOC, in order to maximize survival and minimize the morbidity of over‒treatment (radiation injury, regimen‒related toxicity) and the effects of under‒treatment (recurrent disease, increased mortality).3‒8,23‒26

Acknowledgments

None.

Conflicts of interest

None.

References

  1. Decavalas G, Adonakis G, Androutsopoulos G, et al. Synchronous primary endometrial and ovarian cancers: a case report. Eur J Gynaecol Oncol. 2006;27(4):434‒436.
  2. Terzakis E, Androutsopoulos G, Adonakis G, et al. Fallopian tube primary cancer: report of 5 cases and review of the literature. Eur J Gynaecol Oncol. 2011;32(1):95‒98.
  3. Androutsopoulos G, Decavalas G. Synchronous primary endometrial and ovarian cancers. J Community Med Health Educ. 2013;3(7):e120.
  4. Androutsopoulos G, Decavalas G. Synchronous primary endometrial and ovarian cancers: pathogenesis, treatment and prognosis. Int J Clin Ther Diagn. 2(601):2014.
  5. Androutsopoulos G, Decavalas G. Synchronous primary endometrial and ovarian cancers: a critical update. Int J Gynecol Clin Pract. 2015;2:106‒109.
  6. Androutsopoulos G, Adonakis G, Tsamantas A, et al. Synchronous primary cancers in a woman with scleroderma: a case report. Eur J Gynaecol Oncol. 2008;29(5):548‒550.
  7. Androutsopoulos G, Michail G, Adonakis G, et al. Current treatment approach of endometrial cancer. Int J Clin Ther Diagn. 2015;S1(3):8‒11.
  8. Androutsopoulos G, Adonakis G, Tsamandas A, et al. Systemic sclerosis and multiple cancers of the female genital tract: prolonged survival following current treatment strategies. Case Rep Rheumatol. 2011;392068.
  9. Grigoriadis C, Androutsopoulos G, Zygouris D, et al. Synchronous squamous cell carcinoma of the endometrium and endometrioid adenocarcinoma of the ovary. Eur J Gynaecol Oncol. 2012;33(6):666‒668.
  10. Ayhan A, Yalcin OT, Tuncer ZS, et al. Synchronous primary malignancies of the female genital tract. Eur J Obstet Gynecol Reprod Biol. 1992;45(1):63‒66.
  11. Tong SY, Lee YS, Park JS, et al. Clinical analysis of synchronous primary neoplasms of the female reproductive tract. Eur J Obstet Gynecol Reprod Biol. 2008;136(1):78‒82.
  12. Deligdisch L, Szulman A. Multiple and multifocal carcinomas in female genital organs and breast. Gynecol Oncol. 1975;3(3):181‒190.
  13. Eisner R, Nieberg R, Berek J. Synchronous primary neoplasms of the female reproductive tract. Gynecol Oncol. 1989;33(3):335‒339.
  14. Matlock D, Salem F, Charles E, et al. Synchronous multiple primary neoplasms of the upper female genital tract. Gynecol Oncol. 1982;13(2):271‒277.
  15. Eser S, Gulhan I, Ozdemir R, et al. Synchronous primary cancers of the female reproductive tract in Turkish women. Asian Pac J Cancer Prev. 2011;12(4):857‒859.
  16. Soliman PT, Slomovitz BM, Broaddus RR, et al. Synchronous primary cancers of the endometrium and ovary: a single institution review of 84 cases. Gynecol Oncol. 2004;94(2):456‒462.
  17. Zaino R, Whitney C, Brady MF, et al. Simultaneously detected endometrial and ovarian carcinomas‒‒a prospective clinicopathologic study of 74 cases a gynecologic oncology group study. Gynecol Oncol. 2001;83(2):355‒362.
  18. Liu Y, Li J, Jin H, et al. Clinicopathological characteristics of patients with synchronous primary endometrial and ovarian cancers. A review of 43 cases. Oncol Lett. 2013;5(1):267‒270.
  19. Signorelli M, Fruscio R, Lissoni A, et al. Synchronous early‒stage endometrial and ovarian cancer. Int J Gynaecol Obstet. 2008;102(1):34‒38.
  20. Chiang Y, Chen C, Huang C, et al. Synchronous primary cancers of the endometrium and ovary. Int J Gynecol Cancer. 2008;18(1):159‒164.
  21. Rodolakis A, Thomakos N, Akrivos N, et al. Clinicopathologic insight of simultaneously detected primary endometrial and ovarian carcinomas. Arch Gynecol Obstet. 2012;285(3):817‒821.
  22. Pearl ML, Johnston CM, Frank TS, Synchronous dual primary ovarian and endometrial carcinomas. Int J Gynaecol Obstet. 1993;43(3):305‒312.
  23. Androutsopoulos G, Decavalas G. Management of endometrial cancer. Int J Translation Community Dis. 2013;1(1):1‒3.
  24. Androutsopoulos G. Current treatment options in patients with endometrial cancer. J Community Med Health Educ. 2012;2(12):e113.
  25. Androutsopoulos G, Decavalas G. Endometrial cancer: current treatment strategies. World J Oncol Res. 2014;1(1):1‒4.
  26. ACOG. Management of endometrial cancer. ACOG practice bulletin #65. 2005;106(2):413‒425.
  27. Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet. 2009;105(2):103‒104.
  28. Colombo N, Preti E, Landoni F, et al. Endometrial cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow‒up. Ann Oncol. 2013;24Suppl6:vi 33‒vi38.
  29. Burke W, Orr J, Leitao M, et al. Endometrial cancer: a review and current management strategies: part I. Gynecolgy Oncol. 2014;134(2):385‒392.
  30. Androutsopoulos G, Adonakis G, Decavalas G. Present and future in endometrial cancer treatment. Obstet Gynecol Int J. 2015;2(2):00031.
  31.  Prat J. Staging classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet. 2014;124(1):1‒5.
  32. Benedetti Panici P, Basile S, Maneschi F, et al. Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early‒stage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst. 2008;100(23):1707‒1716.
  33. Franchi M, Ghezzi F, Riva C, et al. Postoperative complications after pelvic lymphadenectomy for the surgical staging of endometrial cancer. J Surgery Oncology. 2001;78(4):232‒237.
  34. May K, Bryant A, Dickinson H, et al. Lymphadenectomy for the management of endometrial cancer. Cochrane Database Syst Rev. 2010(1):CD007585.
  35. Lachance J, Darus C, Rice L. Surgical management and postoperative treatment of endometrial carcinoma. Rev Obstet Gynecolgy. 2008;1(3):97‒105.
  36. Lowery W, Gehrig P, Ko E, et al. Surgical staging for endometrial cancer in the elderly ‒ is there a role for lymphadenectomy? Gynecolgy Oncol. 2012;126(1):12‒15.
  37. Ma S, Zhang H, Sun Y, et al. Synchronous primary cancers of the endometrium and ovary: review of 43 cases. The Chinese‒German Journal of Clinical Oncology. 2009;8(2):95‒99.
  38. Heitz F, Amant F, Fotopoulou C, et al. Synchronous ovarian and endometrial cancer‒an international multicenter case‒‒control study. Int J Gynecolgy Cancer. 2014;24(1):54‒60.
  39. Castro I, Connell P, Waggoner S, et al. Synchronous ovarian and endometrial malignancies. Am J Clinical Oncol. 2000;23(5):521‒525.
  40. Eifel P, Hendrickson M, Ross J, et al. Simultaneous presentation of carcinoma involving the ovary and the uterine corpus. Cancer. 1982;50(1):163‒170.
  41. Sheu BC, Lin HH, Chen CK, et al. Synchronous primary carcinomas of the endometrium and ovary. Int J Gynaecol Obstet. 1995;51(2):141‒146.
  42. Lim Y, Padma R, Foo L, et al. Survival outcome of women with synchronous cancers of endometrium and ovary: a 10 year retrospective cohort study. J Gynecolgy Oncol. 2011;22(4):239‒243.
  43. Kong A, Johnson N, Kitchener H, et al. Adjuvant radiotherapy for stage I endometrial cancer Cochrane Database Syst Rev. 2011;(4):CD003916.
  44. Nout R, Smit V, Putter H Jurgenliemk‒Schulz I, et al. Vaginal broachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high‒intermediate risk (PORTEC‒2): an open‒label, non‒inferiority, randomised trial. Lancet. 2010;375(9717):816‒823.
  45. Burke W, Orr J, Leitao M, et al. Endometrial cancer: a review and current management strategies: part II. Gynecolgy Oncol. 2014;134(2):393‒402
  46. Chino J, Jones E, Berchuck A, et al. he influence of radiation modality and lymph node dissection on survival in early‒stage endometrial cancer. Int J Radiation Oncol Biolgy Phys. 2012;82(5):1872‒1879.
  47. Creutzberg C, Nout R. The role of radiotherapy in endometrial cancer: current evidence and trends. Curr Oncol Rep. 2011;13(6):472‒478.
  48. Sorbe B, Horvath G, Andersson H, et al. External pelvic and vaginal irradiation versus vaginal irradiation alone as postoperative therapy in medium‒risk endometrial carcinoma: a prospective, randomized study‒‒quality‒of‒life analysis. Int J Gynecolgy Cancer. 2012;22(7):1281‒1288.
  49. Creutzberg C. GOG‒99: ending the controversy regarding pelvic radiotherapy for endometrial carcinoma? Gynecolgy Oncol. 2004;92(3):740‒743.
  50. Creutzberg C, van Putten W, Koper P, et al. Surgery and postoperative radiotherapy versus surgery alone for patients with stage‒1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma. Lancet. 2000;355(9213):1404‒1411.
  51. Keys H, Roberts J, Brunetto V, et al. A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study. Gynecolgy Oncol. 2004;92(3):744‒751.
Creative Commons Attribution License

© . This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.