Japan Society of Gynecologic Oncology 2018 guidelines for treatment of uterine body neoplasms

Abstract

The Fourth Edition of the Guidelines for Treatment of Uterine Body Neoplasm was published in 2018. These guidelines include 9 chapters: 1. Overview of the guidelines, 2. Initial treatment for endometrial cancer, 3. Postoperative adjuvant therapy for endometrial cancer, 4. Post-treatment surveillance for endometrial cancer, 5. Treatment for advanced or recurrent endometrial cancer, 6. Fertility-sparing therapy, 7. Treatment of uterine carcinosarcoma and uterine sarcoma, 8. Treatment of trophoblastic disease, 9. Document collection; and nine algorithms: 1-3. Initial treatment of endometrial cancer, 4. Postoperative adjuvant treatment for endometrial cancer, 5. Treatment of recurrent endometrial cancer, 6. Fertility-sparing therapy, 7. Treatment for uterine carcinosarcoma, 8. Treatment for uterine sarcoma, 9. Treatment for choriocarcinoma. Each chapter includes overviews and clinical questions, and recommendations, objectives, explanation, and references are provided for each clinical question. This revision has no major changes compared to the 3rd edition, but does have some differences: 1) an explanation of the recommendation decision process and conflict of interest considerations have been added in the overview, 2) nurses, pharmacists and patients participated in creation of the guidelines, in addition to physicians, 3) the approach to evidence collection is listed at the end of the guidelines, and 4) for clinical questions that lack evidence or clinical validation, the opinion of the Guidelines Committee is given as a "Recommendations for tomorrow".

Keywords: Clinical Practice Guideline; Endometrial Cancer; Gestational Trophoblastic Disease; Treatment; Uterine Sarcoma.

Fig. 1. Initial treatment for patients with endometrial cancer considered to be stage I or II preoperatively. Surgical staging is estimated before surgery by pathological diagnosis and diagnostic imaging (CQ08). Pelvic and para-aortic lymphadenectomy/lymph node biopsy and omentectomy are considered, in addition to total hysterectomy with bilateral salpingo-oophorectomy, for serous carcinoma or clear cell carcinoma (CQ07). Radiation therapy (CQ15) is considered when surgery cannot be performed.

Fig. 2. Initial treatment for (A) patients who are confirmed to be endometrial cancer after hysterectomy, and (B) patients diagnosed with an intermediate to high risk of recurrence after surgery performed with a presumed low risk of recurrence.

^*In the 2017 NCCN guidelines, observation is possible for patients with a tumor of <2 cm, LVSI negative, and a presumed low recurrence risk.

Fig. 3. Initial treatment for patients with endometrial cancer considered to be stage III or IV preoperatively.

^*If the general condition is not worse, this refers to all patients in stage III and patients who can undergo hysterectomy and cytoreductive surgery in stage IV (CQ24). BSC, best supportive care.

Fig. 4. Postoperative adjuvant treatment for endometrial cancer.

Fig. 5. Treatment of recurrent endometrial cancer.

BSC, best supportive care. ^*Resection should also be considered for cases with a few small lung metastases (CQ27).

Fig. 6. Strategies for fertility-sparing therapy for atypical endometrial hyperplasia and endometrioid adenocarcinoma (corresponding to G1).

CT, computed tomography; MRI, magnetic resonance imaging.

Fig. 7. Treatment for uterine carcinosarcoma.

BSC, best supportive care.

Fig. 8. Treatment for uterine sarcoma.

LGESS, low grade endometrial stromal sarcoma HGESS, high grade endometrial stromal sarcoma; UUS, undifferentiated uterine sarcoma; LMS, leiomyosarcoma; BSC, best supportive care.

Fig. 9. Treatment for choriocarcinoma.

FIGO, International Federation of Gynecology and Obstetrics.

Fig. 10. Classification of postoperative risk of recurrence of endometrial cancer.

LVSI, lymphovascular space invasion. ^*Adnexa, uterine serosa, vagina, cardinal ligament, lymph node, bladder, rectum, intraperitoneal and distant metastasis.