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International Journal of Gynecology & Clinical Practices Volume 2 (2015), Article ID 1:IJGCP-106, 3 pages
http://dx.doi.org/10.15344/2394-4986/2015/106
Commentary
Synchronous Primary Endometrial and Ovarian Cancers: A Critical Update

Georgios Androutsopoulos* and Georgios Decavalas

Department of Obstetrics and Gynecology, University of Patras, Medical School, Rion, Greece
Dr. Georgios Androutsopoulos, Department of Obstetrics and Gynecology, University of Patras, Medical School, Rion 26504, Greece, Tel: +306974088092; E-mail: androutsopoulos@upatras.gr
27 November 2014; 27 January 2015; 29 January 2015
Androutsopoulos G, Decavalas G (2015) Synchronous Primary Endometrial and Ovarian Cancers: A Critical Update. Int J Gynecol Clin Pract 2: 106. doi: http://dx.doi.org/10.15344/2394-4986/2015/106

Synchronous primary cancers are relatively uncommon in general population [1,2]. Only 0.5-1.7% of women with gynecological malignancies, have synchronous primary cancers of the female genital tract [3-8]. In those patients, the most common combination is synchronous primary endometrial and ovarian cancers [3,4,6].

Patients with synchronous primary endometrial and ovarian cancers have distinct clinical characteristics including: young age, obesity, premenopausal status and nulliparity [9]. Usually, they are 10 - 20 years younger than patients with single endometrial or ovarian cancer [4,10-13]. The median age at diagnosis is 50 years [3,8,9,11-15].

The pathogenesis of synchronous primary endometrial and ovarian cancers, remains unclear [2,6,16]. The theory of the secondary Müllerian system has been proposed to explain the development of synchronous primary cancers in the female genital tract [5,6,16-18] According to this theory, the epithelia of the upper female genital tract have common embryologic origin and respond as a morphologic unit to a carcinogenic stimulus (hormone, radiation, other) [2,5,16, 17]. Perhaps shared hormone receptors (estrogen receptors) are responsible for the development of synchronous primary cancers in the female genital tract [5,6,18].

Moreover it is possible that those patients have a more fragile genome and prior genetic damage may predispose them to the development of synchronous primary cancers [16,19-23] Especially in patients with Lynch syndrome, there is a predisposition to multiple synchronous primary cancers (colon, endometrium, ovary, stomach, small bowel, ureter and renal pelvis) [24].

Thus embryologic, hormonal, genetic or other phenomena may be associated with the development of synchronous primary cancers of the female genital tract [5,6,16-19,21-24].

The most common presenting symptoms and signs in patients with synchronous primary endometrial and ovarian cancers, are: abnormal uterine bleeding (46%), abdominal/pelvic pain (17%) and abdominal/ pelvic mass (13%) [1,2,9,11,13,15,16,25].

Synchronous primary endometrial and ovarian cancers may have similar or different histologic appearance [6,10,14]. The distinction between metastatic and synchronous primary cancers is relatively easy, when they have different histologic types [26,27] However the distinction is relatively difficult, when they have the same histologic type [26,27]. For those patients in clinical practise we use well described empirical criteria [26,27].

The treatment of choice for most patients with synchronous primary endometrial and ovarian cancers, is systematic surgical staging [1-4 ,6,11,12,14,15, 28-30]. More specifically in those patients, systematic surgical staging includes: total abdominal hysterectomy with bilateral salpingo-oophorectomy, total omentectomy, appendectomy, pelvic and para-aortic lymphadenectomy, complete resection of all disease, biopsy of any suspected lesion and pelvic washings [1,4,6,11, 12,14,28-32].

That therapeutic approach allows a more clear decision for stage related postoperative adjuvant treatment [1,2,29,30]. Moreover, appropriate surgical staging facilitates targeted therapy that maximize survival and minimize the morbidity of overtreatment (radiation injury, chemotherapy toxicity) and the effects of undertreatment (recurrent disease, increased mortality) [1,2,33].

Pelvic and para-aortic lymphadenectomy is essential for surgical staging in patients with synchronous primary endometrial and ovarian cancers [1,2,31,32]. It has diagnostic, therapeutic and prognostic value. It defines accurately the extent of disease and determines the prognosis of patients [1,2]. Undoubtedly, pelvic and para-aortic lymphadenectomy is the only way to identify patients with stage III disease [1,2,31,32]. However, the extension of pelvic and para-aortic lymph node dissection (more than 14 lymph nodes) is an independent risk factor for postoperative complications [1,2,29,30,34-36] Moreover in elderly patients and in patients with relevant comorbidities (obesity, diabetes, coronary artery disease), morbidity must be carefully weighed against any survival advantage [1,2,33,37,38].

The significance of postoperative adjuvant treatment in patients with synchronous primary endometrial and ovarian cancers, remains controversial [14,15,39]. However in most cases, postoperative adjuvant treatment should be individualized according to the risk of relapse of each primary cancer [2,39,40] Moreover, the treatment of one primary cancer does not compromise the treatment of the other primary cancer [2,41].

Especially in patients with advanced stage disease, unfavorable histologic types and high grade disease, required postoperative adjuvant treatment tailored to both tumors [1-3,6,10-12,15,25,28-30,39,41-43]. More specifically, postoperative adjuvant treatment in those patients includes: radiotherapy and/or chemotherapy [1,2,10,11,39].

Postoperative adjuvant radiotherapy includes: external pelvic radiotherapy and/or brachytherapy. It is the appropriate treatment for high risk primary endometrial cancer [1,2,29,30].

Postoperative adjuvant chemotherapy is the appropriate treatment for advanced stage primary endometrial and ovarian cancers [1,2,40]. The most active chemotherapeutic agents for those patients, are: taxanes, anthracyclines and platinum compounds [11,15].

Prognostic factors for synchronous primary endometrial and ovarian cancers are: age, stage of ovarian cancer, grade of endometrial cancer and adjuvant treatment [43-45]. Patients with synchronous primary endometrial and ovarian cancers have 5-year overall survival 85.9% and 10 year overall survival 80.3%.14 Patients with synchronous primary endometrial and ovarian cancers have better overall survival than patients with single primary ovarian or endometrial cancer [1,2,9,39,41,43,46]. Moreover, patients with synchronous primary endometrial and ovarian cancers endometrioid type have better overall survival than patients with non-endometrioid or mixed histologic types [1,2,9,39,43].

The reason for the better overall survival of those patients, is not intuitively obvious [1,2,14]. Perhaps favorable prognosis related with the detection of patients at early stage and low grade disease [1-3,6,20-22,25,28,46,47]. Moreover, the influence of the postoperative adjuvant treatment needs to be further investigated [39].

Competing Interests

The authors declare that they have no competing interests.


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