SGOP 2019

CPG

MAIN TOPICS found to be safe and tests resulted in

1. CERVICAL CANCER lower prevalence of high grade cervical
cancer precursor lesions.
2. ENDOMETRIAL HYPERPLASIA 2. Do cervical cancer screening
3. ENDOMETRIAL CANCER recommendations differ among women at
different age groups?
Screening should not be done among women
I. CERVICAL CANCER less than 21 years old
-Cancer of the cervix is the third most common [Quality of Evidence: 1A / Strength: A]
cancer among women worldwide with an - There is adequate evidence that
estimated 569,847 new cases and 311,365 screening women before age 21 does
deaths. About 85% of new cases and 90% of not reduce cervical cancer incidence
deaths occur in low resource regions or and mortality. Approximately 90% of
socioeconomically weaker sections of the HPV infections spontaneously clear
society. within two years.
It ranks as the 2nd most frequent cancer in the Women aged 21-29 years old should have a
Philippines and the 2nd most frequent cancer Pap smear test every 3 years
among women between 15 and 44 years of age. [Quality of Evidence: 1A / Strength: A]
About 2/3 of cervical cancer are diagnosed in an - In the ATHENA study, approximately
advance stage, leading to high mortality rate. 30% of CIN3+ cases were found in
Cervical cancer is a rare long term outcome of women between aged 25-29 but more
persistent infection of the lower genital tract than half of these women were found
with one of about 15 high risk HPV types known to have normal cytology.
as “the necessary cause of cervical cancer.” Women aged 30-65 years old should undergo
co-testing with Pap test and HPV test every 5
Screening and Prevention years. Another option for screening this age
1. What are the recommended screening group is a pap test every 3 years.
methods to decrease the incidence of cervical [Quality of Evidence: 1A / Strength: A]
cancer? - A consistently lower 6-year cumulative
Women should be screened via regular incidence rate of CIN 3+ among women
gynecologic examination and cytologic tests negative or HPV suggests that cervical
(Pap smear) screening strategies in women are
Women should undergo treatment of screened for HPV every 6 years are safe
precancerous abnormalities to decrease the and effective.
incidence and mortality of cervical cancer.
Liquid based cytology may be offered as this
has the advantage of doing HPV testing on the
same preparation with a lower rate of
unsatisfactory results.
[Quality of Evidence: 2A / Strength: B]
- Newer techniques that employ liquid
based cytology have been developed to
improve the sensitivity of screening.
Evidence is also conflicting as to
whether liquid based techniques
improves rates of test adequacy.
HPV DNA testing should be used as a part of
co-testing for cervical cancer among women
aged 30 and above.
[Quality of Evidence: 2B / Strength: B]
- The addition of HPV testing to cytology
increases the detection of prevalent
CIN3 or more severe lesions. ASCUS is
seen in nearly half of the abnormal
results of primary screening rests.
In low resource settings, visual inspection with
acetic acid (VIA) may be done as an acceptable
alternative to Pap smear
[Quality of Evidence: 1A / Strength: A]
- Cervical cancer demonstrated a 35%
relative reduction in subjects who
undergone VIA compared to those who
did not. Bothe HPV DNA testing and
VIA screen-and-treat approaches were

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Cervical cancer screening should be For HIV – positive women 30 years old and
discontinued between 65 years and 70 years of above, co-testing with cervical cytology and
age in women who have three or more HPV test may be done every 3 years as long as
negative cytology test results in a row and no results are negative.
abnormal test results in the past 10 years Screening should continue throughout an HIV-
[Quality of Evidence: 2A / Strength: B] positive woman’s lifetime.
- In women who have never been [Quality of Evidence: 3A / Strength: C]
screened before age 65 years old, - Woman infected with HIV are more
screening every 2 to 5 years until age readily infected with high-risk HPV
70 years balances the benefits and types and are more likey to develop
harms of screening. precancerous lesions and develop them
3. Can vaccination with HPV vaccines prevent more rapidly than HIV negative women
cervical cancer? in the same category.
Vaccination should be advised against HPV
16/18 as this shown to be efficacious against
persistent HPV infection and CIN 2+ lesions
[Quality of Evidence: 1A / Strength: A]
- All women aged 9 and above should
have access to vaccination against
cervical cancer. The nonavalent vaccine
is indicated in females aged 9 and older
for the prevention of precancerous
lesions or cervical, vulvar, vaginal and
anal cancers caused by HPV 16, 18, 31,
33, 45, 52 and 58 and genital warts
caused by types 6 and 11.
Vaccination against HPV 16/18 should not be
given during pregnancy
[Quality of Evidence: 1A / Strength: B]
- Although HPV vaccination is not
recommended, neither is routine
pregnancy testing before vaccination. If
the HPV series was interrupted for
pregnancy, the series should be
resumed postpartum with the next
dose.
4. Should women who have completed HPV
vaccination discontinue cervical cancer
screening?
Women who have been immunized against
HPV should be screened by the same regimen
as non-imunized women. Vaccination does not
eliminate the necessity to undergo the
recommended cervical cancer screening.
[Quality of Evidence: 1A / Strength:B]
- If HPV immunization is widely
implemented, its impact in terms of
reduction in cervical cancer will not be
realized until after 15-20 years. In the
meantime, secondary prevention
through a screening regimen of cervical
cytology with or without concomitant
HPV DNA testing remains the best
approach to protect women from
cervical cancer. Among HIV-negative immunocompromised
5. Among women at high- risk for the women, screening should begin within 1 year
development of cervical cancer, how often of sexual debut and continued throughout the
should cervical cancer screening be done? lifetime.
Among HIV positive women, cytology should Among HIV-negative immunocompromised
be done at the time of diagnosis then every 8 women less than 30 years old, cytology should
months to one year thereafter. After 3 be done yearly. After 3 consecutive normal
consecutive normal cytology tests, follow-up cytology tests, followup cervical cytology
cervical cytology should be done every 3 years. should be done every 3 years.
For HIV0negative immunocompromised
women 30 years old and above, co-testing with

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cervical cytology and HPV test should be done
every 3 years as long as results are negative.
Cytology on a yearly basis until 3 consecutive
normal tests followed by testing every 3 years
may be done in place of co-testing.
[Quality of Evidence: 3A / Strength: C]
- Women who have undergone organ
transplantation and being treated with
immnosuppressive drugs have a
greater risk of cervical cancer than the
general population and should have
more intensive screening and
surveillance.
6. How should we manage women with
abnormal Pap smears?
Atypical squamous cells of undetermined
significance (ASC-US)
For women with ASC-US cytology, reflex HPV
testing should be done.
If HPV test cannot be done, repeat cytology at
1 year should be done.
Colposcopy may be offered as another option
For woman aged 21-24 years with ASC-US
cytology alone at 12 month intervals should be
done. Reflex HPV testing may also be advised.
Women 65 yars and older with ASC-US
cytology should have reflex HPV testing done.
Colposcopy should be done if HPV is positive. If
HPV test is negative, repeat co-testing or
cytology alone in 1 year should be done.
Pregnant women with ASC-US should be
managed as in the non-pregnant population
except the deferring colposcopy until 8 weeks
postpartum is acceptable.
Endocervical curettage should not be done for
pregnant women
- ASC-US is the most common cytologic
abnormality but it carries the lowest
risk of CIN3+ partly because 1/3 to 2/3
are not HPV associated.
Low-grade Squamous intraepithelial lesions
(LSIL)
Colposcopy should be done for women with
LSIL cytology and with either positive HPV test
or HPV not done. If the HPV test is negative,
repeat co-testing at 1 year is the preferred but
colposcopy is acceptable.
For women 21-34 years with LSIL, follow up
with cytology at 12-month intervals should be
done.
For pregnant women with LSIL, colposcopy
should be recommended
Endocervical curettage should not be done in
pregnant women.
For pregnant women 21-24 years old with LSIL,
the same recommendations as for non-
pregnant women of the same age group should
be followed. Deferring colposcopy until 8
weeks postpartum is acceptable.
For postmenopausal women with LSIL, the
following options may be advised: HPV testing,
repeat cytology at 6 and 12 months and
colposcopy.
- The natural history of LSIL
approximates that of HPV –positive
ASC-US, suggesting that women with
either should be managed similarly.
Atypical Squamous Cells: Cannot exclude high-
grade squamous intraepithelial lesion (ASC-H)
For women with ASC-H cytology, colposcopy
should be performed regardless of HPV result.
[Quality of Evidence: 2A / Strength: D]
- A report of ASC-H confers higher risk
for CIN 3+ over time compared to ASC-
US or LSIL although the risk is lower
than that following HSIL.
High grade Squamous Intraepithelial Lesion
(HSIL)
Women with HSIL cytology should undergo
immediate loop electrosurgical excision or
colposcopy.
For women aged 21-24 years old, with HSIL,
colposcopy should be done.
- CIN 2+ is found at colposcopy in about
60% of women with HSIL. This justifies
immediate excision of he
transformation zone for many women,
especially those who are at risk for loss
to followup or who have completed
childbearing.
Atypical Glandular Cells (AGC) Cytologic s,
adenocarcinoma in Situ (AIS) Benign glandular
changes.
For women with all subcategories of AGC and
AIS except atypical endometrial cells,
colposcopy with endocervical sampling should
be done regardless of HPV status.
Endometrial sampling should be done in
conjunction with colposcopy and endocervical
sampling in women 35 years of age and older,
and in those younger than 35 years but with
clinical indications suggesting they may be at
risk for endometrial neoplasia.
For women with atypical endometrial cells,
endometrial and endoecervical sampling
should be done. Colposcopy may also be
acceptable.
For pregnant women with AGC, management
should be identical to that of non-pregnant
women except that endocervical curettage and
endometrial biopsy are unacceptable.
The endometrium should be assessed for
postmenopausal women with benign
endometrial cells.
Asymptomatic premenopausal women with
benign endometrial cells, endometrial stromal
cells or histiocytes, should not undergo further
evaluation.
Posthysterectomy patients with a cytologic
report of benign glandular cells should not
undergo further evaluation.
- AGC has been associated with polyps
and metaplasia, but also with
neoplasias, including adenocarcinomas
of the endometrium, cervix, ovary,
fallopian tube and other sites.
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7. How should we manage women diagnosed
with premalignant lesions?
A. Cervical Intraepithelial neoplasia (CIN) 1
Women with no lesion or CIN1 preceded by
ASC-US or LSIL cytology, HP 16+ or 18+ and
persistent HPV should undergo co-testing at 12
months. If CIN 1 is detected on endocervical
sampling, management is the same, but a
repeat endocervical sampling in 12 months
should also be done.
For women with no lesion or CIN 1 preceded by
ASC-H or HSIL cytology any of the following
may be done: (1) diagnostic excisional
prodecure (2) co-testing at 12 and 24 months if
colposcopic examination is adequate and the
endocervical sampling is negative (3) a review
of the cytologic histologic and colposcopic
findings
For women aged 21-24 years with CIN after
ASC- US and LSIL a repeat cytology at 12-month
interval should be done.
For women aged 21-24 years with CIN-1 after
ASC-H or HSIL, cytology both colposcopy and
cytology at 6-month intervals should be done
for up to 24 months provided that colposcopic
examination is adequate and endocervical
assessment
For pregnant women with CIN 1, follow up
without treatment should be recommended
B. CIN 2, CIN 3 and CIN 4
For women with CIN 2, CIN 3, or CIN 2, 3 and
adequate colposcopy both excision and
ablation may be done, except in pregnant
women and young women
For recurrent CIN 2, CIN3, CIN 2,3 or
inadequate colposcopy or endocervical
sampling showing CIN 2, CiN 3, or CIN 2,3 a
diagnostic excisional procedure should be
done. For young women with CIN 2,3 not
otherwise specified, either excision ablation, or
observatioin with both colposcopy and
cytology a 6-month intervals for up to 12
months may be done, provided that
colposcopy is adequate.
When a diagnosis of CIN 2 is specified in young
women, the preferred management is
observation with colposcopy and cytology
every 6 months for 12 months. Treatment with
either ablation or excision may also be done.
When CIn3 is specified or colposcopy is
inadequate excision or ablation should be
done.
For pregnant women with CIN 2, CIN 3 or CIN
2,3 additional colposcopic and cytologicc
examinations at intervals not more frequent
than 12 weeks should be done
C. Adenocarcinoma in situ (AIS)
For women who have complete childbearing
and have a histologic diagnosis of AIS from a
diagnostic excisional procedure, hysterectomy
should be done
If future fertility is desired, conservative
management may be done.
DIAGNOSTIC AND MANAGEMENT OF CERVICAL
CANCER
A. How is cervical cancer diagnosed?
Cervical biopsy should be done in patients with
cervical mass highly suspicious for malignancy
Cone biopsy through conization of loop
electrosurgical excision procedure should be
done if the cervical biopsy is inadequate to
determine invasiveness.
B. What diagnostic workups should be
requested for patients diagnosed with cervical
cancer?
Patients diagnosed with cervical cancer should
undergo the following laboratory tests,
complete blood count and platelets, liver and
renal function test.
Radiologic imaging studies like chest x-ray,
ultrasound, CT scan, PET CT scan, MRI, and
bone scintigraphy should be done as indicated.
Cystoscopy and proctoscopy should be done
for patients with possible bladder or rectal
invasion.
C. How should patients diagnosed with cervical
cancer be managed?
Patients with cervical carcinoma should be
managed with either surgery or radiotherapy
concurrent with chemotherapy. Surgery is
performed for early stage disease and those
with small tumors wuch as Stage 1A, !B! and
selected IIA1 cases.
Fertility sparing treatment may be done in
selected patients who have been properly and
thoroughly informed of disease risks and
perinatal issues.
Total Abdominal Hysterectomy with Bilateral
salpingooophorectomy should not be done
among patients diagnosed with cervical cancer.
- Simple hysterectomy for invasive
cervical cancer should not be
performed for it leads to increase in
recurrence and decrease in survival.
- Simple hysterectomies are performed
for supposedly benign gynecologic
conditions and pre-invasive cervical
lesions or microinvasive cervical
cancer.
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II. ENDOMETRIAL HYPERPLASIA
-abnormal or excessive proliferation of the
endometrium in the presence of high level of
estrogen unopposed by progesterone.
Usually caused by anovulatory menstrual cycles,
polycystic ovarian syndrome and obesity with
metabolic syndrome, unopposed estrogen and
obesity with metabolic syndrome, unopposed
estrogen, replacement therapy or estrogen-
secreting tumors.
-The 2014 WHO Classification of endometrial
hyperplasia differentiates between two
categories: hyperplasia without atypia and
atypical hyperplasia/endometrioid
intraepithelial neoplasia
a. Hyperplaisa with atypia – exhibits benign
changes and resolves after the estrogen-
progesterone imbalance has normalized .
Coexistent invasive endometrial carcinoma is
<1% and relative risk of progression to
endometrial cancer.
b. Atypical hyperplasia/endometroid –
intraepithelial neoplasia – contains similar
mutations as invasive endometrioid endometrial
cancer. Prevalence of underlying endometrial
carcinoma has been reported to be as high as
42.6% with a relative risk of 14-45 for
progression to invasive cancer.
Atypical hyperplasia WHO classification and
endometrial intraepithelial neoplasia were
found to have a 45-fold increased risk of
progression to carcinoma after the first year of
diagnosis.
MANAGEMENT OF HYPERPLASIA WITHOUT
ATYPIA
1. What is the first-line treatment for patients
with endometrial hyperplasia without atypia?
Since endometrial hyperplasia without atypia
responds well to progestins, medical
management must be the first line of
treatment for endometrial hyperplasia without
cytological atypia.
Levonorgestrel – releasing intrauterine system
(LNG-IUS) should be recommended as the first
line- treatment.
Oral progestins and intramuscular progestins
may be used as alternative treatment to LNS-
IUS
- Progestogens antagonize the effect of
estrogen on the endometrium. It
decreases glandular cellularity by
inducing apoptosis and inhibiting
angiogenesis in the myometrium
underlying the hyperplastic
endometrium resulting into
endometrial regression and prevention
of progression to cancer.
2. What is the optimal dose and duration of
treatment with progestins?
Progesterone treatment should be initiated for
at least 3 to 6 months. If there is no regression
to normal endometrium after 3-6 months, the
dose of oral progesterone may be increased.
The median time to complete response In 6
months and a majority will have complete
regression within 1 year.
3. How are patients monitored after hormonal
treatment?
Endometrial sampling should be performed to
document response after 3 months of
treatment. Endometrial biopsy with LNG-IUS in
place can be done. Maintenance treatment
after regression to normal endometrium is 6-12
months
- Conservative management of
endometrial hyperplasia involves
accurate assessment of response of the
endometrium to hormonal therapy.
However, no definitive method of
follow up has been established so far.
4. What are the indications for surgery in
patients with Endometrial Hyperplasia without
atypia?
Hysterectomy may be performed in women not
wanting to preserve their fertility in the
following:
a. Progression to atypical hyperplasia during
follow up
b. Absence of histological regression of
hyperplasia despite 12 months of treatment
c. Recurrence of endometrial hyperplasia after
completing progestin treatment
d. Persistence of aginal bleeding symptoms
despite treatment
e. Failure to comply with medical management
and endometrial surveillance.
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MANAGEMENT OF ATYPICAL HYPERPLASIA
1. What is the first-line treatment for patients
with atypical hyperplasia (AH)?
Definitive surgery in the form of extrafasccial
hysterectomy must be performed for women
with endometrial hyperplasia with atypia who
are not desirous of pregnancy.
- Total hysterectomy provides definitive
assessment of a possible concurrent
carcinoma and effectively treats
premalignant lesions
2. Is there a need to refer cases of atypical
hyperplasia to gynecologic oncologist?
Cases of atypical hyperplasia must be referred
preoperatively to a gynecologic oncologist
because of the high coexistence of endometrial
adenocarcinoma and atypical hyperplasia.
- The prevalence of endometrial
carcinoma in patients who have
atypical endometrial hyperplasia is
high, approximately 43%. Conequently
the ACOG and the SGO published a
practice bulletin recommending
preoperative consultation with a
gynecologic oncologist with training
and competence.
3. What is the role of froze section in patients
undergoing hysterectomy for atypical
hyperplasia?
Frozen section of the uterus of patients
preoperatively diagnosed with atypical
hyperplasia may be done to guide decisions
about the need for comprehensive surgical
staging.
- The scope of the operation may be
changed based on intraoperative
assessment and pathologic review such
that a hysterectomy is sufficient
treatment of atypical hyperplasia.
4. What are the nonsurgical management
options for atypical hyperplasia?
Conservative management with hormonal
treatment may be considered for patients with
atypical hyperplasia who are young (<40 years)
who desire future fertility and for patients who
are medically unfit to undergo surgery.
- The therapeutic goals for patients who
desire future fertility are complete
clearance of disease, reversion to
normal endometrial function and
prevention of invasive
adenocarcinoma.
5. How are patients monitored after nonsurgical
treatment for atypical hyperplasia?
Posthormonal treatment surveillance after
nonsurgical management of atypical
hyperplasia should be performed and include
transvaginal sonography and serial
endometrial sampling every 3-6months but the
appropriate frequency has not yet been
determined.
- All patients had no evidence of
progressive disease within these first 6
months while on treatment. Thus, it
seems that an earlier follow up might
not be warranted.
III. ENDOMETRIAL CANCER
-Third most common gynecologic malignancy in
the Philippines.
Risk factors for endometrial cancer include
unopposed estrogen therapy, tamoxifen use,
obesity, nulliparity infertility, diagbetes mellitus,
early menarche and late menopause.
Protective factors on the other hand include
oral contraceptive use and Raloxifene use as
prophylaxis for breast cancer.
Endometrial cancer is surgico-pathologically
staged and mainstay of treatment is surgery.
SCREENING
1.Among women with no risk factors, how
effective is surveillance in preventing
endometrial cancer?
Surveillance for endometrial cancer should not
be done in the general population
- There is no indication that population-
based screening has a role in the early
detection of endometrial cancer among
women who are low risk for the
disease.
2. Among women with moderate risk factors,
how effective is routine screening in preventing
endometrial cancer?
Routine screening should not be done to
moderate risk patients.
- Women who are at moderate risk for
endometrial cancer are those with
history of any of the following:
unopposed estrogen therapy late
menopause, tamoxifen therapy,
nulliparity, infertility or failure to
ovulate, obesity, diabetes or
hypertension should be informed of
the risks and symptoms of endometrial
cancer.
3. Among high risk women, how effective is
surveillance in preventing endometrial cancer?
For high-risk patients surveillance of the
endometrium by gynecological examination,
tranvaginal ultrasound and aspiration biopsy
starting from age of 35 years should be offered.
Prophylactic hysterectomy and bilateral
salpingo0oophorectomy, preferably using a
minimally invasive approach, should be
discussed in the age of 40 as an option to
prevent endometrial and ovarian cancer.
- Women who re at high risk for
endometrial cancer include known
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carriers of HNPCC-associated genetic
mutations, those who have a
substantia likelihood of being a
mutation carrier nd those without
mutation is known to be present in the
family.
4. Among asymptomatic Tamoxifen users, how
effective is surveillance in preventing
endometrial cancer?
Routine screening for endometrial cancer in a
symptomatic tamoxifen users should not be
done.
- Women taking tamoxifen shuld be
informed abou the risks of endometrial
proliferation, endometrial hyperplasia,
endometrial cancer, and uterine
sarcomas, and any abnormal vaginal
bleeding, bloody vaginal sarcomas, and
any abnormal vaginal bleeding, bloody
vaginal discharge, staining aor spotting
should be investigated.
5. Among premenopausal women, how effective
is routine ultrasound as a screening tool for
endometrial carcinoma?
Routine endometrial thickness measured
through ultrasound in premenopausal women
should not be performed
- The literature is unclear about when
evaluation with imaging I indicated in
premenopausal women with abnormal
uterine bleeding since ultrasound
measurement of endometrial thickness
has no diagnostic value in this age
group.
6.Among asymptomatic postmenopausal
women, how effective is routine ultrasound as a
screening tool for endometrial carcinoma?
Routine ultrasound in asymptomatic
postmenopausal women should not be
performed.
- Routine transvaginal ultrasound use for
endometrial thickness measurement is
not effective diagnostic tool for
endometrial cancer for asymptomatic
postmenopausal women.
DIAGNOSIS
1. Among symptomatic postmenopausal
women, how effective is transvaginal ultrasound
as a diagnostic tool for endometrial carcinoma?
Transvaginal ultrasound may be used to triage
patients for endometrial sampling. Endometrial
thicknesss of >4mm has a sensitivity of 95-
100% for endometrial cancer in women with
postmenopausal bleeding.
Histologic evaluation of the endometrium
should be performed in the presence of
persistent and recurrent uterine bleeding
regardless of endometrial thickness.
International endometrial tumor analysis
(IETA) may be included in the evaluation of
women with postmenopausal bleeding.
- Transvaginal ultrasound is an
appropriate initial diagnostic test to
evaluate the endometrium for women
with postmenopausal bleeding.
2. Among symptomatic postmenopausal
women, how effective is hysteroscopy-guided
biopsy as a diagnostic tool for endometrial
carcinoma?
Hysterectomy should be the gold standard for
diagnostic of endometrial cancer in
symptomatic postmenopausal women
- Office hysteroscopy or
hydrosonography (infusion of saline
into the endometrial cavity during
ultrasound scanning) can be used as a
first step of investigation to disclose
the presence of focal lesions in the
uterine cavity.
3. Among symptomatic postmenopausal
women, how effective is endometrial biopsy as a
diagnostic tool for endometrial?
Office endometrial biopsy using Pipelle device
has a sensitivity of 99.6% in the detection of
endometrial cancer in postmenopausal
women. It may be used to sample the
endometrium for histologic evaluation.
Endometrial biopsy and dilatation and
curettage have comparable accuracy in
diagnosing endometrial cancer, the latter more
accurately reflecting final tumor grade.
- Dilation and curettage provides a more
accurate reflection of true FIGO grade
than endometrial aspiration biopsy.
4. What is the role of frozen section in the
diagnosis of endometrial cancer?
Uterine specimens from hysterectomies
performed for endometrial adenocarcinoma
may be send for frozen section to determine
high risk factors such as myometrial invasion.
Frozen section of endometrial curettings is not
recommended due to lack of large studies for
its use.
- Frozen section of endometrial tissue
from biopsy or curettage have marked
artifactual changes due to its size,
fragmented nature and presence of
food.
PREOPERATIVE WORKUP
1. What are the preoperative work ups for the
patients with endometrial cancer?
a. Complete blood count, renal and liver
function tests – routinely tested in corpus
cancer
b. Chest X-ray – universally available, low cost
rarely positive in early stage disease but
significan when found to be positive.
c. CA-125- valuable in advanced diseases and in
poor histologi types
d. CT scan of chest, abdomen and pelvis or
PET-CT in high risk patients to determine the
surgical approach
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e. Cystoscopy and proctoscopy may be helpful

if directed extension to the bladder or rectum
is suspected.

MANAGEMENT
1. What is the recommended surgery for
endometrial cancer?
The initial surgical management of endometrial
cancer should include extrafascial
hysterectomy, peritoneal fluid cytology,
bilateral salpingo-oophorectomy and pelvic
and para-aortic lymphadenopathy. Exceptions
to his approach should be made only after
consultation with a gynecologic oncologist.
- FIGO stated that endometrial cancer
should be surgically staged.
Comprehensive surgical evaluation of
peritoneal washings for cytology,
extrafacial hysterectomy, bilateral
salpingooophorectomy and pelvic and
para-aortic lymphadenopathy.
Although positive peritoneal fluid
cytology is not included in the final
surgico-pathologic stage, its presence is
reported because retrospective studies
has shown it has prognostic value.
2. When should a patient with endometrial
cancer or suspecte endometrial cancer be
referred to a gynecologic oncologist?
Referrak to a gynecologic oncologist should be
made upon diagnosis of endometrial cancer
pre-operatively or when the suspicion of
endometrial cancer is high.
- A gynecologic oncologist should be
involved in the initial care of every
woman seeking treatment for
endometrial cancer. Such involvement
enhances the preoperative and
intraoperative decision process allows
completion of any necessary procedure
facilitates the decision regarding the
need for additional therapy and results
in a comprehensive and cost effective
clinical approach.