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ABSTRACT:
 

Background:
Primary treatment for endometrial cancer (EC) is surgical with hysterectomy and bilateral salpingo-oophorectomy and added lymphadenectomy fo staging.

Aim:
The aim of this thesis was to study recurrence, survival, and surgical complications in a population-based cohort and to assess the introduction of the first national guidelines (NGEC). A second aim was to evaluate preoperative risk classification with transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) in low-grade endometrioid EC.

Methods:
 In Paper I-III, data from the Swedish Quality Register for Gynecological Cancer was retrieved and completed with medical records reviews. Survival and regression analyses for risk factors were performed.
Paper IV was a prospective multicenter study in the WSHCR including patients with low-grade EC. Myometrial infiltration (MI) and cervical stroma invasion (CSI) were assessed with both TVUS and MRI and the methods were analyzed for diagnostic accuracy and compared.

Results:
The recurrence rate was 8.3% in endometrioid (Paper I) and 29% in non-endometrioid EC (Paper II). The total 5-year DFS was 83.9% and 61.9% for endometrioid and non-endometrioid EC respectively. If no recurrence occurred, the 5-year OS was 91.9% in endometrioid and 88.5% in non-endometrioid EC. The OS increased from 57.3% to 72.0% after the implementation of NGEC (Paper II). SurgicalClavien-Dindo complications grade >II occurred in 19.7% and surgical technique, obesity and lymph node dissection, were found to be independent risk factors (PaperIII). In Paper IV, MRI had a higher accuracy for deep MI than TVUS, but no difference in sensitivity.

Conclusions:
 The survival was excellent when no recurrence occurred, in both endometrioid and non-endometrioid EC. A significant improvement in survival was seen in non-endometrioid EC after implementation of NGEC with lymph node staging, despite less adjuvant radiotherapy administered. For the assessment of deep MI, MRI had a higher accuracy than TVUS. The sensitivity of TVUS performed by gynecologists was evaluated as acceptable and did not differ from MRI.

Figure 20B. 5-year NS for non-endometrioid EC before/after NGEC (Paper II)