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Recommendations for diagnosis and treatment of malignant ovarian tumors with regard to the most recent data were worked out in a consensus process and valued by level of evidence (LoE) and grade of recommendation (GoR) of the Canadian Task Force for Preventive Health Care by the members of the Kommission Ovar der Arbeitsgemeinschaft für Gynäkologische Onkologie (AGO) in June 2005. A short version of these guidelines is presented.

The German Medical Association (Bundesärztekammer) has launched a new organisational structure in the curriculum of medical qualification. Beside the field of obstetrics and gynecology this has led to three specialisation. The newly established specialisation is that of gynecological oncology. Therewith in the future the treatment and care for women with genital or breast cancer will be focused to those centers having the necessary qualification. In addition the German qualification is identical to that of the European Society of Gynecological Oncology (ESGO). So German fellows can obtain a national and international qualification at qualified centers.

Surgical therapy is the mainstay of the treatment of endometrial cancer. Apart from total abdominal hysterectomy und bilateral salpingo-oophorectomy, complete pelvic and paraaortic lymphadenectomy has become an integral part of the primary surgical procedure, allowing for definite surgical/histopathological staging. In surgically staged patients, adjuvant measures including external radiotherapy can be applied with a clear indication and unnecessary toxicity can be avoided. In addition complete lymphadenectomy has probably a relevant therapeutic effect. As so far no randomized trials have been completed and lymphadenectomy in the often multi-morbid and obese endometrial cancer patients requires a certain amount of expertise, it is not accepted by all experts or is accepted only if a variety of parameters obtained pre- and intraoperatively are present. On the other hand, the National Comprehensive Cancer Network of the USA recommends a complete pelvic and paraaortic lymphadenectomy for all patients with endometrial cancer, except for those with Stage IA, Grade 1 disease where this procedure is optional. The efficacy of an adjuvant pelvic teletherapy in Stage I patients has been questioned by several randomized trials. In patients having a complete surgical staging, external radiotherapy is often not necessary and can be replaced by vaginal brachytherapy. In advanced stages of endometrial cancer chemotherapy has been shown to be superior to whole abdominal radiotherapy. New multimodal concepts including surgical staging, adjuvant chemo- and targeted radiotherapy have to be evaluated. In the palliative setting novel endocrine strategies are being assessed in addition to the well established progestagen therapy. The efficacy of the standard chemotherapy with adriamycin/cisplatin could be somewhat improved by adding paclitaxel, at the expense of a markedly increased toxicity. Women with the diagnosis of endometrial cancer should be treated in the context of certified clinical trials as it has become the standard for patients with breast or ovarian cancer.

It is well accepted that unopposed estrogens increase the risk of developing endometrial cancer. A relationship between estrogen exposure and the risk for breast cancer is very probable. In addition, an association of long-term estrogen substitution and ovarian cancer risk has been postulated recently. Estrogens have been considered as typical tumor promotors. Due to their estrogen-receptor-mediated mitogenic activity, these steroids were supposed to increase the statistical probability of spontaneous mutations. Recent experimental findings, however, suggest that estrogen metabolites, in particular 4-hydroxyestrogens are capable of inducing DNA-damage and transforming mutations. The clinical relevance of these genotoxic properties of estrogens remains to be established, but could obtain great importance. First molecular-epidemiologic studies suggest that due to the specific activity of their estrogen metabolizing enzymes some women might produce relevant amounts of mutagenic estrogen metabolites, increasing their risk for breast-, endometrial- or ovarian cancer respectively. These findings might result in novel preventive strategies. The present data do not justify to abandon the practice of hormone replacement therapy with estrogens or estrogens plus progestins in non hysterectomised women. It seems to be wise, however, to restrict hormone replacement therapy to symptomatic women with a clear indication and, according to the actual trend, limit it temporarily.

Radical surgery in stage I and II uterine sarcoma removing all tumor manifestations is the only curative therapy option for early stage disease. Larger tumors (> 4 cm) and the presence of lymph node metastasis correlate with a high local recurrence rate. For these tumors adjuvant radiation and/or adjuvant chemotherapy may be recommended after surgical therapy. Adjuvant therapy however, should preferably be considered for uterine stromal sarcomas and mixed mesodermal tumors. The toxicity of radiation and/or chemotherapy is greater than any possible benefit for patients with leiomysarcomas as these tumors rarely respond to radiation or chemotherapy. For advanced (> stage I and II) and recurrent disease, curative therapy options are not available and palliative therapy for these patients has to take into consideration the negative side effects and weigh up quality of life against an often very limited possible benefit of such therapy.

Endometrial cancer is usually diagnosed at an early stage where surgery alone is the adequate therapy. Chemotherapy and hormonal treatment are therefore almost exclusively performed in palliative situations. Hormonal treatment with progestogens (medroxyprogesterone acetate and megestrol acetate) should be the therapy of choice primarily as these drugs are very well tolerated. Tamoxifen and GnRH analogs are further options but are seldom used. The response rates to hormonal treatment are relatively low (max. 25 %) with short remissions in most cases. - So far neither hormonal treatment nor cytotoxic chemotherapy has been shown to have substantial benefits in the adjuvant setting. In some selected high risk cases (serous papillary carcinomas, extra uterine manifestation) adjuvant chemotherapy may be an option following surgery, before or after radiotherapy. Age, general condition and morbidity of the patients need to be considered as limiting factors for chemotherapy. Crucial for the prognosis of all endometrial cancer patients however, is the stage adapted surgery. - Cytotoxic chemotherapy has failed to bring a break through in the therapy of advanced endometrial cancer. Cisplatin plus doxorubicin is the standard combination to date, with anthracyclines being the more important component. In a mono-therapy setting, doxorubicin and epirubicin are well tolerated and convenient in their efficacy. For recurrent and metastatic disease, docetaxel is being evaluated for efficacy and side effects in a multicenter phase II trial.