ESSENTIALS OF DIAGNOSIS
Abnormal bleeding is the presenting sign in 90% of cases.
Papanicolaou smear is frequently negative.
After a negative pregnancy test, endometrial tissue is required to confirm the diagnosis.
Adenocarcinoma of the endometrium is the second most common cancer of the female genital tract. It occurs most often in women 50–70 years of age. Obesity, nulliparity, diabetes, polycystic ovaries with prolonged anovulation, unopposed estrogen therapy, and the extended use of tamoxifen for the treatment of breast cancer are also risk factors. Women with a family history of colon cancer (hereditary nonpolyposis colorectal cancer, Lynch syndrome) are at significantly increased risk, with a lifetime incidence as high as 30%.
Abnormal bleeding is the presenting sign in 90% of cases. Any postmenopausal bleeding requires investigation. Pain generally occurs late in the disease, with metastases or infection.
Papanicolaou smears of the cervix occasionally show atypical endometrial cells but are an insensitive diagnostic tool. Endocervical and endometrial sampling is the only reliable means of diagnosis. Simultaneous hysteroscopy can be a valuable addition in order to localize polyps or other lesions within the uterine cavity. Pelvic ultrasonography may be used to determine the thickness of the endometrium as an indication of hypertrophy and possible neoplastic change. The finding of a thin endometrial lining on ultrasound is clinically reassuring in cases where very little tissue is obtainable through endometrial biopsy (eFigure 18–20).
Endometrial carcinoma. A: Longitudinal sonogram from a patient with vaginal bleeding. A large soft-tissue mass (arrows) is identified within the uterus. This tissue has the appearance of endometrium but is nonspecific and could represent hyperplasia, polyps, or carcinoma. B: Endovaginal sonogram from the same patient. Prominent soft tissue is seen in the expected location of the endometrium (arrows). At biopsy this proved to be endometrial carcinoma. (Used, with permission, from Peter W. Callen, MD.)
Pathologic assessment is important in differentiating hyperplasias, which often can be treated hormonally.
Prompt endometrial sampling for patients who report abnormal menstrual bleeding or postmenopausal uterine bleeding will reveal many incipient as well as clinical cases of endometrial cancer. Younger women with chronic anovulation are at risk for endometrial hyperplasia and subsequent endometrial cancer; they can significantly reduce the risk of hyperplasia with the use of oral contraceptives or cyclic progestin therapy.
Staging and prognosis are based on surgical and pathologic evaluation only. Examination under anesthesia, endometrial and endocervical sampling, chest radiography, intravenous urography, cystoscopy, sigmoidoscopy, transvaginal sonography, and MRI will help determine the extent of the disease and its appropriate treatment.
Treatment consists of total hysterectomy and bilateral salpingo-oophorectomy. ...