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For further information, see CMDT Part 18-19: Carcinoma of the Endometrium

Key Features

Essentials of Diagnosis

  • Abnormal uterine bleeding is the presenting sign in 90% of cases

  • After a negative pregnancy test, endometrial tissue is required to confirm the diagnosis

General Considerations

  • Adenocarcinoma of the endometrium is the most common cancer of the female genital tract in developed countries

  • Occurs most often in women 50–70 years of age

  • Risk factors

    • Obesity

    • Nulliparity

    • Diabetes mellitus

    • Polycystic ovaries with prolonged anovulation

    • Unopposed estrogen therapy

    • Extended use of tamoxifen for the treatment of breast cancer

  • 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%

Clinical Findings

  • Abnormal uterine 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

Diagnosis

  • Papanicolaou smear of the cervix

    • Occasionally shows atypical endometrial cells

    • However, it is an insensitive diagnostic tool

  • Endocervical and endometrial sampling is

    • The only reliable means of diagnosis

    • Important to differentiate endometrial cancer from hyperplasia, which often can be treated hormonally

  • Simultaneous hysteroscopy can be a valuable addition in order to localize polyps or other lesions within the uterine cavity

  • Vaginal ultrasonography may be used to determine the thickness of the endometrium as an indication of hypertrophy and possible neoplastic change

Treatment

  • Total hysterectomy and bilateral salpingo-oophorectomy

  • Peritoneal washings for cytologic examination are routinely taken and lymph node sampling may be done

  • Postoperative irradiation is indicated if

    • Invasion deep into the myometrium has occurred or

    • Sampled lymph nodes are positive for tumor

  • Patients with stage III endometrial cancer are generally treated with surgery followed by chemotherapy and/or radiation therapy

  • Palliation of advanced or metastatic endometrial adenocarcinoma may be accomplished with large doses of progestins, such as

    • Medroxyprogesterone, 400 mg weekly intramuscularly, or

    • Megestrol acetate, 80–160 mg daily orally

Outcome

Prevention

  • Use of oral contraceptives, cyclic progestin therapy, or a levonorgestrel IUD significantly reduces the risk of hyperplasia in young women with chronic anovulation who are at risk for endometrial hyperplasia and subsequent endometrial cancer

Prognosis

  • With early diagnosis and treatment, the overall 5-year survival for stage I disease is 80–90%

  • With stage I disease, the depth of myometrial invasion is the strongest predictor of survival, with a 5-year survival of

    • 90% with a less than 50% depth of myometrial invasion

    • 80% with a 50% or greater depth of myometrial invasion

When to Refer

  • All patients should be referred to a gynecologic oncologist

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