Endometrial Cancer

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 hormonal 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