Last modified on 22 November 2010, at 19:12

Obstetrics and Gynecology/Endometrial Neoplasia

EpidemiologyEdit

  • Endometrial cancer is the most common gynecological cancer in Canada
  • Endometrial cancer has the best cure rate of all endometrial cancers due to early diagnosis
  • Diagnosed at a median age of 58
  • Most patients present with Stage I disease

Etiology and Risk FactorsEdit

Postmenopausal BleedingEdit

  • The most common cause of postmenopausal bleeding is atrophic endometritis, followed by side effects of exogenous estrogens, endometrial cancer, and other etiologies.

Endometrial HyperplasiaEdit

  • Arises from unopposed estrogen (of at least 6 mo) causing hyperplasia of glandular and stromal tissues in the endometrium
  • Endometrial hyperplasia may lead to estrogen sensitive endometrial cancer

Endometrial AdenocarcinomaEdit

  • Lack of progesterone
    • Anovulation
    • Obesity: aromatization of androstenedione to estrogen in peripheral fat cells. During menopause, fat cells continue to produce estrogen in the absence of progesterone. Therefore, endometrial adenocarcinoma has an increased incidence.
    • SERM use (i.e. Tamoxifen for breast cancer -> 2-3X increased risk)
    • Hormone replacement therapy without progesterone use.
  • Gallbladder disease, diabetes, and/or hypertension
  • History of breast, colorectal, or ovarian cancer (family history of lynch syndrome)
  • Nulliparity
  • Late menopause

Clinical Presentation and Diagnostic ApproachEdit

Endometrial CancerEdit

  • Postmenopausal vaginal bleeding.
    • In any postmenopausal woman, vaginal bleeding is endometrial cancer until proven otherwise.
  • Abnormal premenopausal bleeding
    • Rule out pregnancy.
    • If the woman is anovulatory, they are more likely to have a malignant etiology.
  • Metastatic disease and signs of advanced cancer
  • Hematometrium
  • Endometrial cells on pap smear
  • Enlarged uterus
  • Recurrent endometrial cancer typically presents in the vagina, lymph nodes, and lungs.

Diagnostic Approach to Abnormal Uterine BleedingEdit

  • First, a pap smear should be done, with relevant follow up for pap smear abnormalities (if abnormal)
  • Second, an endometrial biopsy should be performed
  • Finally, transvaginal ultrasound should be requested, with the following parameters qualified
    • Endometrial thickness (<5mm if hypoestrogenic, and >10mm if pathological)
  • Dilation and curettage may be ultimately performed for diagnosis of cancer.
  • For women on tamoxifen, estrogen hormone replacement therapy, and anovulatory women not taking progesterone, perform yearly endometrial biopsies.

Pathology, Histology, and StagingEdit

Endometrial HyperplasiaEdit

  • Simple-cystic
  • Complex Adenomatous
  • Atypical Adenomatous
    • Atypical adenomatous endometrial hyperplasia has a 20-30% chance of malignant transformation.

Endometrial CancerEdit

  • Adenocarcinoma (75% of endometrial cancer)
    • Serous papillary: staging should be done as ovarian cancer
    • Small cell neuroendocrine (oat cell)
    • Clear cell carcinoma
    • Sarcoma
    • Leiomyosarcoma

StagingEdit

  • Stage I (~85% survival at 5yr)
    • IA: Tumor confined to the uterus with less than 1/2 myometrial invasion
    • IB: Tumor confined to the uterus with more than 1/2 myometrial invasion
  • Stage II (~65% survival at 5yr)
    • II: Cervical extension, with persistent uterine confinement
  • Stage III (~45% survival at 5yr)
    • IIIA: Invasion of serosa/adenexa
    • IIIB: Vaginal/parametrial invasion
    • IIIC1: Pelvic node invasion
    • IIIC2: Para-aortic node invasion
  • Stage IV (~16% survival at 5yr)
    • IVA: Tumor invasion of bladder/bowel
    • IVB: Distant metastases (includes inguinal lymph nodes)

ManagementEdit

Endometrial HyperplasiaEdit

  • Hysterectomy for atypical adenomatous.

Endometrial CancerEdit

  • Serous papillary: chemotherapy (carbo/taxol) even if confined to uterus.
  • Small cell neuroendocrine (cisplatin/etoposide)
  • Surgery (total abdominal hysterectomy and bilateral salpingo-oophorectomy with or without lymph node dissection) and postoperative radio- and chemo-therapy.
    • Chemotherapy is reserved for high risk patients with positive nodes, metastatic disease.
    • Chemo- and radio-therapy alone are reserved for inoperable patients.
  • Radiation for vaginal recurrence.
  • High dose progesterone for hormone-sensitive recurrent cancer.