Obstetrics and Gynecology/Endometrial Neoplasia
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 Factors Edit
Postmenopausal Bleeding Edit The most common cause of postmenopausal bleeding is atrophic endometritis, followed by side effects of exogenous estrogens, endometrial cancer, and other etiologies.
Endometrial Hyperplasia Edit 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 Adenocarcinoma Edit Lack of progesterone
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)
Late menopause Clinical Presentation and Diagnostic Approach Edit
Endometrial Cancer Edit 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
Endometrial cells on pap smear
Enlarged uterus Recurrent endometrial cancer typically presents in the vagina, lymph nodes, and lungs.
Diagnostic Approach to Abnormal Uterine Bleeding Edit 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 Staging Edit
Endometrial Hyperplasia Edit Simple-cystic
Atypical adenomatous endometrial hyperplasia has a 20-30% chance of malignant transformation.
Endometrial Cancer Edit
Adenocarcinoma (75% of endometrial cancer)
Serous papillary: staging should be done as ovarian cancer
Small cell neuroendocrine (oat cell)
Clear cell carcinoma
Leiomyosarcoma 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) Management Edit
Endometrial Hyperplasia Edit Hysterectomy for atypical adenomatous.
Endometrial Cancer Edit 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.