Endometrial Cancer

Symptoms

n Post menopausal bleeding
n Endometrial cells on Pap
n Perimenopausal with irregular heavy menses, increasingly heavy menses
n Premenopausal with abnormal uterine bleeding with history of anovulation



Differential Diagnosis for PMB


n Exogenous estrogen use- ie tamoxifen
n Atrophic endometritis/vaginitis
n Endometrial/cervical polyps
n Endometrial hyperplasia
n Endometrial Cancer
n Other gynecologic cancers


Risk factors for Endometrial Cancer
n Increased estrogen
– Hormone therapy
– Obesity
– Anovulation/PCOS
– Estrogen secreting tumors
– Older age
– Infertility
– Early menarche
– Late menopause
n Genetics
– HNPCC
– Caucasian


Preoperative Work-up
n Endometrial biopsy
n Ultrasound
n For suspected advanced stage may need:
– Cystoscopy
– Sigmoidoscopy
– Pelvic and Abdominal CT
n Labs
– CBC
– Chem 7
– Liver function tests
– EKG, CXR

Endometrial Hyperplasia (EIN)
n Precursor to endometrial cancer
– Risk of progression related to cytologic atypia
n Presents with abnormal bleeding
n Simple
– Benign irregular dilated glands
– No atypia: 1% progress
– Atypia: 8% progress
n Complex
– Proliferation of glands with irregular outlines, back to back crowding of glands, but no atypia
– No atypia: 3% progress
– Atypia: 29% progress


Staging of Endometrial Cancer
n I: Confined to uterine corpus
– IA: limited to endometrium
– IB: invades less than ½ of myometrium
– IC: invades more than ½ of myometrium

n II: invades cervix but not beyond uterus
– IIA: endocervical gland involvement only
– IIB: cervical stroma involvement

n III: local and/or regional spread
– IIIA: invades serosa/adnexa, or positive cytology
– IIIB: vaginal metastasis
– IIIC: metastasis to pelvic or para-aortic lymph nodes

n IVA: invades bladder/bowel mucosa
n IVB: distant metastasis

Five Year Survival
n Stage I: 81-91%
– 72% diagnosed at this stage
n Stage II: 71-78%
n Stage III: 52-60%
n Stage IV: 14-17%
– 3% diagnosed at this stage


Spread Patterns
n Direct extension
– most common
n Transtubal
n Lymphatic
– Pelvic usually first, then para-aortic
n Hematogenous
– Lung most common
– Liver, brain, bone


Treatment
n Stage IB or less: total hyst/BSO/PPALND, cytology
n Stage IC to IIB: total hyst/BSO/PPALND, cytology, adjuvant pelvic XRT
n Stage III: total hyst/BSO/PPALND, cytology, adjuvant chemotherapy
n Stage IV: palliative XRT and chemotherapy


Histologic Types
n Estrogen dependent
– Endometrioid- most common
n Non estrogen dependent- worse prognosis
– Papillary Serous
– Clear cell
– Adenosquamous
– Undifferentiated


Other Types of Uterine Cancer


n Leiomyosarcoma
– Rapidly growing fibroid should be evaluated
n Stromal sarcoma
n Carcinosarcoma (MMMT)