Definition
A.Endometrial cancer develops in the uterus and is the most common type of malignancy of the female reproductive system.
B.The majority of all uterine cancers arise from the endometrium (the inner layer) of the uterus. However, uterine leiomyosarcoma is a type of endometrial cancer that develops in the myometrium (the muscle layer) of the uterus.
Incidence
A.It is estimated that 60,050 new uterine cancer cases were diagnosed in 2016, with 10,470 deaths resulting from the disease.
B.Uterine sarcomas are rare, accounting for approximately ~9% of all uterine malignancies.
C.A woman’s lifetime risk of developing endometrial cancer is approximately 2.8%.
D.Endometrial cancer represents 3.6% of all new cancer cases in the United States.
E.The majority of women are diagnosed between ages 45 and 74, with a median age of 62.
Pathogenesis
A.Endometrial cancer is usually preceded by endometrial hyperplasia, which is an overgrowth of the uterine lining.
B.Adenocarcinomas comprise 80% of endometrial cancers.
Predisposing Factors
A.Major risk factors.
1.Obesity.
2.Diabetes.
3.Hypertension.
B.Other risk factors.
1.Increased levels of unopposed estrogen.
2.Early age at menarche.
3.Nulliparity.
4.Late age at menopause.
5.Older age of 55 or more.
6.Tamoxifen use for greater than 5 years.
7.Previous pelvic radiation therapy.
8.A personal family history of breast or ovarian cancer.
9.Family history of hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome).
Subjective Data
A.Common complaints/symptoms.
1.About 90% of women diagnosed with endometrial cancer have abnormal uterine bleeding (i.e., postmenopausal bleeding, recurrent metrorrhagia, or menorrhagia).
2.Asymptomatic women can present with an abnormal Pap smear showing atypical or malignant endometrial cells.
B.Common/typical scenario: Endometrial cancer can be discovered incidentally on ultrasonography, CT, or MRI with a thickened endometrial lining.
C.Family and social history: An accurate history of present illness as well as past medical conditions, family, and social history should be taken.
Physical Examination
A.The physical examination should involve a general inspection of the body for abnormalities, palpation of the inguinal and supraclavicular nodes, and inspection of the vulva, anus, vagina, and cervix to evaluate for metastatic lesions.
B.Bimanual and rectovaginal examination should be performed to evaluate the uterus, cervix, adnexa, parametria, and rectum.
C.The size, mobility, and axis of the uterus should be assessed.
D.A biopsy should be performed for any suspicious genital tract lesions detected on examination.
Diagnostic Tests
A.Histologic evaluation of endometrial tissue is required for diagnosis.
B.Once endometrial cancer is confirmed, additional studies are needed for treatment planning.
1.Complete blood count (CBC) with differential.
2.Serum electrolytes.
3.Kidney and liver function tests.
4.EKG.
5.Transvaginal ultrasound.
6.CT chest, abdomen, and pelvis with intravenous (IV) and oral contrast to rule out extrauterine spread in high-grade malignancies.
7.MRI of the abdomen and pelvis.
8.Chest x-ray (can be used as alternative to CT).
9.CA-125—can be elevated in some uterine subtypes.
10.Colonoscopy, sigmoidoscopy, or barium enema.
11.Genetic testing.
C.Staging: Staging of endometrial cancer is defined by the International Federation of Gynecology and Obstetrics (FIGO) criteria.
Differential Diagnosis
A.Determine source of bleeding.
1.Cervix.
2.Vulva.
3.Vagina.
B.Bleeding can be caused by:
1.Polyps.
2.Endometritis.
3.Neoplasm.
4.Atrophic changes.
Evaluation and Management Plan
A.General plan.
1.Treatment is determined based on disease stage and histologic features.
a.Stage I.
b.Stage II or III.
c.Stage IV.
2.Treatment can continue as long as treatment response is favorable.
3.There are four basic types of treatment for women with endometrial cancer.
a.Surgery: The standard of care for treatment of endometrial cancer is hysterectomy.
b.Radiation therapy.
c.Hormone therapy.
d.Chemotherapy.
4.Fertility-sparing therapy—may be initiated in premenopausal patients with Grade 1 well-differentiated tumor; stage FIGO IA tumor without involvement of myometrium on MRI, absence of lymphovascular invasion, and without intraabdominal disease or adnexal mass.
a.Hormone therapy with megestrol and medroxyprogesterone (most common).
b.Levonorgestrel.
B.Acute care issues in endometrial cancer.
1.Endometrial cancer patients are often admitted for surgical management. Surgery can be performed either open laparotomy or minimally invasive via laparoscopic or robotic approach.
2.Postoperative laparotomy patients without complications will spend 3 to 5 days in the hospital after surgery, compared to 1 to 2 days recovery for patients undergoing minimally invasive surgery (MIS).
Follow-Up
A.Follow-up should occur every 3 to 4 months for the first 2 years and then every 6 months for 5 years.
B.PET/CT has been shown to be more sensitive or specific than CT alone for recurrence but further investigation is being evaluated.
C.Pap smears for detection of local recurrence has not been demonstrated.
Consultation/Referral
A.Gynecology oncology, medical oncology, radiation oncology, and surgery.
Special/Geriatric Considerations
A.Prognosis is favorable for endometrial cancer.
B.Diagnosis at an early stage of the disease process is a key factor for good prognosis.
C.Surgery is a safe option for elderly women, which significantly extends life with a low rate of complications.
Bibliography
National Cancer Institute. (2016, September 12). Surveillance, epidemiology, and end results program. Retrieved from https://seer.cancer.gov/faststats/selections.php?series=cancer
Nordal, R. R., & Thoresen, S. O. (1997). Uterine sarcomas in Norway 1956–1992: Incidence, survival, and mortality. European Journal of Cancer, 33(6), 907–911.
Pecorelli, S. (2009). Revised FIGO staging for carcinoma of the vulva, cervix and endometrium. International Journal of Gynecology and Obstetrics, 105(2), 103–104. doi:10.1016/j.ijgo.2009.02.012
Pecorelli, S. (2010). Corrigendum to Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium
. International Journal of Gynecology and Obstetrics, 108(2), 176. doi:10.1016/j.ijgo.2009.08.009