The Merck Manual of Diagnosis and Therapy 17

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ed, Beers MH, Berkow R, editors. Portland Merck ! "o., #nc$ 1%%%. p. 1%&' ( 1.
ENDOMETRIAL CANCER
#n the )*+, endo,etrial cancer is the ,ost co,,on gynecologic ,alignancy and the fourth ,ost
co,,on ,alignancy in wo,en after -reast, colorectal, and lung cancer. +-out ./,''' new cases of
endo,etrial cancer were diagnosed in 1%%&. #t affects ,ainly post,enopausal wo,en, with incidence peaking
-etween ages 0' and &'$ 1 02 of cases occur a,ong wo,en 1 /' yr.
3*ee also 4ndo,etrial "arcino,a in The Merck Manual of 5eriatrics.6
Etiology and Pathology
4ndo,etrial cancer is ,ore co,,on in industriali7ed countries in which dietary fat intake is high. The
,ost significant risk factor is o-esity, which increases risk -y . to 1' ti,es. 4ndo,etrial cancer is ,ore
co,,on in wo,en with conditions that tend to result in unopposed estrogen 3high circulating le8els of estrogen
with no or low le8els of progesterone6, such as unopposed estrogen replace,ent therapy, o-esity, polycystic
o8arian syndro,e, nulliparity, late ,enopause, estrogen9producing tu,ors, ano8ulation, or oligo9o8ulation.
:o,en with a history of pel8ic radiation therapy or with a personal or fa,ily history of -reast or o8arian
cancer are at increased risk. + s,all percentage of cases ,ay -e hereditary.
4ndo,etrial hyperplasia usually precedes endo,etrial cancer and is classified -y the degree of
cytologic atypia. #ts treat,ent consists of progestins or surgery, depending on the co,ple;ity of the lesion and
the patient<s desire to a8oid hysterecto,y.
4ndo,etrial cancer ,ay spread fro, the surface of the uterine ca8ity to the cer8ical canal$ through the
,yo,etriu, to the serosa and into the peritoneal ca8ity$ 8ia the lu,en of the fallopian tu-e to the o8ary, -road
liga,ent, and peritoneal surfaces$ 8ia the -loodstrea,, leading to distant ,etastases$ or 8ia the ly,phatics. The
higher 3,ore undifferentiated6 the grade of the tu,or, the greater likelihood of deep ,yo,etrial in8asion,
pel8ic or para9aortic ly,ph node ,etastases, or e;trauterine spread.
+denocarcino,a accounts for = >'2 of cases of endo,etrial cancer. *arco,as account for a-out 02 of
all uterine ,alignancies and include ,i;ed ,esoder,al tu,ors, leio,yosarco,as, and endo,etrial stro,al
sarco,as. *arco,as tend to -e ,ore aggressi8e, are ,ore likely to produce local, regional, and distant
,etastases, and ha8e a worse prognosis.
Symptoms, Signs, and Diagnosis
More than %'2 of patients with endo,etrial cancer ha8e a-nor,al uterine -leeding 3eg,
post,enopausal -leeding, pre,enopausal recurrent ,etrorrhagia6. +-out 1?. of wo,en with post,enopausal
-leeding ha8e endo,etrial carcino,a. #n post,enopausal wo,en, a 8aginal discharge ,ay precede -leeding -y
se8eral weeks or ,onths.
#f a Papanicolaou 3Pap6 s,ear shows endo,etrial cells in a post,enopausal wo,an or atypical
endo,etrial cells in a wo,an of any age, further e8aluation is indicated. Howe8er, a Pap s,ear does not
accurately detect endo,etrial ,alignancies.
Tissue sa,pling fro, the endo,etriu,, usually perfor,ed in the physician<s office, is the definiti8e
diagnostic procedure. This procedure is = %'2 accurate, co,pared with a fractional dilation and curettage with
hysteroscopy, perfor,ed in the operating roo,. The latter is used when outpatient sa,pling is not diagnostic.
Trans8aginal ultrasonography ,ay also -e useful.
@nce a histologic diagnosis of endo,etrial cancer is ,ade, pretreat,ent e8aluation includes seru,
che,istry studies, li8er function tests, a "B", chest ;9ray, and 4"5. +dditional endoscopic and radiologic
studies are not routinely necessary. Pel8ic and a-do,inal "T ,ay help if e;trauterine or ,etastatic disease is
suspected.
Staging, Prognosis, and Treatment
*taging is -ased on histologic differentiation 3grade6 of the tu,or and findings during surgery, including
depth of in8asion, cer8ical in8ol8e,ent 3glandular in8ol8e,ent 8s. stro,al in8asion6, and e;trauterine
,etastases, such as those to the adne;a, ly,ph nodes, and peritoneal ca8ity 3see Ta-le A/1(16. +n adeBuate
a-do,inal incision is ,ade, allowing sa,pling of peritoneal fluid for cytologic e8aluation and e;ploration of
the a-do,en and pel8is, with -iopsy or e;cision of suspicious e;trauterine lesions. Pel8ic and para9aortic
1
ly,ph nodes should -e sa,pled in high9risk situations and, if suspicious, re,o8ed. + radical hysterecto,y with
pel8ic and para9aortic ly,ph node dissection is indicated if cer8ical in8ol8e,ent is suspected.
Prognosis is influenced -y the tu,or<s histologic appearance and grading, the patient<s age 3older
wo,en ha8e a poorer prognosis6, and ,etastatic spread. @8erall, &.2 of patients are cancer9free = 0 yr after
treat,ent. Cor patients with stage # disease, the reported 09yr sur8i8al rate is 7' to %02$ the 09yr sur8i8al rate
for those with stage ### or #D disease is 1' to &'2.
*tage #, grade 1 endo,etrial cancer without deep ,yo,etrial in8asion is usually locali7ed$ the
pro-a-ility of ly,ph node ,etastasis is 1 A2. *urgery can usually -e li,ited to a total hysterecto,y, -ilateral
salpingo9oophorecto,y, and peritoneal cytologic e;a,ination. Cor grades A and . and for grade 1 with deep
,yo,etrial in8asion, a pel8ic and para9aortic ly,phadenecto,y ,ay -e added.
Dery few patients with cancer confined to the uterus ha8e recurrences. +ccurate surgical staging ena-les
0' to 702 of patients with stage # disease to forego postoperati8e radiation therapy. 4;trapel8ic cancer,
depending on the site and e;tent, is treated with e;tended9field radiation, syste,ic che,otherapy, or hor,one
therapy. Most patients with stage #D disease are -est treated with syste,ic che,otherapy.
Progesterone therapy, used for ad8anced or recurrent disease, leads to regression in .0 to /'2 of
patients. Progesterone can induce regression of pul,onary, 8aginal, and ,ediastinal ,etastases. Treat,ent
continues indefinitely if the response is fa8ora-le. The duration of re,ission 8aries -ut ,ay last A to . yr.
*e8eral cytoto;ic drugs 3especially do;oru-icin and cisplatin6 are acti8e against ,etastatic and recurrent
endo,etrial cancer. Monthly regi,ens co,-ining do;oru-icin &' ,g?,A and cisplatin 70 ,g?,A #D ,ay ha8e
o8erall response rates of = 0'2. Paclita;el shows acti8ity against this cancer.
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