Endometrial Cancer 1

Endometrial Cancer

Endometrial cancer is the most common gynecologic malignancy. Two to 3% of women will develop endometrial cancer
at some time during their lives.
I. Risk factors
A. Endometrial cancer is predominantly a disease of postmenopausal women. When endometrial cancer develops
before age 40, it occurs most often in women who are obese or chronically anovulatory.
B. The principal risk factor for endometrial cancer is chronic, unopposed estrogen exposure, due to early menarche,
late menopause, obesity, chronic anovulation, or estrogen-secreting ovarian tumors.
C. Endometrial cancer has been associated with pelvic radiation and breast or ovarian cancer.
II. Diagnosis
A. Ninety percent of patients present with abnormal uterine bleeding occurring after menopause. Only 1-5% present
with abnormal cells on Pap smear.
B. Endometrial cancer should be suspected in postmenopausal women who have any bleeding, and in
perimenopausal women who have increased menstrual flow, a decreased menstrual interval, or intermenstrual
bleeding.
C. The Pap smear cannot be relied upon to detect endometrial cancer. However, endometrial cancer should be
suspected when atypical endometrial cells are found in the Pap smear of a nonpregnant woman of any age or
when normal endometrial cells are found in a postmenopausal woman not taking estrogens.
D. Evaluation of suspected endometrial cancer
1. A Pap smear of the ectocervix and endocervix should be completed.
2. The uterus, adnexa, cervix, vagina, and rectum should be palpated by bimanual rectovaginal exam for masses,
nodularity, induration, and immobility.
3. Endometrial sampling with a Pipelle aspirator is indicated in postmenopausal women with vaginal bleeding
or perimenopausal women with a menstrual abnormality.
4. Suspicious lesions are biopsied.
5. A stool occult blood test is completed.
6. Endocervical curettage is necessary because endocervical carcinoma can missed by endometrial biopsy.
E. If the endometrial biopsy has been performed and no significant abnormality was detected, no further evaluation
is needed. If high-risk factors are present and the cause of the bleeding remains undiagnosed, a fractional D&C
should be completed. Hysteroscopy may also be helpful to evaluate the endometrium further.
F. Laboratory evaluation of endometrial carcinoma
1. Two-view chest X-ray
2. Serum electrolytes, complete blood count, renal and hepatic function tests, urinalysis.
3. Other studies that may be performed, include sigmoidoscopy and barium enema, intravenous pyelogram, or
colonoscopy. When a high-grade cancer is found, serum CA 125 assay and CT of the abdomen and pelvis
may be helpful.
III. Staging and management
A. Surgical staging for patients with endometrial carcinoma that is apparently confined to the uterus requires the
following:

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1. The supraclavicular and inguinal lymph nodes and the abdomen should be examined.
2. Abdominal laparotomy.
3. Peritoneal washings for cytology.
4. Inspection and palpation of the abdominal and pelvic organs (diaphragm, liver, omentum, retroperitoneal
nodes, pelvic peritoneum).
5. Total hysterectomy and bilateral salpingo-oophorectomy.
6. A frozen section is completed to determine if invasion is present. If invasion is seen, a pelvic and paraaortic
node biopsy is completed and enlarged nodes are removed.

FIGO staging for carcinoma of the corpus uteri

Stage Clinical Findings

Stage IA Tumor limited to endometrium; no invasion

Stage lB Invasion to less than one-half the myometrium

Stage IC Invasion to more than one-half the myometrium

Stage IIA Endocervical glandular involvement only

Stage lIB Cervical stromal invasion

Stage IlIA Tumor invades serosa, and/or adnexa, and/or positive peritoneal cytology

Stage IIIB Vaginal metastases

Stage IIIC Metastases to pelvic and/or paraaortic nodes

Stage IVA Tumor invasion of bladder and/or bowel mucosa

Stage IVB Distant metastases including lymph nodes

B. Postoperative management
1. Adjuvant radiation is offered to patients at high risk of recurrence (lymphovascular space
involvement, cervical invasion).
2. Hormone therapy
a. Cancers associated with a high progesterone receptor concentration are associated with a
better prognosis.
b. Hormone therapy with megestrol acetate (Megace) is offered for recurrent or metastatic
disease. The response is 20-30%, with prolongation of survival for 1 year.
3. Chemotherapy. The most effective regimen includes adriamycin; however, tamoxifen (Taxol) is
emerging as an effective agent. Overall responses are moderate.
IV. Serous and clear cell adenocarcinomas
A. These cancers are considered in a separate category from endometrioid adenocarcinomas. They
have a worse prognosis overall. Patients with serious carcinomas have a poorer survival. The 3 year
survival is 40% for stage I disease.

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B. Serous and clear cell carcinomas are staged like ovarian cancer. A total abdominal hysterectomy and
bilateral salpingo-oophorectomy, lymph node biopsy, and omental biopsy/omentectomy are
completed. Washings from the pelvis, gutters and diaphragm are obtained, and the diaphragm is
sampled and peritoneal biopsies completed. §

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