Endometrial Carcinoma

Original article by Munisa Patel | Last updated on 16/5/2014
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Epidemiology

  • The most common genital tract cancer
  • Every year, about 4500 women in the UK develop endometrial cancer
  • The majority (93%) of cases are diagnosed in women aged over 50 years
  • Geographical variation exists - North American: Chinese ratio of about 7: 1
 

Pathology

  • Adenocarcinoma of the endometrial columnar cellsis the most common type (>90%)
  • Others include adenosquamous carcinoma
  • Pre-malignant disease occurs (endometrial hyperplasia with atypia)
 

Aetiology

  • High oestrogen / progesterone ratio
  • Nulliparity
  • Late menopause
  • Polycystic ovarian syndrome (if long term amenorrhoea)
  • Obesity
  • Unopposed oestrogens and tamoxifen
  • Diabetes mellitus
  • Family history of breast, ovary or colon carcinoma
  • Combined pill and pregnancy are protective
 

Clinical features

  • Abnormal vaginal bleeding
  • Postmenopausal bleeding (10% risk of endometrial cancer), usually little and occasional (+/- watery discharge), then bleeding gets heavier and more frequent
  • Premenopausal women get a change in bleeding pattern; irregular, intermenstrual or heavier bleeding
 

Investigations

  • History - determine if any risk factors are present
  • Examination - bimanual (? abdominal mass)
 

Postmenopausal

  • USS
  • Biopsy
    • Pipelle or during hysteroscopy
    • If endometrium > 5mm (on USS) or multiple episodes of bleeding
 

Premenopausal

  • If abnormal or change in periods and >40 yrs of age
 

Determining cancer spread and fitness for surgery

 

Staging

Staging is surgico-pathological
  1. In the body of the uterus only
    1. endometrium
    2. <1/2 myometrial invasion
    3. 1/2 myometrial invasion
  2. In the body of uterus and cervix
  3. <Outside uterus, but not outside pelvis
  4. Extending outside the pelvis (bowel and bladder or distant spread)
 

Treatment

Usually total abdominal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy

  • Radiotherapy if:
    • Lymph nodes positive/likely to be positive
    • Recurrent disease
    • Unfit for surgery
    • Palliative
    • Poor grade

High dose progestogens

  • eg medroxyprogesterone acetate
  • Used in advanced and/or recurrent disease
  • Shrinks the tumour
 

Prognosis

  • Dependent on histology (adenomosquamous poorer prognosis), grade and patient’s fitness
  • Overall 75% 5 year survival
  • Recurrence most common at vaginal vault within 3 years.