Contents
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
- MRI
- Bloods- FBC, U&E’s, glucose
- Chest x-ray
- ECG
Staging
Staging is surgico-pathological
- In the body of the uterus only
- endometrium
- <1/2 myometrial invasion
- 1/2 myometrial invasion
- In the body of uterus and cervix
- <Outside uterus, but not outside pelvis
- Extending outside the pelvis (bowel and bladder or distant spread)
| Stage 1 | Stage 2 | Stage 3 |
|---|---|---|
 |
 |
 |
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.
References
- Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
- Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
- Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy