Obstetrics and Gynecology/Endometrial Neoplasia
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- 1 Epidemiology
- 2 Etiology and Risk Factors
- 3 Clinical Presentation and Diagnostic Approach
- 4 Pathology, Histology, and Staging
- 5 Management
- Endometrial cancer is the most common gynecological cancer in Canada
- Endometrial cancer has the best cure rate of all endometrial cancers due to early diagnosis
- Diagnosed at a median age of 58
- Most patients present with Stage I disease
Etiology and Risk Factors
- The most common cause of postmenopausal bleeding is atrophic endometritis, followed by side effects of exogenous estrogens, endometrial cancer, and other etiologies.
- Arises from unopposed estrogen (of at least 6 mo) causing hyperplasia of glandular and stromal tissues in the endometrium
- Endometrial hyperplasia may lead to estrogen sensitive endometrial cancer
- Lack of progesterone
- Obesity: aromatization of androstenedione to estrogen in peripheral fat cells. During menopause, fat cells continue to produce estrogen in the absence of progesterone. Therefore, endometrial adenocarcinoma has an increased incidence.
- SERM use (i.e. Tamoxifen for breast cancer -> 2-3X increased risk)
- Hormone replacement therapy without progesterone use.
- Gallbladder disease, diabetes, and/or hypertension
- History of breast, colorectal, or ovarian cancer (family history of lynch syndrome)
- Late menopause
Clinical Presentation and Diagnostic Approach
- Postmenopausal vaginal bleeding.
- In any postmenopausal woman, vaginal bleeding is endometrial cancer until proven otherwise.
- Abnormal premenopausal bleeding
- Rule out pregnancy.
- If the woman is anovulatory, they are more likely to have a malignant etiology.
- Metastatic disease and signs of advanced cancer
- Endometrial cells on pap smear
- Enlarged uterus
- Recurrent endometrial cancer typically presents in the vagina, lymph nodes, and lungs.
Diagnostic Approach to Abnormal Uterine Bleeding
- First, a pap smear should be done, with relevant follow up for pap smear abnormalities (if abnormal)
- Second, an endometrial biopsy should be performed
- Finally, transvaginal ultrasound should be requested, with the following parameters qualified
- Endometrial thickness (<5mm if hypoestrogenic, and >10mm if pathological)
- Dilation and curettage may be ultimately performed for diagnosis of cancer.
- For women on tamoxifen, estrogen hormone replacement therapy, and anovulatory women not taking progesterone, perform yearly endometrial biopsies.
Pathology, Histology, and Staging
- Complex Adenomatous
- Atypical Adenomatous
- Atypical adenomatous endometrial hyperplasia has a 20-30% chance of malignant transformation.
- Adenocarcinoma (75% of endometrial cancer)
- Serous papillary: staging should be done as ovarian cancer
- Small cell neuroendocrine (oat cell)
- Clear cell carcinoma
- Stage I (~85% survival at 5yr)
- IA: Tumor confined to the uterus with less than 1/2 myometrial invasion
- IB: Tumor confined to the uterus with more than 1/2 myometrial invasion
- Stage II (~65% survival at 5yr)
- II: Cervical extension, with persistent uterine confinement
- Stage III (~45% survival at 5yr)
- IIIA: Invasion of serosa/adenexa
- IIIB: Vaginal/parametrial invasion
- IIIC1: Pelvic node invasion
- IIIC2: Para-aortic node invasion
- Stage IV (~16% survival at 5yr)
- IVA: Tumor invasion of bladder/bowel
- IVB: Distant metastases (includes inguinal lymph nodes)
- Hysterectomy for atypical adenomatous.
- Serous papillary: chemotherapy (carbo/taxol) even if confined to uterus.
- Small cell neuroendocrine (cisplatin/etoposide)
- Surgery (total abdominal hysterectomy and bilateral salpingo-oophorectomy with or without lymph node dissection) and postoperative radio- and chemo-therapy.
- Chemotherapy is reserved for high risk patients with positive nodes, metastatic disease.
- Chemo- and radio-therapy alone are reserved for inoperable patients.
- Radiation for vaginal recurrence.
- High dose progesterone for hormone-sensitive recurrent cancer.