Snap Shot
  • A 72-year-old woman was evaluated for post-menopausal bleeding. A fractional dilatation and curettage revealed endometrial carcinoma. Her cervical Pap smear was normal. She had not been on any hormone replacement therapy. An ultrasound is performed.
  • Fourth most common malignancy in women after breast, colorectal, and lung cancer
  • Most common gynecologic malignancy
    • ovarian cancer is the leading cause of gynecological cancer deaths
  • It affects mainly postmenopausal women, with incidence peaking between ages 50 and 60
  • An estrogen dependent cancer. Sources can be from
    • ovary
    • extraglandular from peripheral conversion of androstenendione to estrone
    • exogenous from oral estrogen, patches, cremes.
  • Risk factors include
    • unopposed postmenopausal estrogen replacement
    • obesity, which increases risk by 3 to 10 times
    • hypertension
    • high fat diet as found in industrialized nations
    • nulliparity
    • late menopause (after 52)
    • anovulation
    • oligo-ovulation
    • polycystic ovarian syndrome
    • diabetes
    • estrogen-producing tumors
    • h/o of colon cancer, breast cancer, or ovarian cancer
    • h/o of cervical carcinoma in situ is not a risk factor
  • Endometrial hyperplasia usually precedes endometrial cancer
    • classified by the degree of cytologic atypia.
  • Histology
    • Adenocarcinoma accounts for > 80% of cases of endometrial cancer
    • Sarcomas account for about 5% of all uterine malignancies and include
      • mixed mesodermal tumors
      • leiomyosarcomas
      • endometrial stromal sarcomas
  • More than 90% of patients with endometrial cancer have abnormal uterine bleeding
    • postmenopausal bleeding
      • 1/3 of women with postmenopausal bleeding have endometrial carcinoma
    • premenopausal
    • recurrent metrorrhagia
  • Any post-menopasual woman with uterine bleeding requires an endometrial biopsy
    • tissue biopsy is the definitive diagnostic procedure
    • procedure is > 90% accurate
  • Pap smears NOT RELIABLE (miss 60%) of endometrial carcinoma cases
    • AGCUS on Pap smear requires endometrial evaluation
  • Pelvic and abdominal CT may help if extrauterine or metastatic disease is suspected
  • FIGO staging

    Stage Description
    1A Limited to the endometrium
    IIB Invasion of cervical stroma
    IIIC, Grade 3 Pelvic lymph metastases
    IVA Invasion to the bladder and/or bowel mucosa
    IVB Distant metastasis including lungs, vagina, abdomen, bone,intrabdominal
  • Endometrial hyperplasia
  • Simple or complex hyperplasia
    • progesterone to reverse hyperplastic process (e.g., Provera X 10 days)
  • Atypical hyperplasia
    • hysterectomy because of liklihood of invasion
    • progestin-only therapy if patient seeking to become pregnant
  • Stage I, grade 1 endometrial cancer without deep myometrial invasion
    • Probability of lymph node metastasis is < 2%.
    • TAH / BSO, and peritoneal cytologic examination
    • Accurate surgical staging enables 50-75% of patients with stage I disease to forego postoperative radiation therapy
  • For grades 2 and 3 and for grade 1 with deep myometrial invasion
    • TAH / BSO with pelvic and para-aortic lymphadenectomy
    • Extended-field radiation forextrapelvic cancer, depending on the site and extent
  • Stage IV disease are best treated with systemic chemotherapy
  • Valium to prevent spasms
  • Treatment for recurrence is high-dose progestins (Depo-Provera)
Prognosis, Prevention, and Complications
  • Very few patients with cancer confined to the uterus have recurrences
  • Histoligical grade is most important prognostic factor
  • Depth of invasion is second most important histological factor



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