Obstetrics and Gynecology/Endometrial Neoplasia

Epidemiology

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

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
- Anovulation
- 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)
Nulliparity
Late menopause

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
Hematometrium
Endometrial cells on pap smear
Enlarged uterus

Recurrent endometrial cancer typically presents in the vagina, lymph nodes, and lungs.

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.

Simple-cystic
Complex Adenomatous
Atypical Adenomatous
- Atypical adenomatous endometrial hyperplasia has a 20-30% chance of malignant transformation.

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)

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.