Endometrial Carcinoma

Snapshot

• A 58-year-old woman presents to her gynecologist for vaginal bleeding. She denies any vaginal pain or trauma and is not on any medications. Medical history is notable for morbid obesity and denies undergoing menopause. A transvaginal ultrasound is performed, which demonstrates endometrial thickening of 6 mm. She underdgoes an endometrial biopsy, which is consistent with endometrial cancer.

Introduction

• Overview
  • malignancy affecting the endometrium of the uterus
• Epidemiology
  • incidence
    • most commonly affects women > 40 years of age
  • risk factors 
    • elevated estrogen exposure
      • unopposed estrogen use
      • polycystic ovarian syndrome
      • early menarche
      • estrogen producing tumor
    • obesity
    • nulliparity or history of infertility 
    • longterm tamoxifen use
    • Lynch syndrome
    • family history
• Pathophysiology
  • estrogen acts on estrogen receptors in the endometrium, promoting endometrial proliferation and increasing the risk of cancer development
    • normally, progesterone inhibits proliferation of the endometrium
      • abnormalities in progesterone lead to unopposed endometrial proliferation
• Associated conditions
  • cervical adenocarcinoma
  • primary or ovarian cancer
• Prognosis
  • prognostic factors
• improved

Presentation

• Symptoms
  • abnormal uterine bleeding
    • postmenopause
      • any bleeding
    • 45 to menopause
      • frequent, heavy, or prolonged bleeding
    • < 45 years of age
      • persistent bleeding
• concerning in patients with risk factors (e.g., chronic anovulation and obesity)

Imaging

• Transvaginal ultrasound
  • indication
    • initial imaging study for the evaluation of abnormal uterine bleeding in postmenopausal women
      • determines endometrial thickness
• Hysteroscopy
  • indication
• performed with dilation and curettage (D&C) in cases where transvaginal ultrasound and endometrial biopsy is unremarkable

Studies

• Invasive studies
  • endometrial biopsy
    • indication
• a method of confirming the diagnosis via histology

Differential

• Uterine leiomyoma
  • differentiating factors
    • enlarged smooth muscle tumor
• Adenomyosis
  • differentiating factors
• endometrial gland and stroma in the myometrium

Treatment

• Treatment depends whether the tumor is confined to the uterus or has metastasized
  • treatment involves surgery with or without chemotherapy, hormonal therapy, and radiation
• Medical
  • progestine therapy
    • indication
      • endometrial cancer confined to the uterus in women who want to preserve fertility
• Surgical
  • total hysterectomy and bilateral salpingo-oophorectomy
    • indication
      • initial management for endometrial cancer
        • along with pelvic and para-aortic lymphadenectomy
• also collecting peritoneal fluid for cytology

Complications

• Anemia
• Metastasis