Endometrial cancer is an epithelial malignancy of the uterine corpus mucosa. 90% are adenocarcinomas. It is characterised by abnormal uterine bleeding, particularly post-menopausal bleeding.
It peaks between 60 and 70 years.
Types of endometrial cancer
| Type I | Type II | |
|---|---|---|
| Unopposed estrogen | Present | Absent |
| Estrogen responsive | Yes | No |
| Rate of growth | Slow | Rapid |
| Precursor lesion | Atypical hyperplasia | Atrophic epithelium, Endometrial intraepithelial carcinoma |
| Histology | Endometrioid | Non-endometrioid (Serous or clear cell) |
| Grade | Low | High |
| Depth of invasion | Superficial | Deep |
| Age at diagnosis | Younger | Older |
| Prognosis | Better | Worse |
| Genetic changes | PTEN, KRAS | p53 (90%), HER2/Neu (serous) |
- Risk factors
- Hyperestrogenism
- High-dose menopausal estrogen
- Obesity
- Nulliparity
- Early menarche
- Late menopause
- Use of tamoxifen
- Polycystic ovarian syndrome
- Medical conditions
- Type 2 diabetes mellitus
- Hypertension
- Gallbladder disease
- Lynch syndrome
- Higher socioeconomic status
- Older age
- Living in North America or Northern Europe
- Hyperestrogenism
- Protective factors
- Multiparity
- Combined oral contraceptives
- Regular exercise
- Smoking
- Associated conditions
- Lynch syndrome
- Pathophysiology
- Chronic oestrogen stimulation of the endometrium in the absence of opposition by progesterone → persistence of the proliferative endometrium → glandular cell hyperplasia → somatic mutations → abnormal proliferation of endometrial glands → neoplasia
- The absence of progesterone prevents the endometrial lining from shedding
- Signs and Symptoms
- Abnormal uterine bleeding
- Post-menopausal bleeding
- Menorrhagia
- Intermenstrual bleeding
- Abnormal uterine bleeding
- Differentials
- Atrophic vaginitis
- Endometrial hyperplasia
- Endometrial polyp
- Investigations
- Transvaginal ultrasound is the first investigation
- Thickened endometrial stripe
- Endometrial biopsy for confirmatory diagnosis
- Hysteroscopy, dilatation and curettage if endometrial biopsy cannot be performed
- CT scan of the chest, abdomen and pelvis for staging
- Transvaginal ultrasound is the first investigation
- Treatment
- Surgery
- Total abdominal hysterectomy -Bilateral salpingo-oophorectomy (TAH-BSO) and Lymphadenectomy
- Radiation therapy for ≥ stage IB
- Chemotherapy and radiation therapy for stage III and IV
- Progestin (low dose megestrol) and frequent endometrial sampling for low-risk disease if fertility needs to be preserved
- Surgery
Staging of endometrial carcinoma
| Stage | Description | % at diagnosis | 5-year survival |
|---|---|---|---|
| Stage I | Tumor confined to the corpus uterus (endometrium and myometrium) | 75% | |
| IA | < 50% myometrial invasion | 88-91% | |
| IB | ≥ 50% myometrial invasion | 75-88% | |
| Stage II | Tumor invades cervical stroma but does not extend beyond the uterus | 25% | 67-77% |
| Stage III | Local and/or regional spread of the tumor | ||
| IIIA | Invades the serosa, adnexae, or peritoneum | 58-60% | |
| IIIB | Vaginal and/or parametrial involvement | 41-50% | |
| IIIC | Metastasis to pelvic or para-aortic nodes | 32-47% | |
| Stage IV | Metastasis to bowel, bladder, or beyond | ||
| IVA | Metastasis to bowel or bladder mucosa | 17-20% | |
| IVB | Distant metastasis including abdominal structures and/or inguinal nodes | 5-15% |