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

Postmenopausal Bleeding

 * The most common cause of postmenopausal bleeding is atrophic endometritis, followed by side effects of exogenous estrogens, endometrial cancer, and other etiologies.

Endometrial Hyperplasia

 * 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

Endometrial Adenocarcinoma

 * 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

Endometrial Cancer

 * 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.

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.

Endometrial Hyperplasia

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

Endometrial Cancer

 * Adenocarcinoma (75% of endometrial cancer)
 * Serous papillary: staging should be done as ovarian cancer
 * Small cell neuroendocrine (oat cell)
 * Clear cell carcinoma
 * Sarcoma
 * Leiomyosarcoma

Staging

 * 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)

Endometrial Hyperplasia

 * Hysterectomy for atypical adenomatous.

Endometrial Cancer

 * 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.