• Clinical science

Endometrial cancer

Summary

Endometrial cancer is the most common cancer of the female genital tract in the US, with a peak incidence between 65 and 74 years of age. Endometrial cancers can be divided into two types based on histological characteristics; type I cancers account for 80% of all endometrial cancers and are of endometrioid origin, while type II cancers originate mostly from serous or clear cells. Several risk factors are associated with the development of endometrial cancer, of which the most important is long-term exposure to increased estrogen levels, especially in type I cancer. The main symptom is often painless, vaginal bleeding, which presents at an early stage. Later stages may manifest with pelvic pain and a palpable mass, whereby pelvic exams are often normal. The diagnosis is made primarily via an endometrial biopsy, which shows endometrial hyperplasia and atypical cells. Additional imaging studies (e.g., ultrasonography, abdominal CT, and abdominal x-ray) are usually required for the detection and staging of metastases. Treatment of early-stage endometrial cancer involves total hysterectomy with bilateral salpingo-oophorectomy and may also require additional lymph node removal. Radical hysterectomy according to the Wertheim-Meigs method is performed in cases of advanced carcinomas and can be combined with radiotherapy and progestin treatment. The prognosis is usually favorable in cancers diagnosed at an early stage.

Definition

Etiology

Type I endometrial cancer

  • Directly related to long-term exposure to increased estrogen levels
  • Some genetic mutations (e.g., in the PTEN gene or mismatch repair genes) are also associated with this type of cancer.

Type II endometrial cancer

Risk factors for estrogen-dependent tumors

Protective factors

Low estrogen and high progestin or progesterone levels have a protective effect.

Epidemiology

  • Prevalence [4][5]
    • 1–2% in the US
    • The most common cancer of the female genital tract in the US [6]
    • Fourth most common cancer in women (after breast, lung, and colorectal cancer)
    • Type I endometrial cancer accounting for ∼ 80% of endometrial cancers, whereas type II endometrial cancer comprise 10–20% of cases [2]
  • Incidence: ∼ 20–28 per 100,000 women per year [4]
  • Age [4]
    • Primarily affect postmenopausal women
    • Peak incidence: 65–74 years
      • Onset of type I cancer is usually nearer to menopause
      • Type II cancer typically occurs in women who are much older, with the mean age of diagnosis being 67 years.

Epidemiological data refers to the US, unless otherwise specified.

Clinical features

Tumor-related

The majority of endometrial cancers are diagnosed at an early stage and have a good prognosis.

Metastases [7]

Diagnostics

Endometrial biopsy with histology [5]

Imaging

Laboratory tests

There is no routine screening test for endometrial cancer.

Pathology

Endometrioid adenocarcinoma [4]

Tumors of nonendometrioid histology

Treatment

Surgical management [8][9]

  • Indication: women with endometrial cancer who are postmenopausal, perimenopausal, or do not intend to become pregnant
  • Procedures
    • Total hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO) with or without lymph node removal
    • Advanced radical hysterectomy and removal of the upper vagina according to Wertheim-Meigs additional

Nonsurgical management

Complications

  • Pyometra [10]
    • An accumulation of pus in the uterine cavity
    • Caused by infection resulting from obstruction of the cervical opening by the tumor and secondary blood stasis (hematometra)
    • Can develop in patients with duplication of the cervix or as an uncommon complication of gynecological malignancy
    • Presented with purulent vaginal discharge, lower abdominal pain, and enlarged uterus
    • Diagnosed by imaging studies (e.g., abdominal ultrasound or CT scan)
    • Treated with drainage and dilation of the cervical lumen

We list the most important complications. The selection is not exhaustive.

Prognosis

To remember the prognoses of gynecological cancers, think of “CEOs (Cervical, Endometrial, Ovarian cancers) progressively decline.

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  • 2. Setiawan VW, Yang HP, Pike MC, et al. Type I and II Endometrial Cancers: Have They Different Risk Factors?. Journal of Clinical Oncology. 2013; 31(20): pp. 2607–2618. doi: 10.1200/jco.2012.48.2596.
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  • 9. Braun MM, Overbeek-Wagner EA, Grumbo RJ. Diagnosis and management of endometrial cancer. Am Fam Physician. 2016; 93(6): pp. 468–474. url: https://www.aafp.org/afp/2016/0315/p468.html.
  • 10. Lien W-C, Ong A-W, Sun J-T, et al. Pyometra: a potentially lethal differential diagnosis in older women. Am J Emerg Med. 2010; 28(1): pp. 103–105. doi: 10.1016/j.ajem.2009.08.024.
last updated 10/08/2020
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