Endometrial Cancer

Epidemiology

• Most commone cancer of the female genital tract
• Occurs mainly in older women (>50)
• It has quite a high 5-year survival as most cases are caught early-ish
  • Stage IA has a 90% 5-year survival; II has 69%; IIIB has 50% and IV has 16%

Pathology

Endometrial cancer is a cancer of the columnar epithelial cells of the endometrium.  The most common type is an adenocarcinoma of these cells.

Causes

• Endogenous causes
  • e.g. obesity (combined lifestyle and hormonal factors at play since the more peripheral fat an individual has, the more oestrogen can be produced)
  • Nulliparity (2-3 x risk)
  • Late menopause (>52years old)
• Unapposed Oestrogen e.g. in HRT (this is why progestogen MUST be given in conjunction with oestrogen in women with a uterus)
  • Tamoxifen
• Causes of amenorrhea (e.g. PCOS)
• FHx

NB Pregnancy, the COC and smoking seem to reduce the risk of endometrial cancer.

Clinical Features

• Post-menopausal bleeding
  • Should always be investigated (if the patient is on cyclic HRT, then irregular bleeding should be investigated)
• In the pre/peri-menopausal patients:
  • Irregular bleeding (metrorrhagia) should be investigated (for exclusion if nothing else)
    • IMPORTANT TO REMEMBER: irregular bleeding is NOT a true feature of the menopause- bleeding should become less frequent and lighter but not irregular.
• Other subtle signs of cancer may be present
  • e.g. weight loss; night sweats etc.

On examination

• A smear should be taken to exclude cervical causes and a swab should be taken to exclude chlamydia/gonorrhea
• Bimanual examination and abdominal examination may be completely normal.

Investigations

• Transvaginal USS is first line investigation
  • Looking for any thickening of the endometrium
  • Looking to exclude any other pathology e.g. polyp
• Biopsy (Pipelle/Hysteroscopic)
  • Usually only done if there is an abnormality at USS- however, if the patient is symptomatic (I.e. not a single episode) then this may be the investigation of choice anyway
• Further investigation to check degree of spread (staging) may include MRI/CXR/ECG/FBC/LFT/U&E etc etc

Staging

The International Federation of Gynaecology and Obstetrics (FIGO) staging system:

1. Confined to the uterus
   1. Confined to endometrium
   2. Less than half myometrial invasion
   3. Equal or more than half myometrial invasion
2. Tumour has invaded the cervical stroma (i.e. glandular and squamous components) (as well as the uterus)
3. Local and/or regional spread
   1. Invasion of the uterine serosa and/or uterine adnexae
   2. Vaginal metastases and/or parametrial involvement
   3. Metastases to pelvic and/or para-aortic lymph nodes
      1. Positive pelvic nodes
      2. Positive para-aortic nodes +/- positive pelvic nodes
4. Tumour invasion of bladder and/or bowel mucosa and/or distant metastases
   1. Bladder and/or bowel spread
   2. Distant metastases (including intra-abdominal and/or inguinal lymph nodes)

Other staging is histopathological:

• G1- nonsquamous or nonmorular solid growth pattern of 5% or less (i.e. resembles normal)
• G2- nonsquamous or nonmorular solid growth pattern of 6-50% (i.e. some abnormal with some normal)
• G3- nonsquamous or nonmorular solid growth pattern of >50% (i.e. grossly abnormal)

Treatment

• Usually surgical
  • Hysterectomy +/- bilateral salpingo-oophorectomy
• +/- Radio- +/- Chemotherapy
• High dose progestogens may help

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