HemeOnc

Endometrial Cancer

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Endometrial Cancer, Uterine Cancer, Endometrial Carcinoma

  • Epidemiology
  1. Onset age over 50 years in 90% of cases (mean age is 63 years)
    1. Premenopausal diagnosis of Endometrial Cancer occurs in 20% of cases
  2. Most common gynecologic tract cancer
    1. Incidence 1.5 times more common than Ovarian Cancer
    2. Incidence 3 times more common than Cervical Cancer
  3. U.S. Statistics from 2015 (increasing Incidence, doubling in the last 20 years)
    1. Incidence: 54, 870 new cases per year
    2. Mortality: 10,170 deaths per year
    3. ACS Cancer facts and figures
      1. http://www.cancer.org/research/cancerfactsstatistics/index
  • Risk Factors
  1. See Endometrial Cancer Risk Factors (also includes protective factors)
  2. Hereditary Nonpolyposis Colorectal Cancer (HNPCC, Lynch Syndrome) are at high risk of Endometrial Cancer
    1. Offer annual Endometrial Biopsy starting at age 35 years
  3. Paradoxically, Tobacco use is associated with a lower Incidence of Uterine Cancer
  • Types
  1. Type I - Endometrioid (70 to 75% of cases)
    1. Typically associated with Unopposed Estrogen with Endometrial Hyperplasia as a precursor
  2. Type II - Non-Endometrioid (10%)
    1. Not associated with Unopposed Estrogen, Endometrial Hyperplasia or other typical Endometrial Cancer Risks
    2. Includes serous, papillary, clear cell, mucinous, squamous, an adenosquamous types
    3. Onset at older age, more advanced stage and with worse prognosis (accounts for 40% of mortality)
    4. Most common in black women over age 50 years old
  3. Familial Tumors (10%)
    1. Most associated with Lynch Syndrome (Hereditary Nonpolyposis Colorectal Cancer, HNPCC)
    2. HNPCC confers a 22-50% lifetime risk of Endometrial Cancer
  • Pathophysiology
  1. See Endometrial Hyperplasia (precursor of Type I, endometrioid cancers)
  • Symptoms
  • Presentation (90% of cases)
  1. Abnormal Uterine Bleeding (most common symptom)
  2. Abnormal Vaginal Discharge
  • Exam
  1. Evaluate for other sources of bleeding (e.g. vagina, Cervix)
  2. Bimanual exam
  • Evaluation
  1. See Endometrial Cancer Screening
    1. Covers Indications (includes Endometrial Hyperplasia)
    2. Includes evaluation with Trasvaginal Ultrasound and Endometrial Biopsy
  2. See Dysfunctional Uterine Bleeding
  • Imaging
  1. See Endometrial Cancer Screening for Transvaginal Ultrasound recommendations
  2. At time of Endometrial Cancer diagnosis
    1. Chest XRay
    2. Trasvaginal Ultrasound (if not already performed)
    3. Consider Pelvic MRI
  • Labs
  1. Urine Pregnancy Test
  2. Pap Smear (if due)
    1. AGUS on Pap Smear may suggest Endometrial Hyperplasia or Endometrial Cancer
  • Management
  1. Precautions
    1. Biopsy may under-grade Endometrial Cancer (e.g. Grade I is really a Grade 3)
  2. Surgery
    1. Total Hysterectomy with bilateral salpingoophorectomy
      1. First-line management in Stages I-III
      2. Tumor debulking in Stage IV Endometrial Cancer
      3. Vaginal Hysterectomy is not recommended
        1. Does not allow for abdominal evaluation or lymphadenectomy
    2. Peritoneal washings (pelvic washings)
      1. Indicated in Stages I-III
    3. Para-aortic or pelvic lymph node dissection may be needed depending on staging
      1. Indicated in Stages I-III
  3. Radiation Therapy
    1. Indicated in Stages II, III
  4. Systemic therapy (indicated in Stages III, IV)
    1. Progestins
    2. Tamoxifen
    3. Chemotherapy
      1. Doxorubicin (Adriamycin)
      2. Paclitaxel (Taxol)
  5. Post-treatment surveillance
    1. History and exam every 3-6 months for 2 years, then every 6 months for 3 years, then yearly
  • Prevention
  1. Manage Unopposed Estrogen states (e.g. OCP, weight loss)
  2. Consider prophylactic Hysterectomy at age 40 years old for women with Lynch Syndrome