A10. Endometrial cancer; symptoms and diagnosis

Endometrial cancer is the cancer of the uterine corpus. There are multiple histological types, but the most common is the endometroid carcinoma. It’s mostly a disease of postmenopausal women.

It’s the most common form of gynaecological cancer (but not the most deadly, ovarian cancer is). It causes symptoms early, enabling diagnosis at a stage where there is a high likelihood of cure. The mortality is relatively low.

Pathological classification

These are most common histological types:

• Endometrioid type (80%)
• Non-endometrioid type
  • Serous adenocarcinoma
  • Clear cell carcinoma
  • Mucinous adenocarcinoma
  • +++

However, we can also distinguish two types based on the incidence, responsiveness to hormones, and clinical behaviour:

• Type I tumours – 80% of cases
  • Endometrioid carcinoma grade 1
  • Endometrioid carcinoma grade 2
• Type II tumours
  • Endometrioid carcinoma grade 3
  • Non-endometrioid carcinomas

Compared to type II tumours, type I tumours have a favourable prognosis, are oestrogen-induced, responsive to progestins, and may be preceded by an intraepithelial neoplasm.

Etiology

The risk factors for type I and type II are different. Type I is generally related to increased unopposed oestrogen exposure, while type II is unrelated to oestrogen:

• Type I tumours
  • Obesity
  • Unopposed oestrogen therapy
  • Tamoxifen
  • PCOS
  • Early menarche
  • Late menopause
• Type II tumours
  • Old age
  • Low BMI
  • Non-white ethnicity

Clinical features

The characteristic symptom is abnormal uterine bleeding, which is the presenting complaint in almost all cases. There is often metrorrhagia or hypermenorrhoea.

Diagnosis and evaluation

As always, history and physical examination is important. History should evaluate if the patient has received unopposed oestrogen therapy, if there is family history of gynaecological cancer, etc. Physical examination should include a conventional gynaecological exam, as well as a rectovaginal examination, to assess the rectovaginal septum. This can give information on whether the cancer has spread regionally.

Imaging is important. Transvaginal ultrasound can be used to evaluate the endometrial thickness. A thickness of ≤4 mm in postmenopausal women means a very low risk for endometrial cancer.

Endometrial carcinoma is a histological diagnosis based on an endometrial biopsy, curettage sample, or hysterectomy specimen. The endometrial biopsy may be blind or guided by hysteroscopy.

Staging

MRi or CT is important in staging the tumour, to evaluate the local and distant spread. The complete staging can only be performed after total hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy.