Signs and Symptoms
Symptoms of early endometrial carcinoma are few but common. However, 90% of patients complain of abnormal vaginal discharge, and 80% of these women experience abnormal bleeding, usually after menopause. In the general population, 15% of postmenopausal women presenting with abnormal bleeding will be found to have endometrial carcinoma. Signs and symptoms of more advanced disease include pelvic pressure and other symptoms indicative of uterine enlargement or extrauterine tumor spread.
The diagnosis of endometrial cancer may be difficult to make in premenopausal patients. The physician must maintain a high index of suspicion in this group of patients and perform endometrial sampling in any women who complain of prolonged, heavy menstrual periods or intermenstrual spotting.
There is no role for screening of average-risk, asymptomatic patients for endometrial cancer.
Outpatient endometrial sampling
These procedures, such as endometrial biopsy or aspiration curettage coupled with endocervical sampling, are definitive if results are positive for cancer. The results of endometrial biopsies correlate well with endometrial curettings, and these biopsy procedures have the advantage of avoiding general anesthesia. However, if sampling techniques fail to provide sufficient diagnostic information or if abnormal bleeding persists, formal dilation and curettage is required.
Dilation and curettage
This is the gold standard for assessing uterine bleeding and diagnosing endometrial carcinoma. Before dilating the cervix, the endocervix should be curetted. Next, careful sounding of the uterus is accomplished. Dilation of the cervix is then performed, followed by systematic curetting of the entire endometrial cavity. Cervical and endometrial specimens should be kept separate and forwarded for pathologic interpretation.
The American Cancer Society (ACS) has concluded that there is insufficient evidence to recommend routine screening for endometrial cancer for average-risk women. However, the ACS recommends that at the time of menopause, all women should be informed about the risks and symptoms of endometrial cancer and strongly encouraged to report any unexpected bleeding or spotting to their physicians. Women at elevated risk for endometrial cancer from tamoxifen(Drug information on tamoxifen) therapy should be informed about the risk and symptoms of endometrial cancer and strongly encouraged to report any unexpected bleeding or spotting to their physicians.
Women who carry the HNPCC abnormailty should be considered for a prophylactic total abdominal hysterectomy bilateral saphingo-oophorectomy (TAH-BSO), especially after childbearing and when contemplating abdominal surgery for any reason. Additional investigation is needed to determine the appropriate monitoring for endometrial cancer in HNPCC carriers.
Endometrioid adenocarcinoma is the most common form of endometrial carcinoma, comprising 75% to 80% of cases. It varies from well differentiated to undifferentiated. The former demonstrates well-preserved glands in at least 95% of the tumor, whereas in the latter, less than half of the neoplasm shows glandular differentiation. Squamous differentiation can be seen in 30% to 50% of cases.
Adenocarcinoma with benign squamous differentiation has been termed adenoacanthoma and generally has a good prognosis.
If the squamous component resembles squamous carcinoma, the tumor is designated an adenosquamous carcinoma. These lesions tend to have a worse prognosis due to their association with a poorly differentiated glandular component.
This is an aggressive form of endometrial cancer that accounts for < 10% of these tumors. Serous cancer of the endometrium closely resembles serous carcinoma of the ovaries and fallopian tubes and is usually found in an advanced stage in older women.
Clear-cell carcinomas of the endometrium closely resemble their counterparts in the cervix, vagina, and ovaries. As with serous cancers, these tumors generally occur in older women and have a poor prognosis due to their propensity for early intraperitoneal spread.
This is an uncommon endometrial cancer that resembles secretory endometrium with its associated progestational changes. These cancers tend to be of low grade and have a good prognosis.
Two large prospective GOG surgical staging trials reported in 1984 and 1987 helped define the prognostic factors for endometrial carcinoma and the current treatment approaches. In addition to evaluating the predictive value of such factors as age, race, and endocrine status, the studies confirmed that prognosis is directly related to the presence or absence of easily determined uterine and extrauterine risk factors. Uterine prognostic factors include histologic cell type, tumor grade, depth of myometrial invasion, occult extension of disease to the cervix, and vascular space invasion. Extrauterine prognostic factors include adnexal metastases, intraperitoneal spread of disease to other extrauterine structures, positive peritoneal cytology, pelvic lymph node metastases, and aortic node involvement.
The revised staging system takes into account the nearly equivalent survival rates among low to intermediate grade IA and IB tumors, the lack of prognostic significance of endocervical gland involvement, and the marked survival differences of pelvic node or para-aortic node involvement. A revised staging system can be seen in Table 1.
Peritoneal cytology is no longer included in the staging system. It is to be reported separately without changing the stage. Several reports of patients with positive peritoneal cytology have failed to demonstrate that peritoneal cytology is a poor prognostic factor.
The size of the uterus was previously believed to be a risk factor and was part of the older clinical staging system. However, recent information indicates that uterine size is not an independent risk factor but rather relates to cell type, grade, and myometrial invasion.
Cell type and grade can be determined before hysterectomy, although in some series, grade, as determined by dilation and curettage, has an overall inaccuracy rate of 31% compared with grade in the hysterectomy specimen, and grade 3 tumors have an inaccuracy rate of 50%. Recognition of all of the other factors requires an exploratory laparotomy, peritoneal fluid sampling, and hysterectomy with careful pathologic interpretation of all removed tissue. This primary surgical approach led the International Federation of Gynecology and Obstetrics (FIGO) to define endometrial cancer as a surgically staged disease in 1988, incorporating many of the prognostic factors into the staging process (Table 2).