Endometrial carcinoma

Definition

Cancer definitions are always a bit silly as it's generally just "cancer of bit". This is no different - the cancer is a carcinoma (involves epithelial cells) and the bit is the endometrium

Epidemiology

Peak age around 55-65 years old. 75% of women affected are postmenopausal.

Pathophysiology

Unopposed oestrogen has been implicated in the initial development of this cancer. It causes endometrial hyperplasia which increases the risk of cancer developing. (More cell division, the more chance that something will go wrong.)

The tumour tends to spread over the endometrium before invading myometrium. Growths in the lower part of the uterus can block the cervix. This causes fluid and pus to build up in the uterus and is known as a pyometra.

Risk Factors

• Being overweight
• Hypertension
• Infertility
• Late menopause
• Diabetes
• Breast or ovarian cancer
• High levels of oestorgen

Clinical Features

The main features are bloody discharge (postmenopause) and/or irregular bleeding (premenopause), both of which trigger hysteroscopy. Sometimes the discharge can be watery but this uncommon. Lower abdominal pain can also occur. On examination, the uterus is normal unless there is a pyometra.

Investigations

• FBC - anaemia is present in women who are bleeding heavily
• USS - measure the thickness of the endometrium
• Hysteroscopy and biopsy - this is done in all women who present with bloody discharge or irregular bleeding.

Classification

The staging of endometrial cancer is done using the FIGO (International Federation of Obstetricians and Gynaecologists) system. There are four main stages, each split further into A, B etc.

• IA - limited to endometrium; IB - invasion of < half myometrium; IC - > half myometrium
• IIA - involvement of endocervical glands; IIB - invasion of cervical stroma
• IIIA - invasion of serosa (the outer bit of the uterus)/adnexae/peritoneum cytology +ve; IIIB - metastases in vagina; IIIC - pelvic mets/para-aortic lymph nodes
• IVA - bladder/bowel invasion; IVB - distant metastases

Management

The management is based on the stage but over 75% of cases are caught in the early stages. The treatment of choice is hysterectomy with bilateral salpingo-oopherectomy (removal of uterus, fallopian tubes and ovaries). Radiation therapy is used in more advanced cancer and pelvic lymphadenectomy can be performed if necessary.

If surgery is not possible (e.g. the patient is unfit), medroxyprogesterone acetate can be given 200-400mg daily orally.

Prognosis

This is dependent on the stage but varies from 90% to 10%.

• IA - 90%, B - 88%, C - 80%
• IIA - 77%, B - 67%
• III - 40%
• IV - 10%