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Endometrial carcinoma

Endometrial cancer- uterine cancer arising from the innermost layer of the uterus

 

Use of Oral contraceptives is considered to have a protective effect and studies have shown that the lower risk may be limited to women
 with + 5 yrs of OC use and this may persist for 20 yrs after stopping use of OC.

 

Unopposed oestrogen exposure -it is thought that oestrogen leads to endometrial hyperplasia -dysplasi and later carcinoma – Increased oestrogen in conditions as obesity ,metabolic syndrome , diabetes -adipose tissue converts androgens to oestrogen.

 

Functional layer of endometrium is hormone sensitive and excess oestrogen can lead to endometrial hyperplasia -causes increased sloughing of the endomEtrial tissue through endometrial canal into vagina -hence HMB or bleeding after menopause.

 

Screening is not recommended for asymptomatic women ( lack of evidence of using TVS or endometrial sampling ) American Cancer Society recommends that women > 65 should be advised about risks and symptoms of Ca endometrium Classified into 2 types.

 

Type 1 Most common form Associated with unopposed oestrogen stimulation Called as endometrioid adenocarcinoma Oestrogen dependent Responsible for 70% to 80 % of new cases Often seen in obese women with evidence of endogenous oestrogen excess

 

Type 2 More likely to be high grade and of papillary serous or clear histologic type Overall poor prognosis with high risk of relapse and metastases.

 

Most endometrial carcinomas are sporadic Inherited genetic mutation syndromes as Lynch syndrome , hereditary nonpolyposis colorectal cancer and can carry a high risk of endometrial cancer ( upto 70 % in Lynch syndrome ) It is recommended that women ( and their 1s degree relatives ) who are at high risk for e.g Lynch syndrome are screened with TVS and endometrial biopsy from age of 35 annually.

 

Tamoxifen – Tamoxifen increases the risk of endometrial cancer Used in treatment of breast cancer Tamoxifen stimulates oestrogen receptors in endometrium If a patient on tamoxifen reports vaginal bleeding consider the possibility of EnCa and refer promptly.

 

Differentials – In premenopausal women abnormal uterine bleeding may be due to endometriosis , fibroids , adenomyosis and ovulatory dysfunction In postmenopausal women conditions as atrophic vaginitis , endometrial atrophy , endometrial hyperplasia and endometrial / cervical polyps may be the potential differentials Infection Coagulopathy.

 

Vaginal bleeding in a postmenopausal women is the most common presentation ( not taking HRT ) Abnormal uterine bleeding ( for e.g intermenstrual bleeding and irregular menstrual cycle ) in premenopausal women can can also be a presenting feature Other features may include
○ vague abdominal pain
○ pelvic discomfort
○ nausea
○ dysuria.

 

Examination – Examination may not reveal much Examine to r/o bleeding from other sources as vagina or cervix If excessive blood loss has happened the patient may appear pale Abdominal examination is likely to be normal if the uterus is small in size and non – tender PV- you may note bloody vaginal discharge or blood clots.

 

Investigations – Pregnancy test in women of chidbearing age Check FBC if bleeding heavy Coagulation profile Transvaginal ultrasound ( TVS ) Endomtetrial biopsy Dilatation and curettage Hysteroscopyo. MRI may provide information on endometrial thickening or structural abnormalities such as fibroids or adenomyosis.

 

Refer 2 week USC – 55 and over with post menopausal bleeding which is unexplained vaginal bleeding more than 12 months after menstruation has stopped because of menopause.

 

Consider 2 week USC – Aged < 55 with post 
menopausal bleeding

 

Direct access US for women 55 and over – unexplained symptoms of vaginal discharge who have
○ come for the first time regarding this OR
○ have thrombocytosis OR
○ report haematuria
 Visible haematuria and
○ low hemoglobin OR
○ thrombocytosis OR
○ high blood glucose levels

any woman on HRT presenting with persistent or unexplained PMB after stopping HRT for 4 weeks Unscheduled vaginal bleeding in a patient taking tamoxifen PMB Persistent IMB + other risk factors even if pelvic examination is normal Palpable abdominal or pelvic mass which is not obvious uterine fibroid , GI or urological origin -refer for urgent US scan and simultaneously to a specialist

 

How is endometrial cancer managed – Surgery ( hysterectomy with b/l salpingo-oophorectomy ) is the main modality of treatment ,radiation and chemotherapy can also play a role Overall 5 year survival rate is about 81 % Stages 1 to IV Grades – low risk ( 1-2 ) and high risk 3 As with most cancers this varies -based on stage of the cancer at the time of diagnosis Addressing risk factors as obesity , diabetes and hypertension could play a preventative role

References

  1. Faizan U, Muppidi V. Uterine Cancer. [Updated 2020 Sep 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562313/
  2. Braun MM, Overbeek-Wager EA, Grumbo RJ. Diagnosis and Management of Endometrial Cancer. Am Fam Physician. 2016 Mar 15;93(6):468-74. PMID: 26977831.( Abstract )
  3. Sorosky JI. . Endometrial Cancer. Obstetrics & Gynecology. 2012;120(2):383–397. doi: 10.1097/AOG.0b013e3182605bf1.
  4. American Cancer Society- Endometrial Cancer Risk Factors Endometrial Cancer Risk Factors
  5. Cancer Research UK Uterine cancer Uterine cancer statistics | Cancer Research UK
  6. PDQ Adult Treatment Editorial Board. Endometrial Cancer Treatment (PDQ®): Patient Version. 2020 Nov 13. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK65896/
  7. Tran, Arthur-Quan, and Paola Gehrig. “Recent Advances in Endometrial Cancer.” F1000Research vol. 6 81. 27 Jan. 2017, doi:10.12688/f1000research.10020.1
  8. Scottish Referral Guidelines for Suspected Cancer Gynaecological Cancers (scot.nhs.uk)
  9. Casey MJ, Summers GK, Crotzer D. Endometrial Cancer. [Updated 2020 Jul 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525981/
  10. Suspected cancer: recognition and referral NICE guideline [NG12]Published:  Last updated: 

  11. BGCS Uterine Cancer Guidelines: Recommendations for Practice *_ (bgcs.org.uk)

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