Endometrial Cancer: Diagnosis and Treatment

Diagnosis

The patient's medical history may reveal abnormal vaginal bleeding or discharge, in addition to nonspecific findings such as lower abdominal pain, dysuria, and dysparuenia. Pelvic exam may reveal uterine enlargement, but cannot distinguish whether it is benign or malignant. An incidental Pap smear finding of either normal or atypical endometrial cells increases the chance of a uterine cancer diagnosis. However, a normal Pap result does not rule out endometrial cancer.

Endometrial biopsy should follow any Pap smear that shows endometrial cells, whether normal or atypical. It is a simple procedure. An exception may occur when normal endometrial cells are present and the woman is premenopausal and asymptomatic. Annual endometrial biopsy may be used to screen women with a personal or family history of hereditary nonpolyposis colorectal cancer gene mutations or an extensive family history of colon cancer.

Hysteroscopy or dilation and curettage can also provide endometrial tissue samples, but these procedures are far more invasive, require anesthesia, and have more frequent complications compared with endometrial biopsy. Although it is the preferred procedure for diagnosis, hysteroscopy can be reserved for cases in which endometrial biopsy is inconclusive, but the pre-test probability is high.

Transvaginal ultrasound can measure the endometrial thickness, which should be less than 4 mm in a postmenopausal woman. Sonohysterography, which involves infusion of fluid into the uterus, may also help distinguish normal from abnormal endometrium.

Treatment

Endometrial cancer staging requires hysterectomy and bilateral salpingo-oophorectomy. Perioperative inspection of the opened uterus, along with clinical history, helps determine if lymphadenectomy is required. Selective lymphadenectomy reduces associated morbidity and mortality. Peritoneal fluid cytology should be obtained during surgery for purposes of staging.

Surgical cytoreduction, radiation, hormone therapy, and chemotherapy may all be part of a treatment regimen. Progestin therapy may be used in women with the lowest stage or grade of disease who would like to preserve their fertility.

The International Federation of Gynecology and Obstetrics defines the following stages of endometrial cancer:

I. Cancer only in body of uterus.
II. Cancer spread from uterus to cervix.
III. Cancer spread outside the uterus, but inside the pelvis; bladder and rectum are not affected; lymph nodes may be positive.
IV. Cancer involves bladder, rectum, or organ outside pelvis.

Cancer antigen (CA) 125 measured preoperatively helps predict whether cancer has spread beyond the uterus. However, it cannot be used as a screening tool or as a substitute for surgical staging.