Endometrial Cancer

Background

• Malignancies of the lining of the uterus are classified either as type I (endometrioid adenocarcinoma) or type II endometrial carcinoma, which includes mucinous, serous, clear cell, and carcinosarcoma histological subtypes.
• Endometrial carcinoma typically affects women over the age of 40 years old.
• Endometrial hyperplasia is a precursor lesion to type I endometrial adenocarcinoma, which is part of the continuum of endometrial intraepithelial neoplasia.
• Risk factors for endometrial carcinoma include elevated estrogen exposure, increasing years of menstruation, polycystic ovary syndrome, obesity, nulliparity or history of infertility, family history, long-term use of tamoxifen, and hereditary nonpolyposis colorectal cancer (HNPCC) syndrome (Lynch syndrome).

Evaluation

• Most cases (90%) present with abnormal vaginal bleeding.
• Initial assessment may be with either transvaginal ultrasound (TVUS) or endometrial biopsy, but diagnosis is usually made by endometrial biopsy.
• TVUS may also be used for initial testing (Weak recommendation), and if the endometrial thickness is ≤ 4 mm, endometrial sampling is not required.
• If the initial evaluation is negative for endometrial cancer but bleeding persists, additional assessment is usually indicated.

Management

• Total abdominal hysterectomy and bilateral salpingo-oophorectomy is the primary treatment (Strong recommendation).
  • For stage I, low-risk endometrial adenocarcinomas, risk for recurrent disease is low and no further treatment should be given after definitive surgery.
  • For stage III-IV, maximal surgical debulking is indicated in patients with a good performance status and a resectable tumor.
• A lymphadenectomy should be performed in patients with stage II or higher endometrial cancer (Strong recommendation).
• Consider adjuvant platinum-based chemotherapy for patients with high-risk endometrioid adenocarcinoma and minimal comorbidities, but emphasize toxicity and small potential survival benefit (Weak recommendation).
• Consider adjuvant radiation therapy if the patient has positive pelvic or para-aortic nodes (Weak recommendation).
• Consider definitive radiation therapy when surgery is not feasible due to medical contraindications or unresectable disease (Weak recommendation).