1. SurgicoMed.com Endometrial Cancer (Malignant Diseases of the Uterus)
Endometrial Cancer
(Malignant Diseases of the Uterus)
Endometrial cancer is a malignant disease of the uterus accounting for 30% of all of all other gynecological
malignancies. For its quick understanding, we also have to keep in mind the anatomy of the uterus and
endometrium especially.
Background
Uterus is the structure of female anatomy present in the pelvic girdle. It consists of three separate layers i-e
endometrium, myometrium and perimetrium from inside to outside respectively. Malignant diseases of the
uterus can present in any of these layer but endometrium is the most commonly effected layer.
Endometrium is the inner most glandular epithelial lining of the uterus so the malignancy arising from it mostly
presents in abnormal glandular pattern so termed as adenocarcinoma (adeno means glandular, carcinoma
means malignancy).
Adenocarcinoma of endometrium is of two type i-e endometrioid adenocarcinoma (type 1) and serous papillary
carcinoma (type 2). Clinically these are entirely two different entities. Let's clear our vision.
Differences Endometrioid Adenocarcinoma Serous Papillary Carcinoma
Incidence 90 % 10 %
Age of involvement Younger females Elderly females
Estrogen dependency Dependent Independent
Prognosis Good prognosis Poor prognosis
Rarely endometrial malignancy can present in fashion other than abnormal glandular pattern (adenocarcinoma)
so must be kept in mind during evaluation. Like clear cell carcinoma also arise from endometrium.
Rarely endometrial malignancy can present in fashion other than abnormal glandular pattern (adenocarcinoma).
Incidence
Endometrial cancers cover 30% of all gynecological malignancies. These cancers can be found throughout the
reproductive life of women but most cases are reported around 54 years of age (after menopause & average age
of menopause is > 52 years). 25 percent of the cases occur before menopause. Lifetime risk of developing
endometrial cancer is one in 90. Age related incidence is 95 per 100,000.

2. SurgicoMed.com Endometrial Cancer (Malignant Diseases of the Uterus)
Aetiology
As for aetiology, no pin point cause is identified yet but there is confirmed association of high circulating
estrogen level with endometrial cancer. The proof comes by the fact, oral contraceptive pill (OCP) and
progesterone only pill reduce the incidence up to 50%. More of that, smoking also decreases the risk of
endometrial cancer possibly by tobacco's anti-estrogenic effects. So any factor leading to high circulating
estrogen level may be responsible for endometrial caner. Certain risk factor are;
Risk Factor Possible Explanation
Obesity Androgens are converted to estrogen in peripheral adipose tissue
Diabetes Insulin & insulin like growth factor in diabetics stimulate estrogen interaction
Nulliparous Estrogen remains unopposed and elevated throughout the reproductive age just
due to lack of pregnancy
Late menopause For more life span, endometrium is exposed to estrogen
Unopposed estrogen therapy (You are welcome to explain here)
Tamoxifen Therapy As selective estrogen receptor modulator (SERM), prevents breast cancer by
selectively blocking estrogen receptors in breast but increases its circulating
level on other side and increases risk by factor of 2.5
Hormone replacement therapy
(HRT)
(You are welcome to explain here)
Family history of colorectal or
ovarian cancer
(You are welcome to explain here)
Clinical Presentation
Clinically two types of patients you may confront either post-menopausal or pre-menopausal ones. So clinical
presentation for both of them should be in mind. The classical and common symptom for both is abnormal
vaginal bleeding (in 90% of cases).
Pre-menopausal women commonly present with inter-menstrual bleeding (IMB), blood stained vaginal
discharge, heavy menstrual bleeding (HMB), lower abdominal pain or dyspareunia.
Post-menopausal women with vaginal bleeding should be investigated for malignancy as incidence of
gynecological malignancies is 10% in post-menopausal women.
Abnormal vaginal bleeding is the classic and common symptom both for pre-menopausal and post-menopausal
women.
10% of the cases have unusual presentation and are more prone to be misdiagnosed and advance to
complications. In advanced cancer, fistula formation, bony metastases, altered liver functions and respiratory
symptoms may be evident.
Abnormal glandular cytology found at the time of cervical smear merit further investigations which may reveal
endometrial cancer but such a case is very rare.

3. SurgicoMed.com Endometrial Cancer (Malignant Diseases of the Uterus)
Diagnosis
Cancers are finally diagnosed by the histological examination of the biopsy samples but what triggers to take
biopsy in such patients is the question. The array should be such, the patient comes to you with abnormal
vaginal bleeding and you would start with proper history and examination.
Then speculum examination reveals the blood arising from the cervix. Now you perform the bimanual
examination of the uterus which shows its enlargement. It is the time to seek help from investigations to
confirm your findings, the mainstays of which are ultrasound scanning, hysteroscopy and endometrial biopsy.
Transvaginal ultrasound scans (TVS) tells quick and accurate assessment of endometrial thickness. Cancer is
very unlikely to be present if endometrium is less than 4 mm thickened. If measurements are more than 4 mm,
we have to perform hysteroscopy (usually done in general anaesthesia) which allow direct visualization of the
endometrium. We can pick biopsy sample during hysteroscopy directly with the help of Pipelle or curettage.
Now the histological report confirms whether the uterus is malignant or not? It tells us clearly about the grade
and stage of the tumor so we manage it accordingly.
Following a diagnosis of endometrial cancer, MRI is performed to declare extent of disease (stage) and its
involvement of the structures surrounding the uterus.
Staging & Management
FIGO classification is a surgical classification to stage the endometrial cancer.
Stage Explanation
1 Confined to uterine body
1a Less than 50% invasion
1b More than 50% invasion
2 Tumor invading cervical stroma
3 Local and / regional spread of tumor
3a Invades serosa of uterus
3b Invades vagina and / parametrium
3c Metastases to pelvic and / para-aortic nodes
4 Tumor invades bladder +/- bowel +/- distant metastases
Management of endometrial cancer depends upon the stage at at the time of presentation. Surgery is the most
common treatment for endometrial cancer in most instances.
Surgery
Majority of the patients present with stage 1 disease so surgery is the most acceptable treatment for such
scenarios. The extent of surgery will depend upon a number of factors including grade of disease, MRI stage

4. SurgicoMed.com Endometrial Cancer (Malignant Diseases of the Uterus)
and patient's co-morbidities.
The standard surgery is total hysterectomy & bilateral salpingectomy. These procedures can be performed
abdominally or laparoscopically (total, vaginally or robotically). If patient is low grade (grade 1-2) or MRI
suggests disease less than stage 1B, this surgery is adequate. If MRI suggests cervical involvement, a radical
hysterectomy with pelvic node dissection can be performed. If the tumor is high grade (grade 3) or papillary
serous, many centres will perform pelvic and para-aortic node dissection as the risk of nodal disease (to pelvic
or para-aortic chain) can be as high as 30%.
Adjuvant Treatment
Postoperative radiotherapy reduces the local recurrence rate but it does not influence survival rate. Different
strategies for treatment for treatment include local radiotherapy to vaginal vault given over a short period of
time (high dose radiotherapy, HDR), external beam radiotherapy given for locally advanced disease (stage 3) in
combination with HDR. Chemotherapy is also useful for metastatic disease to combat the risk of distant spread
of the cancer.
Prognosis
Five-year survival rate for endometrial cancer is 80% but considerable variation is there depending upon tumor
type, stage and grade of tumor.
Stage 5-Year Survival rate (%)
1 88 (66-93)
2 75
3 55
4 16
Adverse prognostic features for survival include advanced age (more than 70 years), high BMI, grade 3 tumors,
papillary serous or clear cell histology, lymphovascular space involvement, nodal metastases and distant
metastases.
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