Endometrial Cancer

Cancer of the endometrium is a cancer of the lining of the uterus.  This is the part of the uterus which is shed away every month during reproductive years.  This is the most common gynaecological malignancy and accounts for 6% of all cancers in women.  The lifetime risk of endometrial cancer in Australia is 4%.  The majority of cases are diagnosed at an early stage and are amenable to treatment with surgery alone.  Patients with advanced stage or more aggressive types of endometrial cancer will require radiation and/or chemotherapy for optimal outcomes.

Endometrial cancer can be broadly categorized into two groups or types.

Type 1 endometrial cancers constitute about 75% and typically occur around the time of menopause.  These cancers are more often associated with obesity, hypertension and diabetes.  They most often are early stage, and of low grade (less aggressive) and have a good prognosis.

Type 2 endometrial cancers more commonly occur many years after the menopause, often in thinner women and independent of hormones.  These cancers more frequently present in more advanced stage and are of higher grade (more aggressive).

Symptoms

  • Bleeding – especially postmenopausal bleeding, but also bleeding between periods or after sexual intercourse in reproductive aged women. Abnormal gynaecological bleeding is cancer until proven otherwise
  • Pain
  • discharge

Spread

  • Invasion into the muscle of the uterus (myometrium)
  • Invasion into the cervix
  • Into the peritoneal cavity
  • To the lymph nodes on the side wall of the pelvis and in front of the aorta
  • Rarely, via the blood stream to distant sites

Risk Factors

  • Obesity
  • Hypertension (high blood pressure)
  • Diabetes
  • Hypercholesterolaemia
  • Genetic predisposition eg Lynch Syndrome
  • Tamoxifen therapy
  • Unopposed oestrogen therapy
  • Reproductive factors – nulliparity (no children), early menarche, late menopause, polycystic ovary syndrome.

Pre-operative evaluation of abnormal bleeding

  • Ultrasound scan of the pelvis
  • Ensure cervical cancer screening is up to date
  • Endometrial biopsy – either outpatient endometrial sample with Pipelle (or equivalent) or formal hysteroscopy, dilatation and curettage in an operating theatre.

Investigation of proven endometrial cancer

  • Routine blood tests including FBC, ELFT
  • Often evaluate CA125 or HE4 as a blood marker of more advanced disease
  • CT scan of chest, abdomen and pelvis

Treatment

The most important component of treatment is the surgical removal of uterus, fallopian tubes and ovaries.  This is usually done via a laparoscopic or robotic assisted laparoscopic approach.  Occasionally, surgery will need to be performed through an open surgical approach.  Increasingly, the sentinel lymph nodes (the first and most important lymph nodes draining the uterus) will be removed to determine if the cancer has spread beyond the uterus.

If the sentinel lymph nodes are not removed, a decision will be made during the surgery about removing nodes based on the frozen section characteristics of the malignancy in the uterus

Conservative Treatment

For women with many other medical issues, often associated with older age and frailty, and for women who are young and wish to conserve their reproductive capacity, there may be an option to preserve the uterus.   This usually entails the use of hormone therapy either orally or delivered via a hormone containing intra-uterine device.  This is still considered somewhat experimental and women pursuing this option will need close monitoring.

Adjuvant Treatment

For women who are found to have high grade (aggressive) cancer deeply invading the myometrium (muscle of the uterus) or the cervix, or evidence of disease outside the uterus, there may be a place for further treatment.  This may entail chemotherapy given every 3 weeks for 4 -6 cycles or radiation, most commonly given as external treatment over about 5 weeks, or occasionally internal treatment given over a couple of days.

Follow up

For all cancers there is some chance of the cancer coming back, and that is the reason for ongoing follow up.  As a rough rule patients are followed every 3 months for 2 years, then 6 monthly for 3 years, then some patients are followed yearly thereafter.  For patients with earlier stage, better prognosis disease, the follow up is less intense and for a shorter duration.