Uterine cancer

Endometrial hyperplasia and cancer Posted by Ahmad Azizov on February 17, 2021

Uterine cancer

The uterus contains tissue that can proliferate out of control and lead to malignancy. This happens in different stages carrying varying degrees of mortality and morbidity.

Endometrial hyperplasia 

Diagram 1. Simple endometrial hyperplasia

Prolonged unopposed estrogen leads to abnormal endometrial tissue proliferation. The estrogen in this case can be endogenous (obesity, polycystic ovarian syndrome) or exogenous (estrogen-only pill, tamoxifen). 

  • Hyperplasia with cytologic atypia 
    • Abnormality of the endometrial cells
      • Loss of cell polarity 
      • Hyperchromasia 
    • >40% of the patients with this biopsy will have endometrial adenocarcinoma 
  • Hyperplasia without cytologic atypia 
    • Clinically benign 

Diagnosis

  • Diagnosis is usually done when patients present with vaginal bleeding and/or abnormal pap smears. On pap smear, atypical glandular cells are seen. In office an endometrial biopsy can make a definitive diagnosis. 
  • Normal pap smear

Treatment

  • Oral contraceptives, progestins, progesterone IUDs and a repeat biopsy in 3-6 months. 
  • The definitive treatment for cytologic atypia is a hysterectomy and is recommended for those patients who are not planning on getting pregnant 

Endometrial cancer

There are near 50,000 cases of endometrial cancer in the USA every year with a lifetime risk of about 2%. The median age of these patients is 60. Similar to endometrial hyperplasia, this condition is caused by unopposed estrogen as well. Interestingly, smoking, pregnancy and having multiple pregnancies are protective factors to developing endometrial cancer. Additionally, women with a hereditary non-polyposis colorectal cancer gene mutation have a 40-60% chance of developing endometrial cancer in their lifetime. 

Diagnosis/Prevention 

  • Routine screening with an endometrial biopsy is not recommended (even for patients on tamoxifen). Pap smear is unfortunately not sensitive for screening either
  • Oral contraceptive use and endometrial hyperplasia treatment will decrease the risk of developing this condition
  • Symptoms requiring workup 
    • Prolonged bleeding in premenstrual or any bleeding in a postmenstrual woman
  • Workup 
    • Pelvic exam
    • Endometrial biopsy 
    • Pap smear

Pathophysiology 

  • Most common type is endometrial adenocarcinoma 
  • It is also the most curable type 
  • Other types 
    • Uterine papillary serous carcinoma
    • Clear cell carcinoma
    • Mixed Mullerian mesodermal tumour
  • Any high-risk features on biopsy indicate abdominal, pelvic and thoracic imaging
  • Grading 
    • Assesses the tumour architecture (non-glandular = solid)
    • Grade 1  <5% solid tumour
      Grade 2 6-50% solid tumour
      Grade 3 >50% solid tumour
  • This condition spreads by the lymphatic, hematologic, direct and transtubal pathways 

Stages

  • Requires surgery to be staged
  • Most patients are diagnosed at stage 1

Treatment 

  • Surgical therapy 
    • Total abdominal hysterectomy 
    • Bilateral salpingo-oophorectomy 
    • Radiation therapy for those that cannot tolerate a surgery 
  • Lymph node 
    • Sentinel lymph node mapping currently being analyzed 
  • Adjuvant therapy 
    • Vaginal brachytherapy 
  • Recurrent disease
    • Local disease can be cured with radiation and pelvic exenteration 
    • Systemic disease has more success with chemotherapy 
  • Palliation 
    • Hormonal therapy (progestin and tamoxifen) 
    • Especially helpful in grade 1 tumours 

Prognosis 

  • The prognosis is generally excellent because abnormal bleeding occurs early
  • 5 year survival with treatment is 85% for stage 1, 50% for stage 2, 30% for stage 3, 5% for stage 4

Uterine Sarcoma

These tumours are aggressive and consequently have a poor prognosis.

Treatment 

  • Surgery is the only treatment worth exploring

Types 

  • Leiomyosarcomas
    • Smooth muscle cells from the uterus go rogue
    • Increased number of mitoses 
    • Can spread to the lungs
  • Endometrial stromal sarcoma
    • Soft and polyploid tumours that invade the endometrial cavity
    • Better prognosis than undifferentiated sarcoma 

All information provided on this website is for educational purposes and does not constitute any medical advice. Please speak to you doctor before changing your diet, activity or medications. 


Written by
Ahmad Azizov Member since April 2020
Interested in vascular surgery, surgery, endovascular procedure

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