Snap Shot A 72-year-old woman was evaluated for post-menopausal bleeding. A fractional dilatation and curettage revealed endometrial carcinoma. Her cervical Pap smear was normal. She had not been on any hormone replacement therapy. An ultrasound is performed. Introduction Fourth most common malignancy in women after breast, colorectal, and lung cancer Most common gynecologic malignancy ovarian cancer is the leading cause of gynecological cancer deaths It affects mainly postmenopausal women, with incidence peaking between ages 50 and 60 An estrogen dependent cancer. Sources can be from ovary extraglandular from peripheral conversion of androstenendione to estrone exogenous from oral estrogen, patches, cremes. Risk factors include unopposed postmenopausal estrogen replacement obesity, which increases risk by 3 to 10 times hypertension high fat diet as found in industrialized nations nulliparity late menopause (after 52) anovulation oligo-ovulation polycystic ovarian syndrome diabetes estrogen-producing tumors h/o of colon cancer, breast cancer, or ovarian cancer h/o of cervical carcinoma in situ is not a risk factor Endometrial hyperplasia usually precedes endometrial cancer classified by the degree of cytologic atypia. Histology Adenocarcinoma accounts for > 80% of cases of endometrial cancer Sarcomas account for about 5% of all uterine malignancies and include mixed mesodermal tumors leiomyosarcomas endometrial stromal sarcomas Presentation More than 90% of patients with endometrial cancer have abnormal uterine bleeding postmenopausal bleeding 1/3 of women with postmenopausal bleeding have endometrial carcinoma premenopausal recurrent metrorrhagia Evaluation Any post-menopasual woman with uterine bleeding requires an endometrial biopsy tissue biopsy is the definitive diagnostic procedure procedure is > 90% accurate Pap smears NOT RELIABLE (miss 60%) of endometrial carcinoma cases AGCUS on Pap smear requires endometrial evaluation Pelvic and abdominal CT may help if extrauterine or metastatic disease is suspected FIGO staging Stage Description 1A Limited to the endometrium IIB Invasion of cervical stroma IIIC, Grade 3 Pelvic lymph metastases IVA Invasion to the bladder and/or bowel mucosa IVB Distant metastasis including lungs, vagina, abdomen, bone,intrabdominal Differential Endometrial hyperplasia Treatment Simple or complex hyperplasia progesterone to reverse hyperplastic process (e.g., Provera X 10 days) Atypical hyperplasia hysterectomy because of liklihood of invasion progestin-only therapy if patient seeking to become pregnant Stage I, grade 1 endometrial cancer without deep myometrial invasion Probability of lymph node metastasis is < 2%. TAH / BSO, and peritoneal cytologic examination Accurate surgical staging enables 50-75% of patients with stage I disease to forego postoperative radiation therapy For grades 2 and 3 and for grade 1 with deep myometrial invasion TAH / BSO with pelvic and para-aortic lymphadenectomy Extended-field radiation forextrapelvic cancer, depending on the site and extent Stage IV disease are best treated with systemic chemotherapy Valium to prevent spasms Treatment for recurrence is high-dose progestins (Depo-Provera) Prognosis, Prevention, and Complications Very few patients with cancer confined to the uterus have recurrences Histoligical grade is most important prognostic factor Depth of invasion is second most important histological factor