GuidelinesOther guideline
Endometrial Cancer
This guideline is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Presentation at the oncology meeting
Stages, grades & types of endometrial cancer
Diagnosis
- Usually presents with postmenopausal bleeding (see Postmenopausal Bleeding), can occur before
- Endometrial biopsy is obtained by z-sampling, curettage or hysteroscopic biopsy
- Rarely endometrial cancers present with distant metastases. All patients should be evaluated for metastases as for cervical cancer
Treatment
- Total abdominal hysterectomy & bilateral salpingo-oophorectomy (TAH & BSO) unless spread beyond the uterus
- Additional radiotherapy is for Grade 3 (poorly differentiated), some Grade 2, 1B and above, & for +ve nodes if taken. The place of chemo remains uncertain at present
- Hormone therapy (Provera 30mg e.g) may shrink lung mets or be used for infirm old ladies but is not part of routine treatment
- Vault radiation prevents local recurrence but not distal
Pre-operative preparation
- Prepare the patient as for any hysterectomy
- Pay attention to associated diabetes or hypertension;
- anaesthetic consult if necessary
Postoperative review
- This is done two weeks after the operation
- Histology results should be available
- The oncology forms are prepared for presentation at the oncology meeting
Presentation at the oncology meeting
- Staging is done at surgery, so most cases are presented after operation
- Patients who are unfit for, or refuse, surgery, are presented on diagnosis
Follow up
- Patients treated with radiotherapy are followed up by the radiotherapy department
- Patients requiring only surgery are followed up as for cervical cancer
Stages, grades, and types of endometrial cancer (FIGO 2009 and 2018)
- Stage 1a: Limited to the endometrium or inner ½ myometrium
- Stage 2b: Outer ½ of the myometrium
- Stage 2: Involves the uterus and cervix stroma but not beyond. Cervical glandular involvement now considered Stage 1
- Stage 3a: Uterine serosa breached and/or adnexal involvement
- Stage 3b: Vaginal spread/and, or parametrial spread
- Stage 3C1: Involvement of pelvic nodes
- Stage 3C2: Involves para-aortic nodes
- Positive peritoneal cytology is reported separately but does not affect the stage
- Stage 4a: Bladder or bowel mucosa involved
- Stage 4b: Distant metastases including intra-abdominal and/or inguinal lymph nodes
Histological grading
This reflects the degree of differentiation, with grade 3 being the most poorly differentiated & having the worst prognosis for patient survival. It is used in all cancers, but is particularly influential in endometrial.
- Grade 1: 5% of less of a ‘non-morular’ (normal) growth pattern
- Grade 2: 6-50% of a non-morular solid growth pattern
- Grade 3: More than 50% of a non-morular growth pattern
Tumour type
- The majority, also with the best prognosis, are endometrioid adenocarcinomas.
- Adenoacanthomas (endometrioid adenocarcinomas with benign squamous metaplasia) have a relatively good prognosis.
- Adenosquamous and clear cell have a poorer prognosis. Papillary serous adenocarcinoma is by definition poorly differentiated & has a poorer prognosis.