Endometrial cancer arise from the inner lining layer of the uterus. It is often detected at an early stage because it frequently produces abnormal vaginal bleeding and have good prognosis. If diagnosed early, complete cure is feasible with regular follow up. The treatment comprises SURGICAL STAGING with adjuvant RADIOTHERAPY with or without CHEMOTHERAPY depending on final SURGICO- PATHOLOGICAL STAGE.

EPIDEMIOLOGY:

The age standardized incidence rate (ASIR) of endometrial cancer in India is 2.3/100,000 women. The rise in endometrial cancer in India is mainly attributed to changing trends in the lifestyle and reproductive profile of women, especially in urban areas. The majority of cases present in the 6th and 7th decade of life, with the mean age being 60 years at the time of diagnosis.

Risk Factors:

⦁ Nulliparity – 2-3 fold increased risk.
⦁ Menopause past the age of 52.
⦁ Obesity – raises oestrogen levels
⦁ Polycystic ovary syndrome.

ENDOMETRIAL INTRAEPITHELIAL NEOPLASIA (EIN)

(The pooled prevalence of concurrent endometrial cancer was found to be 32.6% in a meta-analysis of studies of EIN conducted in 2020)

⦁ The lifetime risk of developing endometrial cancer among women who have hereditary nonpolyposis colon cancer (HNPCC) is 30-60%.
⦁ There is a slight but consistent and significant risk of developing incidental endometrial cancer in diabetes mellitus patients.
⦁ An increased risk of endometrial cancer has been associated with the use of Tamoxifen.
⦁ Unopposed oestrogen increases the risk of endometrial cancer. Progesterone, however, counteracts the adverse effect of oestrogens.

RISK REDUCTION:

⦁ Among higher age groups, the use of birth control pills (oral contraceptives) is known to reduce the risk of developing endometrial cancer.

TYPES

TYPE 1 – Estrogen dependent – common in Pre and peri menopausal women and constitutes 80% with very favourable prognosis. They are of endometrioid histology and are usually well differentiated.

TYPE 2 – Estrogen independent – Constitutes 10-20% and common in older, postmenopausal, multiparous, non-obese, smokers, and tamoxifen users. The histological types include serous, clear cell, grade 3 endometrioid adenocarcinoma, mucinous and squamous varieties.

STAGING

STAGING WORK UP:

IMAGING AND BIOPSY

Transvaginal Ultrasound (TVS)

TVS is the first line imaging modality to triage these symptomatic patients, to assess uterine size, endometrial thickness, endo-myometrial interface, myometrial echotexture, and adnexa. Endometrial thickness greater than 4 mm in a post-menopausal woman with bleeding, perimenopausal women with intermenstrual bleeding or prolonged heavy bleeding and premenopausal women with anovulatory cycles warrant further evaluation.

Endometrial sampling

• Pipelle sampling (simple out patient procedure)
• Hysteroscopy, D and C

MRI of the abdomen and pelvis is recommended as it is the most accurate modality for assessing the size and extent of tumor, myometrial invasion, extension to cervix and adnexa, and lymph node involvement. Contrast enhanced (CE) MRI to exclude myometrial invasion and cervical extension is mandatory when planning fertility preserving options.

CT (for Lymph node involvement) and PET CT are indicated in high risk cases  for nodal status, distant metastasis and recurrences.

TREATMENT

Ca endometrium is staged SUGICOPATHOGICALLY. Surgery (Total abdominal hysterectomy with bilateral salpingo oophorectomy with or without pelvic and paraaortic lymphadenectomy) forms the mainstay of treatment. For complex hyperplasia and Stage Ia (low risk), TAH with BSO is the treatment of choice. Any further stages need pelvic and paraaortic lymph node dissection. Lymph node dissection might avoid vault Radiotherapy if nodes are negative from Stage 1B disease onwards. Higher stages require all modalities of treatment(Surgery, radiotherapy and chemotherapy).  Endomerial adenocarcinoma has very good prognosis but Serous and clear cell tumours and lymph vascular space invasion are poor prognostic parameters.

CONCLUSION

Ca endometrium has very good prognosis if diagnosed early with complete cure possible in early stages. Most patients have associated co morbidities like Obesity, Diabetes, Hypertension and heart disease which might pose problems in pre and post operative period with complications like DVT, lung complications can delay recovery and further treatment. Research is ongoing about tumour markers and Immunohistochemistry parameters for risk stratification and prognosticating the disease, which can further guide us regarding need for Lymphadenctomy and adjuvant therapy. POLE, p 53 mutations studies are underway and we shall be soon incorporating them in clinical practice.

Dr. Karpagambal Sairam, DGO, DNB, MRCOG (London)
Consultant Obstetrician, Gynaecologist and Fertility Specialist
Kauvery Hospital