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Endometrial cancer is the most common gynecologic malignancy and the 4th
most common cancer in women in the United States.
Risk factors of the disease include length of exposure of unopposed estrogen,
and the most common presenting symptom is postmenopausal bleeding.
Most (>90%) cases of endometrial cancer are adenocarcinoma.
Route of spread is through local extension, lymphatic or hematogenous. Stage,
depth of invasion, lymphovascular space involvement, and lymph node involvement
are the most important prognostic factors.
The majority of patients (>70%) are diagnosed early at stage I, leading to overall
good prognosis: >80% local control and >70% overall survival.
Surgery (total extrafascial hysterectomy with bilateral salpingo-oophorectomy,
peritoneal cytology, and pelvic/para-aortic lymph node dissection) is the mainstay
of diagnosis, pathologic staging, as well as treatment
Early-stage endometrial cancer can usually be treated with surgery with or
without radiation therapy.
Adjuvant radiation therapy (external-beam pelvic radiation and/or vaginal cuff
brachytherapy) has been shown to decrease local recurrence.
Locoregionally advanced endometrial cancer is treated with a combination of
surgery, radiation therapy, and chemotherapy.
Chemotherapy with or without hormonal therapy
Diagnosis
The diagnosis of endometrial cancer depends on the clinical presentation,
history and physical examination, including a thorough gynecologic examination,
imaging studies, and laboratory tests (Figure 21.2).
Tumor, Node, and Metastasis/Federation of Gynecology
and Obstetrics Staging
Endometrial cancer staging is determined by pathologic criteria. Recent
changes in the Federation of Gynecology and Obstetrics (FIGO) and the
American Joint Committee on Cancer (AJCC) staging recommendations
were made to coincide with prognosis and are reflected in Table 21.5.
No longer includes uterine sarcoma (now staged with a new staging system)
Positive peritoneal cytology is no longer considered (previously was T3a/
IIIA)
Involvement of the endocervical glands is not longer considered (previously
was stage IIA)
Stages IA and IB combined (now: IA). IC moved to IB
Stage IIIC subdivided into IIIC1 and IIIC2
Prognostic Factors
Survival is strongly influenced by the stage at diagnosis (Table 21.6). Adverse
prognostic factors include:
More advanced age: associated with higher chance of recurrence (age > 70
have more recurrence versus 5070)
Higher grade: associated with higher chance of recurrence (grades 23)
Aggressive histology: clear cell adenocarcinoma, undifferentiated papillary
serous carcinoma are associated with worse prognosis due to more
distant failure pattern
Depth of myometrial invasion (>66%)
Lymphovascular space invasion
Gynecologic Oncology Group Trial 99 (GOG 99; Figure 21.4) outlines the
prognostic factors in directing treatment.
Brachytherapy
Intravaginal brachytherapy may be given alone or in combination with external-
beam radiotherapy (EBRT), depending on the risk of pelvic lymph
node involvement. Alternatively, it may be omitted when external pelvic irradiation
is used as in the Post-Operative Radiation Therapy for Endometrial
Carcinoma (PORTEC) and GOG-99 studies, while maintaining good
locoregional control rates as shown in Table 21.9 (although the majority of
failures in these studies occurred at the vaginal cuff). The details of vaginal
brachytherapy technique and dose fractionation are discussed below.