Endometrial Cancer Diagnosis and Treatment
for laymen and students
Mario Kopljar, MD

WARNING! This information is for general use only. If you have EC, ask your doctor to explain these facts and how they apply to you.

Anatomy and physiology
Normal endometrium
Generally on cancerogenesis

Etiology and Pathogenesis
Spreading of EC
Grading and Staging
Early symptoms
Diagnostic process

Differential diagnosis
Prevention and Treatment

Early symptoms
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Bleeding is usually the first symptom of EC. Since this tumor is found mostly in elderly women, any bleeding (from vagina) after the menopause is suspicious for endometrial tumor. But tumor may obstruct cervical canal so that blood can not be expelled and that results in abdominal pains that may vary in intensity from mild cramps to labor like pain. If a woman is still having menstrual cycles, bleeding is irregular, massive and does not cease after couple of days like normal menstrual bleeding. Approximately one quarter of all endometrial carcinomas occur in women who still have menstrual bleedings. More advanced stages present with intensive pain, weight loss, anemia (decreased red blood cells count).

Diagnostic process
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Diagnostic procedures are bimanual vaginal and rectal palpation, curettage, cytology and histology. But only curettage and hystological examination under the microscope can result in exact diagnosis. Postmenopausal bleeding is alarming and on examination uterus is enlarged and softened as if a woman is pennant. Other findings are also possible. If tubes and ovaries are fixed and hard it indicates that EC has invaded them (see Staging and grading). With rectal examination one can determine whether the tumor has invaded paracervical tissue. Rectoscopy and cystoscopy may help in exploring intestines and urinary bladder in search for the signs of invasion. Cytology is not very reliable, about 50%. Microscopical examination of the tissue obtained by curettage (DC) is definitely the most exact method in diagnosing EC. It can tell organic bleeding like miomas or adenomas from inflammations (endometritis, TBC) and functional bleeding. It is obligatory in any case of suspicious vaginal bleeding. First a sample is taken from the cervical canal. Then the canal is widened and samples from the uterus lining are taken. Tubar angles and the fundus as common sites of occurrence must be carefully explored. Procedure is done under anesthesia.

Ultrasound can be used to examine both uterus and urinary bladder. Cystoscopy (visualization of the inside of the urinary bladder through a thin tube) can be helpful. CT scan or NMR can be used to determine the spread, and lymphography is the method of radiological examination of the lymph nodes.

Go to the beginning

Inflammation of the uterus (piometra) may occur if the cervical canal gets occluded. The infection ascends and uterus gets enlarged. Patient has fever and blood tests show signs of infection (elevated count of white blood cells, increased sedimentation rate etc.). Intracervical application of radioactive substances, endometrial TBC and some other infections may also result in piometra. Main treatment is to dilate cervix and give antibiotics.

Differential diagnosis (or What else can it be?)
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Any postmenopausal bleeding is suspicious for cervical or endometrial carcinoma, especially in peri- and postmenopausal women. The former often have irregular bleeding which is usually not abnormal. Carcinomas and sarcomas of the vulva and vagina may also be the cause of bleeding. Cervical erosions, polyps, miomas and endometritis are some of the benign diseases of the female genital tract that may, at first sight, be mistaken for endometrial carcinoma. It is only the combination of careful examination and microscopical evaluation than can provide accurate diagnosis. Ovarian tumors may be hormonally active thus presenting themselves with hyperplasia (growth) of endometrium (uterine mucosa) and bleeding.

Prevention and treatment
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Statements under this title are subject to rapid change, as new methods are introduced. Ask your doctor about most recent methods.

Since prolonged growth of endometrium often underlies EC, it is the cessation of that process with synthetic progesterone that stops further growth and helps maturation that may prevent EC. Contraceptives may be used as a source of progesterone that makes endometrial cells to mature. Also it is important to avoid estrogen influence to the endometrium.

Treatment is either surgical or by irradiation. Operation gives generally better results and is therefore method of choice for localized EC (Stages 1 and 2) and if there is no clinical contraindication for surgery.

If cancer is in Stage 1, surgery is required. It can be combined with irradiation, especially if cells are immature (Grade III) or if the invasion of muscular wall is deep. During the operation, lymphatic nodes harvested and are examined.

In Stage 2, surgery (hysterectomy) is usually followed by radiation, and hormonal therapy needed, especially in Grade I tumors.

If they are affected, Stage increases from 1 to 3. Also, peritoneal fluid samples are taken to determine if there are tumor cells in the peritoneum. If they are, Stage also increases from 1 to 3. Before surgery, urinary bladder and bowels are examined to exclude Stage 4 tumor. Vagina is observed and examined to exclude Stage 3a. If cancer is so localized, the removal of uterus, tubes and ovaries with or without irradiation is considered to be enough. If cervix is affected, hysterectomy combined with the removal of the tubes and ovaries is done. Also, radiation therapy should be undertaken.

In Stage 3, surgery (hysterectomy) can sometimes be performed as a radical procedure after the radiation treatment. If distant metastases occur, hormonal therapy may give good results. If cancer has high level of progesterone receptors, it should respond well to hormonal therapy. If not, chemotherapy may do well. Less differentiated tumors (Grade II or III) respond better to chemotherapy. Postoperative radiation is very useful to prevent the tumor to re-occur especially at the upper parts of the vagina. Chemotherapy and especially hormonal therapy are superior to surgery in the treatment of Stage 4.

Mario Kopljar, MD
Department of Surgery
University Hospital Sestre milosrdnice
Vinogradska 29
10000 Zagreb, Croatia

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