Endometrial Carcinoma

Published on 10/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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Endometrial Carcinoma

Synonyms/Description

Uterine cancer

Etiology

Endometrial cancer is the most common cancer of the female genital tract. The overall 5-year survival rate is 85%, 75%, 45%, and 25% for stages I through IV, respectively.
Risk factors for endometrial cancer include obesity, diabetes, nulliparity, estrogen-producing ovarian tumors, polycystic ovarian syndrome, advanced age, unopposed estrogen therapy, tamoxifen, and a family history of nonpolypoid colorectal cancer.
The prognosis depends on the tumor type and stage. Type 1 endometrial cancer or endometrioid carcinoma accounts for 80% of uterine carcinomas and is associated with increased and unopposed estrogen exposure. It typically arises from a background of endometrial hyperplasia and is frequently low-grade and slow-growing.
Type 2 tumors are not estrogen driven and are generally far more aggressive than type 1. They often occur in the setting of atrophic endometrium and include serous, clear cell, and other cell types. These tumors tend to invade the myometrium earlier and spread rapidly.

Ultrasound Findings

The gray-scale sonographic appearance of endometrial cancer depends on the stage of disease. If the tumor is confined to the endometrium and small, the scan may reveal a thickened, heterogeneous endometrium or even a normal-appearing endometrium if the tumor is very small. In postmenopausal patients who are bleeding, an endometrial thickness greater than 4 mm (some use greater than or equal to 5 mm) is considered abnormal and requires further evaluation. Early-stage tumors are typically hyperechoic and may have some but limited color flow within the endometrium. If the endometrium appears abnormal or ill defined, a sonohysterogram can be performed to outline the endometrium and determine whether there is a focal or diffuse process.
More advanced tumors often have a texture of mixed echogenicity and abundant vascularity evident on color Doppler. The tumor vessels are typically multiple, disorganized, and entering from multiple foci. As the tumor continues to grow, the borders become increasingly irregular and ill-defined, invading the myometrium, with loss of definition of the endometrial-myometrial junction. There can be cystic spaces within the characteristically solid tumor and, sometimes, fluid in the endometrial cavity outlining the mass. As the endometrial tumor invades further into the myometrium, the uterus enlarges and becomes blotchy in texture. With extensive myometrial invasion, the residual mantle of myometrium may be very thin. Some tumors seem to be entirely in the myometrium rather than the endometrium (see Figure E2-3).
Endometrial cancer can arise not only in the uterine fundus (most common), but also in the lower uterine segment, at the cervical junction, distorting the shape of the lower segment (see Figure E2-5).

Differential Diagnosis

When the endometrial abnormality is confined to the endometrium and appears typically echogenic, the differential diagnosis includes polyps and endometrial hyperplasia. A sonohysterogram is very helpful as the initial workup for a thickened or ill-defined endometrium in a patient with abnormal or postmenopausal bleeding. The age, history, and hormonal status of the patient are important factors to consider, but tissue sampling is necessary when malignancy is being considered. The differential diagnosis for a uterine mass with irregular cystic areas and excessive vascularity includes sarcoma and fibroids (see Uterine Sarcoma and also Fibroids). Because fibroids are far more common than uterine cancers, a uterine mass may be mistaken for an atypical fibroid at first scan. If a fibroid is unusual in appearance, it is important to rescan the patient in a relatively short time interval to evaluate growth of the lesion. Adenomyosis can give the myometrium a focal blotchy appearance, although the vascularity should differentiate adenomyosis from a cancer.

Clinical Aspects and Recommendations

Endometrial cancer is typically treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, and staging, which includes lymph node sampling. Further therapy depends on the stage and type of tumor; it may involve gynecologic, radiation, and medical oncologists.

Figures

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Figure E2-1 Polypoid endometrial cancer. A, A solid isoechoic mass in the endometrium (calipers). B, Extensive color flow displaying multiple, irregular vessels in the mass (arrows). C, A 3-D coronal rendering of the uterus after saline had been introduced into the cavity. Note the tumor (arrows) at the fundus of the uterus, outlined by fluid.

 

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Figure E2-2 A, Longitudinal view of the uterus in a patient with adenocarcinoma of the endometrium. Note the thick and heterogeneous endometrium with ill-defined borders on the gray scale image. B, The color flow image shows abundant vascularity (arrow) in the endometrium.

 

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Figure E2-3 A and B, Large echogenic endometrial cancer (calipers) invading the myometrium with only a small component in the endometrial cavity. C, The color flow image shows the abundant vascularity in this aggressive tumor.

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Figure E2-4 Large endometrial cancer located within the endometrial cavity and involving approximately 50% of the circumference of the endometrium. This mass is protruding into the cavity and outlined by endometrial fluid. Note the intense vascularity evident on the color flow image.

 

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Figure E2-5 Two different patients with invasive endometrial cancer in the lower uterine segment and upper cervix. A and B, A solid, homogeneous mass (arrows) that is very vascular and located in the lower uterine segment and involving the upper portion of the cervix. C, The 3-D coronal view of the same mass showing its location in the lower portion of the uterus as well as its irregular contour (arrows). D and E, A different patient with a similar tumor (calipers) in the lower uterus/cervix. Note the disorganized abundant vascularity to the mass.

 

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Figure E2-6 Endometrium of a 75-year-old asymptomatic woman who was on unopposed estrogen for more than 10 years. Despite the absence of bleeding, this endometrium of 8 mm was considered heterogeneous and abnormal, prompting sampling. Stage Ib endometrial carcinoma was diagnosed, invading one third of the way through the myometrium (invasion not detectable sonographically).

 

Videos

Video 1 on endometrial carcinoma is available online.

Suggested Reading

Amant F., Moerman P., Neven P., Timmerman D., Van Limbergen E., Vergote I. Endometrial cancer. Lancet. 2005;366:491–505.

Epstein E., Van Holsbeke C., Mascilini F., Måsbäck A., Kannisto P., Ameye L., Fischerova D., Zannoni G., Vellone V., Timmerman D., Testa A.C. Gray-scale and color Doppler ultrasound characteristics of endometrial cancer in relation to stage, grade and tumor size. Ultrasound Obstet Gynecol. 2011;38:586–593.

Leone F.P., Timmerman D., Bourne T., Valentin L., Epstein E., Goldstein S.R., Marret H., Parsons A.K., Gull B., Istre O., Sepulveda W., Ferrazzi E., Van den Bosch T. Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol. 2010;35:103–112.

Van den Bosch T., Coosemans A., Morina M., Timmerman D., Amant F. Screening for uterine tumours. Best Pract Res Clin Obstet Gynaecol. 2012;26:257–266.

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