Endometrial cancer

Malignant tumor of the uterine endometrium (lining); usually an adenocarcinoma arising from endometrial glands.

• Most common gynecologic cancer in developed countries (incidence rising with obesity). Often detected early (due to abnormal bleeding) and curable, but aggressive subtypes have high mortality.

• Postmenopausal vaginal bleeding is endometrial cancer until proven otherwise (e.g., an obese 65-year-old with new bleeding, or a postmenopausal breast cancer patient on tamoxifen).
• Premenopausal women with chronic anovulation (PCOS) can develop endometrial hyperplasia and present with irregular, heavy menstrual bleeding in their 40s.
• Advanced cases may cause pelvic pain, mass effect (enlarged uterus), or weight loss. Occasionally, a Pap smear finds atypical glandular cells pointing to an endometrial lesion.

1. Any suspicious uterine bleeding → obtain an endometrial biopsy (office pipelle or D&C) for histologic diagnosis.
2. In postmenopausal bleeding, first do transvaginal ultrasound: if endometrial thickness >4 mm or polyps/mass seen, proceed to biopsy (a thin stripe <4 mm makes cancer unlikely).
3. If biopsy confirms cancer, perform surgical staging (hysterectomy with BSO and lymph node evaluation). Pre-op imaging (MRI/CT) can help assess depth of invasion and metastases.

1. Surgery is first-line: total hysterectomy + bilateral salpingo-oophorectomy (TH+BSO) to remove uterus, cervix, ovaries, and fallopian tubes (surgical staging).
2. Radiation therapy (vaginal brachytherapy or pelvic external beam) is added for higher-stage or high-grade disease to control local spread; chemotherapy (e.g., carboplatin/paclitaxel) is used for advanced stage or aggressive histology.
3. Selective cases: progestin hormone therapy can treat early-stage disease in young patients desiring fertility, and immune checkpoint inhibitors (e.g., pembrolizumab) can be effective in metastatic MSI-high tumors.

• Risk factor mnemonic HONDA: Hypertension, Obesity, Nulliparity, Diabetes, Advanced age (all linked to unopposed estrogen exposure).
• Tamoxifen is pro-estrogenic in the uterus – prolonged use increases risk of endometrial polyps and carcinoma.
• Lynch syndrome (HNPCC) confers high risk (~50%) of endometrial cancer; such patients often need prophylactic hysterectomy after childbearing.

• Any postmenopausal bleeding is a red flag requiring prompt endometrial evaluation (could be cancer until proven otherwise).
• Atypical endometrial hyperplasia on biopsy (endometrial intraepithelial neoplasia) has high progression risk – manage definitively (usually with hysterectomy).
• Serous carcinoma histology or deep myometrial invasion indicates aggressive disease (poorer prognosis, needs aggressive treatment).

1. Postmenopausal bleeding → transvaginal ultrasound to assess endometrial thickness.
2. If endometrium >4 mm or other suspicious findings → perform endometrial biopsy (office pipelle or D&C).
3. If biopsy confirms cancer → surgical staging (hysterectomy + BSO with lymph node evaluation).
4. Stage and histology guide adjuvant therapy: consider radiation for local control and chemotherapy for disseminated or high-risk disease.

• Obese, hypertensive 61-year-old woman with postmenopausal vaginal bleeding → endometrial carcinoma (unopposed estrogen leading to endometrioid adenocarcinoma).
• 55-year-old breast cancer survivor on tamoxifen with an 8 mm endometrial stripe on ultrasound and vaginal spotting → endometrial carcinoma (tamoxifen-induced).
• 45-year-old with PCOS, obesity, and chronic anovulation has prolonged irregular bleeding → endometrial carcinoma arising from long-standing endometrial hyperplasia.