eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Oncology
Endometrial Carcinoma: Differential Diagnoses & Workup
Updated: Aug 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
Other Problems to Be Considered
Bleeding from the lower genital tract can occur from the cervix, vulva, or vagina. If the bleeding is due to neoplasms, gross inspection usually helps identify these lesions. If cervical cytology findings are abnormal and no gross lesions are identified, further evaluation must be performed. Atrophic changes in the vagina may lead to bleeding, particularly postcoital. Bleeding from the uterus may be due to any of the many types of benign lesions (eg, polyps, endometritis) or to hormone replacement therapy.
Workup
Imaging Studies
- Vaginal ultrasonography
- In the past, the increased use of vaginal ultrasonography to evaluate the endometrial stripe has been reported.
- Some investigators believe that this should be the first diagnostic procedure because vaginal ultrasonography is less invasive than endometrial biopsy.
- One of the difficulties with using the endometrial stripe as a criterion for further diagnostic tests (eg, endometrial biopsy) is that several conditions may be present that yield a false reading on the endometrial stripe. This is particularly true in a patient who might have an endometrial polyp, is obese or diabetic, or who has been taking tamoxifen.
- Hydroultrasonography
- If a thickened endometrium is present, obtain a hydroultrasonogram to make sure a false-positive result is not present. This is accomplished by placing a small volume of saline into the endometrial cavity and then repeating the vaginal ultrasonogram.
- In many instances in which the original vaginal ultrasonogram shows significant endometrial thickness, an ultrasonogram can help differentiate other pathology from true endometrial thickness.
- Another problem that arises is that the thickness of the endometrium can vary considerably depending on different factors. The thickness of the endometrium depends on whether or not the patient is obese or diabetic, whether she is perimenopausal or postmenopausal (and for how long), whether she is taking hormone replacement therapy, and whether the therapy includes estrogen alone or estrogen plus progesterone. Currently, no generally accepted guidelines exist for each of these different clinical scenarios.
Procedures
- Endometrial biopsy
- Although fractional dilatation and curettage was historically the definitive diagnostic procedure to help rule out endometrial cancer, in current practice endometrial biopsy as an office procedure is quick, well tolerated, and quite sensitive for making the diagnosis.
- If endometrial pathology is not present on biopsy specimens and the patient has no further bleeding, no additional diagnostic tests need to be performed.
- If the patient continues to be symptomatic, then further evaluation of the endometrial cavity is necessary.
- Hysteroscopically directed biopsy: Another diagnostic procedure that has been advocated by some as an even more accurate way of determining the status of the endometrium is a hysteroscopically directed biopsy; however, studies have shown that when results are compared with the histopathology, both false-positive and false-negatives results may be noted using this technique.
- Dilatation and curettage: The current role of the formal dilatation and curettage is probably very limited because the diagnosis can usually be made in the office.
- Examination with the patient under anesthesia: This may be necessary in patients who are bleeding and have a cervical os that is very stenotic. Anesthesia may be required to perform adequate dilatation for endometrial sampling.
Histologic Findings
Pathological diagnosis is obviously the criterion standard for evaluation of the endometrial cavity. A high index of suspicion must be maintained if a diagnosis of endometrial cancer is considered.
Endometrioid adenocarcinoma is the most common histopathologic subtype. A squamous component, either benign (adenocanthoma) or malignant (adenosquamous), does not affect prognosis, but the grade of the adeno component does affect prognosis. Papillary serous and clear cell histotypes confer a poor prognosis but, fortunately, are uncommon compared with adenocarcinoma. Secretory carcinomas are the least frequently occurring cancers and are associated with a good prognosis.
Staging
- The International Federation of Gynecology and Obstetrics (FIGO), 2008 staging system for carcinoma of corpus uteri is as follows:4
- Stage IA* - No or less than half myometrial invasion
- Stage IB* - Invasion equal to or more than half of the myometrium
- Stage II* - Tumor invades cervical stroma but does not extend beyond the uterus**
- Stage III - Local and/or regional spread of the tumor
- Stage IIIA* - Tumor invades the serosa of the corpus uteri and/or adnexa †
- Stage IIIB* - Vaginal metastasis and/or parametrial involvement †
- Stage IIIC* - Metastases to pelvic and/or para-aortic lymph nodes
- Stage IIIC1* - Positive pelvic nodes
- Stage IIIC2* - Positive para-aortic lymph nodes with or without positive pelvic nodes
- Stage IV* - Tumor invasion of bladder and/or bowel mucosa and/or distant metastases
- Stage IVA* - Tumor invasion of bladder and/or bowel mucosa
- Stage IVB* - Distant metastases, including intra-abdominal and/or inguinal lymph node
- Cases of carcinoma of the corpus should be classified (or graded) according to the degree of histologic differentiation. The histopathology and degree of differentiation is as follows:
- Class G1 - Nonsquamous or nonmorular solid growth pattern of 5% or less
- Class G2 - Nonsquamous or nonmorular solid growth pattern of 6-50%
- Class G3 - Nonsquamous or nonmorular solid growth pattern of more than 50%
*Either G1, G2, or G3
**Endocervical glandular involvement only should be considered as Stage I and no longer as Stage II
† Positive cytology has to be reported separately without changing the stage
More on Endometrial Carcinoma |
| Overview: Endometrial Carcinoma |
 Differential Diagnoses & Workup: Endometrial Carcinoma |
| Treatment & Medication: Endometrial Carcinoma |
| Follow-up: Endometrial Carcinoma |
| References |
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References
Surveillance, Epidemiology, and End Results (SEER) Program. SEER Database: Incidence - SEER 9 Regs Public-Use. National Cancer Institute, DCCPS, Surveillance Research Program. Available at http://seer.cancer.gov/.
Bernstein L, Deapen D, Cerhan JR, et al. Tamoxifen therapy for breast cancer and endometrial cancer risk. J Natl Cancer Inst. Oct 6 1999;91(19):1654-62. [Medline].
Creasman WT. Endometrial cancer: incidence, prognostic factors, diagnosis, and treatment. Semin Oncol. Feb 1997;24(1 Suppl 1):S1-140-S1-50. [Medline].
Creasman WT. Revised FIGO staging for carcinoma of the vulva, cervix and endometrium. Inter J Gynecol and Obstet. 2009;105:103-4.
Kilgore LC, Partridge EE, Alvarez RD. Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling. Gynecol Oncol. Jan 1995;56(1):29-33. [Medline].
Chan JK, Cheung MK, Huh WK, et al. Therapeutic role of lymph node resection in endometrioid corpus cancer: a study of 12,333 patients. Cancer. Oct 15 2006;107(8):1823-30. [Medline].
American College of Obstetricians and Gynecologists. Estrogen replacement therapy and endometrial cancer. ACOG Committee Opinion: Committee on Gynecologic Practice Number 126--August 1993. Int J Gynaecol Obstet. Oct 1993;43(1):89. [Medline].
Creasman WT, Kohler MF, Odicino F, et al. Prognosis of papillary serous, clear cell, and grade 3 stage I carcinoma of the endometrium. Gynecol Oncol. Dec 2004;95(3):593-6. [Medline].
Creasman WT, Morrow CP, Bundy BN, et al. Surgical pathologic spread patterns of endometrial cancer. A Gynecologic Oncology Group Study. Cancer. Oct 15 1987;60(8 Suppl):2035-41. [Medline].
DiSaia PJ, Creasman WT. 7th ed. Clinical Gynecologic Oncology. St. Louis, Mo: Mosby; 2007.
Ferenczy A, Gelfand M. The biologic significance of cytologic atypia in progestogen-treated endometrial hyperplasia. Am J Obstet Gynecol. Jan 1989;160(1):126-31. [Medline].
Goff BA, Kato D, Schmidt RA, et al. Uterine papillary serous carcinoma: patterns of metastatic spread. Gynecol Oncol. Sep 1994;54(3):264-8. [Medline].
Kadar N, Malfetano JH, Homesley HD. Determinants of survival of surgically staged patients with endometrial carcinoma histologically confined to the uterus: implications for therapy. Obstet Gynecol. Oct 1992;80(4):655-9. [Medline].
Kurman RJ, Kaminski PF, Norris HJ. The behavior of endometrial hyperplasia. A long-term study of "untreated" hyperplasia in 170 patients. Cancer. Jul 15 1985;56(2):403-12. [Medline].
Mariani A, Dowdy SC, Keeney GL, et al. High-risk endometrial cancer subgroups: candidates for target-based adjuvant therapy. Gynecol Oncol. Oct 2004;95(1):120-6. [Medline].
Morrow CP, Bundy BN, Kurman RJ, et al. Relationship between surgical-pathological risk factors and outcome in clinical stage I and II carcinoma of the endometrium: a Gynecologic Oncology Group study. Gynecol Oncol. Jan 1991;40(1):55-65. [Medline].
Silverberg SG, Major FJ, Blessing JA, Fetter B, Askin FB, Liao SY, et al. Carcinosarcoma (malignant mixed mesodermal tumor) of the uterus. A Gynecologic Oncology Group pathologic study of 203 cases. Int J Gynecol Pathol. 1990;9(1):1-19. [Medline].
Further Reading
Keywords
corpus cancer, cancer, endometrial cancer, endometrium cancer, gynecologic cancer, gynecological cancer, adenocarcinoma, cervix cancer, cervical cancer
