eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Oncology

Endometrial Carcinoma: Follow-up

Author: William T Creasman, MD, J Marion Sims Professor, Department of Obstetrics and Gynecology, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Aug 3, 2009

Follow-up

Complications

• Complications that may occur from therapy include complications that are normally expected from the surgical procedure itself. Because a lymphadenectomy is performed, increased bleeding could develop; however, unique complications from the procedure do not usually occur.
• Postoperative complications can be expected, depending on the preoperative clinical condition of the patient. As noted previously (see Causes), many of these patients have comorbidities such as hypertension, obesity, diabetes, and increased age.
• One postoperative complication that may be somewhat more common is thromboembolism because this is increased in patients who have cancer, are obese, and are older. In current practice, most physicians use some type of prophylaxis, either external pneumatic compression or low-dose heparin.

Prognosis

• Multiple prognostic factors exist for endometrial cancer. These prognostic factors generally are related to surgical pathological findings. As in all cancers, the stage of the disease is the most important prognostic factor. Obviously, the surgical procedure helps determine the stage. Listed below are prognostic factors that may relate specifically to the stage of the disease and, thereby, may affect overall survival.
  • Pathology
    • Most endometrial carcinomas are endometrioid adenocarcinomas.
    • Adenoacanthomas (benign squamous components) and adenosquamous carcinoma (malignant squamous components) make up the next largest category.
    • Clear cell and papillary serous adenocarcinomas represent approximately 10% of all endometrial cancers and are considered to be poor histopathological subtypes. These latter subtypes tend to have deeply invasive myometrial involvement, and they have a propensity for extrauterine spread, even though the myometrium may be superficially involved.
    • Previously, a patient with an adenosquamous carcinoma was thought to have a poor prognostic histotype because of the malignant squamous component.
    • Contemporary data suggest that irrespective of whether a squamous component is present (either benign or malignant), prognosis is related directly to the grade of the adeno component and not the fact that a squamous malignancy is present. If a malignant squamous component is present, a greater tendency exists for a more poorly differentiated adeno component to be present.
  • Histological differentiation
    • The degree of histological differentiation of endometrial cancer has long been accepted as a sensitive indicator of prognosis.
    • Patients with well-differentiated adenocarcinomas tend to have involvement of the endometrium or superficial myometrium, and extrauterine disease is unusual.
    • On the other hand, if a poorly differentiated lesion is present, these cancers tend to be much more aggressive, involving significant myometrial invasion, and often have extrauterine metastasis, either with positive peritoneal cytology, retroperitoneal spread, or involvement of the pelvic and/or para-aortic lymph nodes.
    • Because papillary and clear cell carcinomas are associated with a relatively poor prognosis, these subtypes are not usually graded but are considered in the same category as a poorly differentiated cancer.
  • Myometrial invasion
    • The degree of myometrial invasion continues to be a consistent indication of tumor virulence.
    • As the depth of myometrial invasion increases, the chance of having extrauterine disease is greater.
    • As noted above, grade and depth of invasion, as a generalization, are interrelated. As the grade of the tumor increases, an increase usually occurs in the depth of myometrial invasion; however, exceptions exist in that a grade 1 lesion can have deep myometrial invasion and a grade 3 lesion can be limited to the endometrium.
    • When grade and depth of invasion are evaluated separately, the depth of invasion appears to be a more important prognostic factor than the grade of the tumor.
  • Peritoneal cytology
    • Cytological evaluation of the peritoneum appears to be an important prognostic factor.
    • Although no universal agreement has been reached about the significance of cytological evaluation findings, the vast majority of data in the literature suggest that they represent an independent prognostic factor.
    • Cytological evaluation findings also appear to correlate with other prognostic factors, such as depth of myometrial invasion and lymph node metastasis.
    • The FIGO staging system states that positive cytology should be reported separately without changing the stage. If ascitic fluid is not present at the time of the exploratory laparotomy, a saline lavage of the pelvis and lower abdomen is performed and the specimen is submitted for cytological evaluation.
  • Lymph node metastasis
    • A considerable number of patients who were thought to have clinical stage I endometrial cancer were, in fact, found to have lymph node metastasis when histopathological evaluation was performed on the lymph nodes.
    • Again, a correlation among multiple prognostic factors has been shown to be present. Patients with poorly differentiated cancers, papillary serous and clear cell carcinomas, deep myometrial invasion, positive peritoneal cytology, or adnexal metastasis tend to have an increased risk of having lymph node metastasis.
    • Subsequent therapy after primary surgery depends on prognostic factors and spread of the disease. If the disease is limited to the uterus, surgery appears to be adequate treatment, with the possible exception of patients who have poorly differentiated deeply invasive myometrium. In these patients, data suggest that, possibly, postoperative irradiation may be of benefit. In patients who have disease outside of the uterus, radiation therapy may be effective; however, this has not been evaluated in a prospective randomized study. Most investigators irradiate the appropriate area if lymph node metastasis is present.
    • In patients with advanced disease (ie, intraperitoneal disease, disease outside of the peritoneal cavity), systemic chemotherapy may be of benefit. Studies suggest that cisplatin and doxorubicin are probably the drugs of choice when systemic chemotherapy is needed.
    • As previously noted, staging is the most important prognostic factor. Using the FIGO surgical staging classification from the recent annual report (worldwide data evaluation), 5-year survival rates of 87%, 76%, 63%, and 37% were noted for stages I, II, III, and IV of the disease, respectively. Because substages exist that take into consideration prognostic factors, 4 of the substages within stage I actually have better than 90% 5-year survival rates.

Patient Education

• For excellent patient education resources, visit eMedicine's Women's Health Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Vaginal Bleeding and Cervical Cancer.

Miscellaneous

Medicolegal Pitfalls

• Ignored irregular postmenopausal bleeding could lead to a delay in diagnosis and treatment, which may impact survival.

Special Concerns

• Multiple new prognostic factors of endometrial cancer are being evaluated and are brought about by newer technology, which allows for molecular biological evaluation. Because these evaluations are new, no general agreement has been reached about their importance.
  • Flow cytometry has been used in ploidy analysis (cellular nuclear DNA content) and to measure the proliferative fraction of tumor cells (S phase).
  • The prognostic factors of the endometrial cancer precursor 1 score (ie, myometrial invasion, DNA ploidy, and mean shortest nuclear axis) have been evaluated, and in at least one study, multivariant analysis was noted to be important prognostically.
  • Several other molecular biological characteristics have been noted to be important prognostically, including HER2/NEU and TP53 gene overexpression.
  • Newer characteristics are being identified almost daily. Obviously, the necessity for standardization is needed before applicability is available and conclusions can be reached. As experience is gained with these factors, they may be the new prognostic factors for endometrial cancer.
• The use of pelvic and para-aortic lymphadenectomy in the management of adenocarcinoma of the endometrium is controversial, as follows:
  
  
  • Whether the procedure aids in diagnosis is not in doubt. The question that has been raised is whether or not it also might be therapeutic. It certainly appears to be therapeutic for other gynecological cancers. Retrospective data by Kilgore and colleagues suggest that lymphadenectomy in endometrial cancer can also be therapeutic.⁵
  • The number of lymph nodes removed appears therapeutic even if positive nodes are present. In evaluating the SEER data, Chan has noted that patients with positive lymph nodes but few total nodes removed had a worse prognosis than if multiple nodes were removed.⁶
  • When proposed, the FIGO surgical staging classification was questioned as being efficacious by many investigators. However, data suggest that the gynecologic oncology community worldwide has accepted the surgical staging classification. In fact, lymphadenectomies are being performed routinely by these investigators.

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