Endometrial Carcinoma Follow-up

  • Author: William T Creasman, MD; Chief Editor: Warner K Huh, MD   more...
 
Updated: Dec 7, 2011
 

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.
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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.
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Contributor Information and Disclosures
Author

William T Creasman, MD  J Marion Sims Distinguished University Professor, Department of Obstetrics and Gynecology, Medical University of South Carolina College of Medicine

William T Creasman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Gynecological and Obstetrical Society, American Medical Association, North Carolina Medical Society, Society of Gynecologist Oncologists, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

John J Kavanagh Jr  MD, Chief, Professor, Department of Internal Medicine, Section of Gynecological and Medical Therapeutics, MD Anderson Cancer Center, University of Texas Medical School at Houston

John J Kavanagh Jr is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association for the History of Medicine, American College of Physicians, American Federation for Medical Research, American Medical Association, Society of Gynecologist Oncologists, Southern Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

A David Barnes, MD, PhD, MPH, FACOG  Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Warner K Huh, MD  Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Senior Scientist, Comprehensive Cancer Center, University of Alabama School of Medicine

Warner K Huh, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Society of Clinical Oncology, Massachusetts Medical Society, and Society of Gynecologist Oncologists

Disclosure: MERCK Consulting fee Consulting; GSK Consulting fee Consulting; ROCHE PHARMA/DIAGNOSTICS Consulting fee Consulting; HOLOGICS Consulting fee Consulting; HELIX BIOPHARMA Consulting fee Consulting; COVIDIEN Consulting fee Consulting; INTUITIVE SURGICAL Surgical Proctor

Additional Contributors

Medscape Reference thanks Tarek Bardawil, MD, Assistant Professor, Department of Obstetrics and Gynecology, University of Miami Miller School of Medicine, for assistance with the video contribution to this article.

References

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Diagnostic hysteroscopy for endometrial cancer. Video courtesy of Tarek Bardawil, MD.
 
 
 
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