Endometrial Carcinoma Workup

Updated: Oct 05, 2017
  • Author: William T Creasman, MD; Chief Editor: Warner K Huh, MD  more...
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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.

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Procedures

Biopsy

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 (see the video below); 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.

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

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.

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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.

More recent data would suggest that mixed müllerian tumors originally thought to be a sarcoma are in actuality epithelial in origin and should be included here instead of as a primary sarcoma.

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Staging

The International Federation of Gynecology and Obstetrics (FIGO), 2008 staging system for carcinoma of corpus uteri is as follows [11] :

  • 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.

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