Endometrial Cancer Diagnosis: Difference between revisions
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'''History and Physical''' | '''History and Physical''' | ||
A | A complete medical and family history and physical examination, engaging [[cancer]] genetics counseling and are crucial in narrowing down a diagnosis. | ||
Abnormal uterine bleeding is the most common symptom of endometrial cancer. <ref name="pmid24400027">{{cite journal| author=Pessoa JN, Freitas AC, Guimaraes RA, Lima J, Dos Reis HL, Filho AC| title=Endometrial Assessment: When is it Necessary? | journal=J Clin Med Res | year= 2014 | volume= 6 | issue= 1 | pages= 21-5 | pmid=24400027 | doi=10.4021/jocmr1684w | pmc=3881985 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24400027 }} </ref> | Abnormal uterine bleeding is the most common symptom of endometrial cancer. <ref name="pmid24400027">{{cite journal| author=Pessoa JN, Freitas AC, Guimaraes RA, Lima J, Dos Reis HL, Filho AC| title=Endometrial Assessment: When is it Necessary? | journal=J Clin Med Res | year= 2014 | volume= 6 | issue= 1 | pages= 21-5 | pmid=24400027 | doi=10.4021/jocmr1684w | pmc=3881985 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24400027 }} </ref> | ||
Occasionally, cervicovaginal cytology or abnormal vaginal discharge may lead to the diagnosis of endometrial cancer. Pap smears taken within 6 months prior to the diagnosis of endometrial cancers were reported to be abnormal 38% of the time, consistent with adenocarcinoma 21% of the time, and in 13% of cases showed atypical glandular cells. <ref name="pmid26315394">Lai CR, Hsu CY, Hang JF, Li AF (2015) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=26315394 The Diagnostic Value of Routine Papanicolaou Smears for Detecting Endometrial Cancers: An Update.] ''Acta Cytol'' 59 (4):315-8. [http://dx.doi.org/10.1159/000438975 DOI:10.1159/000438975] PMID: [https://pubmed.gov/26315394 26315394]</ref> | Occasionally, cervicovaginal cytology or abnormal vaginal discharge may lead to the diagnosis of [[endometrial cancer]]. [[Pap smears]] taken within 6 months prior to the diagnosis of [[endometrial cancers]] were reported to be abnormal 38% of the time, consistent with [[adenocarcinoma]] 21% of the time, and in 13% of cases showed atypical glandular cells. <ref name="pmid26315394">Lai CR, Hsu CY, Hang JF, Li AF (2015) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=26315394 The Diagnostic Value of Routine Papanicolaou Smears for Detecting Endometrial Cancers: An Update.] ''Acta Cytol'' 59 (4):315-8. [http://dx.doi.org/10.1159/000438975 DOI:10.1159/000438975] PMID: [https://pubmed.gov/26315394 26315394]</ref> | ||
The definitive diagnosis of endometrial cancer is accomplished by the use of histology. However, the personal and family history of the patient together with a complete physical examination are instrumental. Intrauterine pregnancy should be considered in women of reproductive age with abnormal uterine bleeding or amenorrhea unless post-menopausal status has been confirmed. If suspicious symptoms, signs, and/or family history are present, basic laboratory evaluation, cervical-vaginal Pap smear, and transvaginal TVU scanning generally are considered. Patients with an abnormal Pap smear should undergo further investigation regardless of age. <ref name="pmid28508342">{{cite journal| author=Tzur T, Kessous R, Weintraub AY| title=Current strategies in the diagnosis of endometrial cancer. | journal=Arch Gynecol Obstet | year= 2017 | volume= 296 | issue= 1 | pages= 5-14 | pmid=28508342 | doi=10.1007/s00404-017-4391-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28508342 }} </ref> | The definitive diagnosis of [[endometrial cancer]] is accomplished by the use of histology. However, the personal and family history of the patient together with a complete physical examination are instrumental. Intrauterine pregnancy should be considered in women of reproductive age with abnormal uterine bleeding or amenorrhea unless post-menopausal status has been confirmed. If suspicious symptoms, signs, and/or family history are present, basic laboratory evaluation, cervical-vaginal [[Pap smear]], and transvaginal TVU scanning generally are considered. Patients with an abnormal Pap smear should undergo further investigation regardless of age. <ref name="pmid28508342">{{cite journal| author=Tzur T, Kessous R, Weintraub AY| title=Current strategies in the diagnosis of endometrial cancer. | journal=Arch Gynecol Obstet | year= 2017 | volume= 296 | issue= 1 | pages= 5-14 | pmid=28508342 | doi=10.1007/s00404-017-4391-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28508342 }} </ref> | ||
'''Transvaginal Ultrasound''' | '''Transvaginal Ultrasound''' | ||
This is often the next step when suspicious history or physical findings are seen. In some cases, abdominal ultrasound may also be used. In women aged 35 years or younger who are diagnosed with benign gynecologic conditions or non-gynecologic etiologies and are determined to be of low risk for endometrial pathology, transvaginal ultrasound can be skipped. However, if there is a subsequent failure of medical management, transvaginal ultrasound should be performed. <ref name="pmid11296797">{{cite journal| author=ACOG Committee on Practice Bulletins--Gynecology. American College of Obstetricians and Gynecologists.| title=ACOG practice bulletin: management of anovulatory bleeding. | journal=Int J Gynaecol Obstet | year= 2001 | volume= 72 | issue= 3 | pages= 263-71 | pmid=11296797 | doi=10.1016/s0020-7292(01)00357-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11296797 }} </ref> | This is often the next step when suspicious history or physical findings are seen. In some cases, abdominal ultrasound may also be used. In women aged 35 years or younger who are diagnosed with benign gynecologic conditions or non-gynecologic etiologies and are determined to be of low risk for endometrial pathology, transvaginal ultrasound can be skipped. However, if there is a subsequent failure of medical management, [[transvaginal ultrasound]] should be performed. <ref name="pmid11296797">{{cite journal| author=ACOG Committee on Practice Bulletins--Gynecology. American College of Obstetricians and Gynecologists.| title=ACOG practice bulletin: management of anovulatory bleeding. | journal=Int J Gynaecol Obstet | year= 2001 | volume= 72 | issue= 3 | pages= 263-71 | pmid=11296797 | doi=10.1016/s0020-7292(01)00357-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11296797 }} </ref> | ||
Transvaginal ultrasound should be performed in younger women with recurrent abnormal uterine bleeding and anovulatory bleeding in women over the age of 35 years together with examination under anesthesia with dilation and curettage or endometrial sampling in an outpatient setting. Any suspicious findings warrants further investigation. | Transvaginal ultrasound should be performed in younger women with recurrent abnormal uterine bleeding and anovulatory bleeding in women over the age of 35 years together with examination under anesthesia with [[dilation and curettage]] or endometrial sampling in an outpatient setting. Any suspicious findings warrants further investigation. | ||
Currently, the cut-off for endometrial thickness that requires further investigation in patients with abnormal uterine bleeding is ≥5 mm in post-menopausal women as measured by transvaginal ultrasound. <ref name="pmid31777741">Park YR, Lee SW, Kim Y, Bae IY, Kim HK, Choe J | display-authors=etal (2019) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=31777741 Endometrial thickness cut-off value by transvaginal ultrasonography for screening of endometrial pathology in premenopausal and postmenopausal women.] ''Obstet Gynecol Sci'' 62 (6):445-453. [http://dx.doi.org/10.5468/ogs.2019.62.6.445 DOI:10.5468/ogs.2019.62.6.445] PMID: [https://pubmed.gov/31777741 31777741]</ref> However, a recent meta-analysis and systematic review recommended that the cut-off for exclusion of endometrial cancer in women with post-menopausal bleeding be changed to ≤3 mm. <ref name="pmid11587008">{{cite journal| author=Goldstein RB, Bree RL, Benson CB, Benacerraf BR, Bloss JD, Carlos R | display-authors=etal| title=Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. | journal=J Ultrasound Med | year= 2001 | volume= 20 | issue= 10 | pages= 1025-36 | pmid=11587008 | doi=10.7863/jum.2001.20.10.1025 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11587008 }} </ref> <ref name="pmid20567183">{{cite journal| author=Timmermans A, Opmeer BC, Khan KS, Bachmann LM, Epstein E, Clark TJ | display-authors=etal| title=Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis. | journal=Obstet Gynecol | year= 2010 | volume= 116 | issue= 1 | pages= 160-7 | pmid=20567183 | doi=10.1097/AOG.0b013e3181e3e7e8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20567183 }} </ref> | Currently, the cut-off for endometrial thickness that requires further investigation in patients with abnormal uterine bleeding is ≥5 mm in post-menopausal women as measured by transvaginal ultrasound. <ref name="pmid31777741">Park YR, Lee SW, Kim Y, Bae IY, Kim HK, Choe J | display-authors=etal (2019) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=31777741 Endometrial thickness cut-off value by transvaginal ultrasonography for screening of endometrial pathology in premenopausal and postmenopausal women.] ''Obstet Gynecol Sci'' 62 (6):445-453. [http://dx.doi.org/10.5468/ogs.2019.62.6.445 DOI:10.5468/ogs.2019.62.6.445] PMID: [https://pubmed.gov/31777741 31777741]</ref> However, a recent meta-analysis and systematic review recommended that the cut-off for exclusion of endometrial cancer in women with post-menopausal bleeding be changed to ≤3 mm. <ref name="pmid11587008">{{cite journal| author=Goldstein RB, Bree RL, Benson CB, Benacerraf BR, Bloss JD, Carlos R | display-authors=etal| title=Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. | journal=J Ultrasound Med | year= 2001 | volume= 20 | issue= 10 | pages= 1025-36 | pmid=11587008 | doi=10.7863/jum.2001.20.10.1025 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11587008 }} </ref> <ref name="pmid20567183">{{cite journal| author=Timmermans A, Opmeer BC, Khan KS, Bachmann LM, Epstein E, Clark TJ | display-authors=etal| title=Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis. | journal=Obstet Gynecol | year= 2010 | volume= 116 | issue= 1 | pages= 160-7 | pmid=20567183 | doi=10.1097/AOG.0b013e3181e3e7e8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20567183 }} </ref> | ||
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'''Endocervical Sampling and Endocervical Curettage''' | '''Endocervical Sampling and Endocervical Curettage''' | ||
Endocervical sampling of endocervical curettage is sometimes done before endometrial sampling so determine if there is involvement of the cervix. Biopsies should be taken of any unusual findings and these may prove useful in planning patient management. | Endocervical sampling of [[endocervical curettage]] is sometimes done before endometrial sampling so determine if there is involvement of the cervix. Biopsies should be taken of any unusual findings and these may prove useful in planning patient management. | ||
'''Hysteroscopy''' | '''Hysteroscopy''' | ||
Hysteroscopic examination can be used in detection of endometrial polyps, which can be associated with endometrial cancer particularly among post-menopausal women. <ref name="pmid28763739">{{cite journal| author=Bel S, Billard C, Godet J, Viviani V, Akladios C, Host A | display-authors=etal| title=Risk of malignancy on suspicion of polyps in menopausal women. | journal=Eur J Obstet Gynecol Reprod Biol | year= 2017 | volume= 216 | issue= | pages= 138-142 | pmid=28763739 | doi=10.1016/j.ejogrb.2017.07.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28763739 }} </ref> When used in conjunction with dilation and curettage, hysteroscopy can be used in the removal of these polyps and detection of focal lesions. <ref name="pmid3348309">{{cite journal| author=Gimpelson RJ, Rappold HO| title=A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. | journal=Am J Obstet Gynecol | year= 1988 | volume= 158 | issue= 3 Pt 1 | pages= 489-92 | pmid=3348309 | doi=10.1016/0002-9378(88)90011-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3348309 }} </ref> <ref name="pmid11846711">{{cite journal| author=Epstein E, Ramirez A, Skoog L, Valentin L| title=Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding. | journal=Acta Obstet Gynecol Scand | year= 2001 | volume= 80 | issue= 12 | pages= 1131-6 | pmid=11846711 | doi=10.1034/j.1600-0412.2001.801210.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11846711 }} </ref> Hysteroscopy can also be used to detect submucosal myomas. | Hysteroscopic examination can be used in detection of [[endometrial polyps]], which can be associated with endometrial cancer particularly among post-menopausal women. <ref name="pmid28763739">{{cite journal| author=Bel S, Billard C, Godet J, Viviani V, Akladios C, Host A | display-authors=etal| title=Risk of malignancy on suspicion of polyps in menopausal women. | journal=Eur J Obstet Gynecol Reprod Biol | year= 2017 | volume= 216 | issue= | pages= 138-142 | pmid=28763739 | doi=10.1016/j.ejogrb.2017.07.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28763739 }} </ref> When used in conjunction with dilation and curettage, hysteroscopy can be used in the removal of these polyps and detection of focal lesions. <ref name="pmid3348309">{{cite journal| author=Gimpelson RJ, Rappold HO| title=A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. | journal=Am J Obstet Gynecol | year= 1988 | volume= 158 | issue= 3 Pt 1 | pages= 489-92 | pmid=3348309 | doi=10.1016/0002-9378(88)90011-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3348309 }} </ref> <ref name="pmid11846711">{{cite journal| author=Epstein E, Ramirez A, Skoog L, Valentin L| title=Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding. | journal=Acta Obstet Gynecol Scand | year= 2001 | volume= 80 | issue= 12 | pages= 1131-6 | pmid=11846711 | doi=10.1034/j.1600-0412.2001.801210.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11846711 }} </ref> Hysteroscopy can also be used to detect submucosal myomas. | ||
'''Endometrial Biopsy''' | '''Endometrial Biopsy''' | ||
When there are abnormal findings on transvaginal [[ultrasound]] such as endometrial thickness of ≥5 mm or any abnormal uterine or adnexal findings in women with post-menopausal bleeding, . | |||
'''Other Diagnostic Methods''' | '''Other Diagnostic Methods''' | ||
* If there is recurrent post-menopausal bleeding or the results of an endometrial biopsy is equivocal evaluation under anesthesia and fractional dilation and curettage should be performed, and the diagnosis may be enhanced by hysteroscopy for the detection of focal lesions. <ref name="pmid3348309">{{cite journal| author=Gimpelson RJ, Rappold HO| title=A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. | journal=Am J Obstet Gynecol | year= 1988 | volume= 158 | issue= 3 Pt 1 | pages= 489-92 | pmid=3348309 | doi=10.1016/0002-9378(88)90011-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3348309 }} </ref> <ref name="pmid11846711">{{cite journal| author=Epstein E, Ramirez A, Skoog L, Valentin L| title=Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding. | journal=Acta Obstet Gynecol Scand | year= 2001 | volume= 80 | issue= 12 | pages= 1131-6 | pmid=11846711 | doi=10.1034/j.1600-0412.2001.801210.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11846711 }} </ref> | * If there is recurrent [[post-menopausal]] bleeding or the results of an endometrial [[biopsy]] is equivocal, evaluation under anesthesia and fractional [[dilation and curettage]] should be performed, and the diagnosis may be enhanced by hysteroscopy for the detection of focal lesions. <ref name="pmid3348309">{{cite journal| author=Gimpelson RJ, Rappold HO| title=A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. | journal=Am J Obstet Gynecol | year= 1988 | volume= 158 | issue= 3 Pt 1 | pages= 489-92 | pmid=3348309 | doi=10.1016/0002-9378(88)90011-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3348309 }} </ref> <ref name="pmid11846711">{{cite journal| author=Epstein E, Ramirez A, Skoog L, Valentin L| title=Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding. | journal=Acta Obstet Gynecol Scand | year= 2001 | volume= 80 | issue= 12 | pages= 1131-6 | pmid=11846711 | doi=10.1034/j.1600-0412.2001.801210.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11846711 }} </ref> | ||
* Chest X-ray can be done pre-operatively to evaluate patients for metastasis. | * Chest X-ray can be done pre-operatively to evaluate patients for [[metastasis]]. | ||
* MRI can be performed in difficult cases when ovarian tumors, adnexal involvement, or parametrial invasion is suspected. <ref name="pmid24852891">{{cite journal| author=Epstein E, Blomqvist L| title=Imaging in endometrial cancer. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2014 | volume= 28 | issue= 5 | pages= 721-39 | pmid=24852891 | doi=10.1016/j.bpobgyn.2014.04.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24852891 }} </ref> | * MRI can be performed in difficult cases when ovarian tumors, adnexal involvement, or parametrial invasion is suspected. <ref name="pmid24852891">{{cite journal| author=Epstein E, Blomqvist L| title=Imaging in endometrial cancer. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2014 | volume= 28 | issue= 5 | pages= 721-39 | pmid=24852891 | doi=10.1016/j.bpobgyn.2014.04.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24852891 }} </ref> | ||
* In patients that are Lynch syndrome mutation carriers, it is advisable to perform sonographic imaging, cystourethroscopy, and colonoscopy due to their increased risk of ovarian, urothelial, and colorectal cancer. <ref name="pmid19215248">{{cite journal| author=Barrow E, Robinson L, Alduaij W, Shenton A, Clancy T, Lalloo F | display-authors=etal| title=Cumulative lifetime incidence of extracolonic cancers in Lynch syndrome: a report of 121 families with proven mutations. | journal=Clin Genet | year= 2009 | volume= 75 | issue= 2 | pages= 141-9 | pmid=19215248 | doi=10.1111/j.1399-0004.2008.01125.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19215248 }} </ref> <ref name="pmid29153248">{{cite journal| author=Hiatt MJ, Casey MJ, Lynch HT, Snyder CL, Stacey M, Walters RW| title=Efficacy of proximal colectomy for surgical management of right-sided first colorectal cancer in Lynch Syndrome mutation carriers. | journal=Am J Surg | year= 2018 | volume= 216 | issue= 1 | pages= 99-105 | pmid=29153248 | doi=10.1016/j.amjsurg.2017.11.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29153248 }} </ref> | * In patients that are [[Lynch syndrome]] mutation carriers, it is advisable to perform sonographic imaging, cystourethroscopy, and [[colonoscopy]] due to their increased risk of ovarian, urothelial, and colorectal cancer. <ref name="pmid19215248">{{cite journal| author=Barrow E, Robinson L, Alduaij W, Shenton A, Clancy T, Lalloo F | display-authors=etal| title=Cumulative lifetime incidence of extracolonic cancers in Lynch syndrome: a report of 121 families with proven mutations. | journal=Clin Genet | year= 2009 | volume= 75 | issue= 2 | pages= 141-9 | pmid=19215248 | doi=10.1111/j.1399-0004.2008.01125.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19215248 }} </ref> <ref name="pmid29153248">{{cite journal| author=Hiatt MJ, Casey MJ, Lynch HT, Snyder CL, Stacey M, Walters RW| title=Efficacy of proximal colectomy for surgical management of right-sided first colorectal cancer in Lynch Syndrome mutation carriers. | journal=Am J Surg | year= 2018 | volume= 216 | issue= 1 | pages= 99-105 | pmid=29153248 | doi=10.1016/j.amjsurg.2017.11.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29153248 }} </ref> | ||
'''Staging''' | '''Staging''' | ||
Management of endometrial cancer and its precursor lesions depends upon the histotype and differentiation | Management of [[endometrial cancer]] and its precursor lesions depends upon the histotype and differentiation[[, extent of disease and status of the patient. The extent of endometrial carcinoma is surgically-pathologically classified, or "staged," according to International Federation of Gynecology and Obstetrics (FIGO) criteria published in 2009 as: | ||
'''Stage I: Tumor confined to the corpus uteri''' | '''Stage I: Tumor confined to the [[corpus uteri]]''' | ||
*IA: No invasion or invasion into less than half of the myometrium | *IA: No invasion or invasion into less than half of the myometrium | ||
*IB: Invasion equal into or more than half of the myometrium | *IB: Invasion equal into or more than half of the myometrium | ||
'''Stage II: Tumor invades cervical stroma but does not extend beyond the uterus''' | '''Stage II: [[Tumor]] invades cervical stroma but does not extend beyond the uterus''' | ||
'''Stage III: Local and/or regional spread of tumor''' | '''Stage III: Local and/or regional spread of [[tumor]]''' | ||
*IIIA: Tumor invades the serosa or corpus and/or adnexa | *IIIA: Tumor invades the serosa or corpus and/or adnexa | ||
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**IIIC2: Positive para-aortic nodes with or without pelvic nodes | **IIIC2: Positive para-aortic nodes with or without pelvic nodes | ||
'''Stage IV: Tumor invades bladder and/or bowel mucosa or distant metastases''' | '''Stage IV: Tumor invades [[bladder]] and/or bowel mucosa or distant metastases''' | ||
*IVA: Tumor invasion of bladder and/or bowel mucosa | *IVA: Tumor invasion of [[bladder]] and/or bowel mucosa | ||
*IVB: Distant metastases, including intra-abdominal and/or inguinal nodes | *IVB: Distant metastases, including intra-abdominal and/or inguinal nodes | ||
Although positive peritoneal cytology does not change FIGO staging, this finding is associated with other factors that portend a poor prognosis. <ref name="pmid29223598">{{cite journal| author=Seagle BL, Alexander AL, Lantsman T, Shahabi S| title=Prognosis and treatment of positive peritoneal cytology in early endometrial cancer: matched cohort analyses from the National Cancer Database. | journal=Am J Obstet Gynecol | year= 2018 | volume= 218 | issue= 3 | pages= 329.e1-329.e15 | pmid=29223598 | doi=10.1016/j.ajog.2017.11.601 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29223598 }} </ref> | Although positive peritoneal cytology does not change FIGO staging, this finding is associated with other factors that portend a poor prognosis. <ref name="pmid29223598">{{cite journal| author=Seagle BL, Alexander AL, Lantsman T, Shahabi S| title=Prognosis and treatment of positive peritoneal cytology in early endometrial cancer: matched cohort analyses from the National Cancer Database. | journal=Am J Obstet Gynecol | year= 2018 | volume= 218 | issue= 3 | pages= 329.e1-329.e15 | pmid=29223598 | doi=10.1016/j.ajog.2017.11.601 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29223598 }} </ref> | ||
It is important to understand that staging is a means of coding and reporting the extent of disease and not a formula for managing endometrial cancer. Current FIGO classification by stage depends upon both surgical and pathological findings. Generally, preinvasive neoplastic lesions are diagnosed clinically and pathologically without resort to surgery. Sometimes, it is necessary to clinically and pathologically "stage" cancers when surgery is incomplete or precluded because of co-morbidity or other forbidding reasons. | It is important to understand that staging is a means of coding and reporting the extent of disease and not a formula for managing [[endometrial cancer]]. Current FIGO classification by stage depends upon both surgical and pathological findings. Generally, preinvasive neoplastic lesions are diagnosed clinically and pathologically without resort to surgery. Sometimes, it is necessary to clinically and pathologically "stage" cancers when surgery is incomplete or precluded because of co-morbidity or other forbidding reasons. | ||
'''References''' | '''References''' | ||
Revision as of 10:49, 16 October 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Ogechukwu Hannah Nnabude, MD
Diagnosis
History and Physical
A complete medical and family history and physical examination, engaging cancer genetics counseling and are crucial in narrowing down a diagnosis. Abnormal uterine bleeding is the most common symptom of endometrial cancer. [1] Occasionally, cervicovaginal cytology or abnormal vaginal discharge may lead to the diagnosis of endometrial cancer. Pap smears taken within 6 months prior to the diagnosis of endometrial cancers were reported to be abnormal 38% of the time, consistent with adenocarcinoma 21% of the time, and in 13% of cases showed atypical glandular cells. [2] The definitive diagnosis of endometrial cancer is accomplished by the use of histology. However, the personal and family history of the patient together with a complete physical examination are instrumental. Intrauterine pregnancy should be considered in women of reproductive age with abnormal uterine bleeding or amenorrhea unless post-menopausal status has been confirmed. If suspicious symptoms, signs, and/or family history are present, basic laboratory evaluation, cervical-vaginal Pap smear, and transvaginal TVU scanning generally are considered. Patients with an abnormal Pap smear should undergo further investigation regardless of age. [3]
Transvaginal Ultrasound
This is often the next step when suspicious history or physical findings are seen. In some cases, abdominal ultrasound may also be used. In women aged 35 years or younger who are diagnosed with benign gynecologic conditions or non-gynecologic etiologies and are determined to be of low risk for endometrial pathology, transvaginal ultrasound can be skipped. However, if there is a subsequent failure of medical management, transvaginal ultrasound should be performed. [4] Transvaginal ultrasound should be performed in younger women with recurrent abnormal uterine bleeding and anovulatory bleeding in women over the age of 35 years together with examination under anesthesia with dilation and curettage or endometrial sampling in an outpatient setting. Any suspicious findings warrants further investigation. Currently, the cut-off for endometrial thickness that requires further investigation in patients with abnormal uterine bleeding is ≥5 mm in post-menopausal women as measured by transvaginal ultrasound. [5] However, a recent meta-analysis and systematic review recommended that the cut-off for exclusion of endometrial cancer in women with post-menopausal bleeding be changed to ≤3 mm. [6] [7]
Endocervical Sampling and Endocervical Curettage
Endocervical sampling of endocervical curettage is sometimes done before endometrial sampling so determine if there is involvement of the cervix. Biopsies should be taken of any unusual findings and these may prove useful in planning patient management.
Hysteroscopy
Hysteroscopic examination can be used in detection of endometrial polyps, which can be associated with endometrial cancer particularly among post-menopausal women. [8] When used in conjunction with dilation and curettage, hysteroscopy can be used in the removal of these polyps and detection of focal lesions. [9] [10] Hysteroscopy can also be used to detect submucosal myomas.
Endometrial Biopsy
When there are abnormal findings on transvaginal ultrasound such as endometrial thickness of ≥5 mm or any abnormal uterine or adnexal findings in women with post-menopausal bleeding, .
Other Diagnostic Methods
- If there is recurrent post-menopausal bleeding or the results of an endometrial biopsy is equivocal, evaluation under anesthesia and fractional dilation and curettage should be performed, and the diagnosis may be enhanced by hysteroscopy for the detection of focal lesions. [9] [10]
- Chest X-ray can be done pre-operatively to evaluate patients for metastasis.
- MRI can be performed in difficult cases when ovarian tumors, adnexal involvement, or parametrial invasion is suspected. [11]
- In patients that are Lynch syndrome mutation carriers, it is advisable to perform sonographic imaging, cystourethroscopy, and colonoscopy due to their increased risk of ovarian, urothelial, and colorectal cancer. [12] [13]
Staging Management of endometrial cancer and its precursor lesions depends upon the histotype and differentiation[[, extent of disease and status of the patient. The extent of endometrial carcinoma is surgically-pathologically classified, or "staged," according to International Federation of Gynecology and Obstetrics (FIGO) criteria published in 2009 as:
Stage I: Tumor confined to the corpus uteri
- IA: No invasion or invasion into less than half of the myometrium
- IB: Invasion equal into 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 tumor
- IIIA: Tumor invades the serosa or corpus and/or adnexa
- IIIB: Vaginal and/or parametrial involvement
- IIIC: Metastases to pelvic and/or para-aortic nodes
- IIIC1: Positive pelvic nodes
- IIIC2: Positive para-aortic nodes with or without pelvic nodes
Stage IV: Tumor invades bladder and/or bowel mucosa or distant metastases
- IVA: Tumor invasion of bladder and/or bowel mucosa
- IVB: Distant metastases, including intra-abdominal and/or inguinal nodes
Although positive peritoneal cytology does not change FIGO staging, this finding is associated with other factors that portend a poor prognosis. [14]
It is important to understand that staging is a means of coding and reporting the extent of disease and not a formula for managing endometrial cancer. Current FIGO classification by stage depends upon both surgical and pathological findings. Generally, preinvasive neoplastic lesions are diagnosed clinically and pathologically without resort to surgery. Sometimes, it is necessary to clinically and pathologically "stage" cancers when surgery is incomplete or precluded because of co-morbidity or other forbidding reasons.
References
- ↑ Pessoa JN, Freitas AC, Guimaraes RA, Lima J, Dos Reis HL, Filho AC (2014). "Endometrial Assessment: When is it Necessary?". J Clin Med Res. 6 (1): 21–5. doi:10.4021/jocmr1684w. PMC 3881985. PMID 24400027.
- ↑ Lai CR, Hsu CY, Hang JF, Li AF (2015) The Diagnostic Value of Routine Papanicolaou Smears for Detecting Endometrial Cancers: An Update. Acta Cytol 59 (4):315-8. DOI:10.1159/000438975 PMID: 26315394
- ↑ Tzur T, Kessous R, Weintraub AY (2017). "Current strategies in the diagnosis of endometrial cancer". Arch Gynecol Obstet. 296 (1): 5–14. doi:10.1007/s00404-017-4391-z. PMID 28508342.
- ↑ ACOG Committee on Practice Bulletins--Gynecology. American College of Obstetricians and Gynecologists. (2001). "ACOG practice bulletin: management of anovulatory bleeding". Int J Gynaecol Obstet. 72 (3): 263–71. doi:10.1016/s0020-7292(01)00357-5. PMID 11296797.
- ↑ Park YR, Lee SW, Kim Y, Bae IY, Kim HK, Choe J | display-authors=etal (2019) Endometrial thickness cut-off value by transvaginal ultrasonography for screening of endometrial pathology in premenopausal and postmenopausal women. Obstet Gynecol Sci 62 (6):445-453. DOI:10.5468/ogs.2019.62.6.445 PMID: 31777741
- ↑ Goldstein RB, Bree RL, Benson CB, Benacerraf BR, Bloss JD, Carlos R; et al. (2001). "Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement". J Ultrasound Med. 20 (10): 1025–36. doi:10.7863/jum.2001.20.10.1025. PMID 11587008.
- ↑ Timmermans A, Opmeer BC, Khan KS, Bachmann LM, Epstein E, Clark TJ; et al. (2010). "Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis". Obstet Gynecol. 116 (1): 160–7. doi:10.1097/AOG.0b013e3181e3e7e8. PMID 20567183.
- ↑ Bel S, Billard C, Godet J, Viviani V, Akladios C, Host A; et al. (2017). "Risk of malignancy on suspicion of polyps in menopausal women". Eur J Obstet Gynecol Reprod Biol. 216: 138–142. doi:10.1016/j.ejogrb.2017.07.013. PMID 28763739.
- ↑ 9.0 9.1 Gimpelson RJ, Rappold HO (1988). "A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases". Am J Obstet Gynecol. 158 (3 Pt 1): 489–92. doi:10.1016/0002-9378(88)90011-7. PMID 3348309.
- ↑ 10.0 10.1 Epstein E, Ramirez A, Skoog L, Valentin L (2001). "Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding". Acta Obstet Gynecol Scand. 80 (12): 1131–6. doi:10.1034/j.1600-0412.2001.801210.x. PMID 11846711.
- ↑ Epstein E, Blomqvist L (2014). "Imaging in endometrial cancer". Best Pract Res Clin Obstet Gynaecol. 28 (5): 721–39. doi:10.1016/j.bpobgyn.2014.04.007. PMID 24852891.
- ↑ Barrow E, Robinson L, Alduaij W, Shenton A, Clancy T, Lalloo F; et al. (2009). "Cumulative lifetime incidence of extracolonic cancers in Lynch syndrome: a report of 121 families with proven mutations". Clin Genet. 75 (2): 141–9. doi:10.1111/j.1399-0004.2008.01125.x. PMID 19215248.
- ↑ Hiatt MJ, Casey MJ, Lynch HT, Snyder CL, Stacey M, Walters RW (2018). "Efficacy of proximal colectomy for surgical management of right-sided first colorectal cancer in Lynch Syndrome mutation carriers". Am J Surg. 216 (1): 99–105. doi:10.1016/j.amjsurg.2017.11.003. PMID 29153248.
- ↑ Seagle BL, Alexander AL, Lantsman T, Shahabi S (2018). "Prognosis and treatment of positive peritoneal cytology in early endometrial cancer: matched cohort analyses from the National Cancer Database". Am J Obstet Gynecol. 218 (3): 329.e1–329.e15. doi:10.1016/j.ajog.2017.11.601. PMID 29223598.