Endometrial Cancer Diagnosis
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Diagnosis |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Monalisa Dmello, M.B,B.S., M.D. [2] Ogechukwu Hannah Nnabude, MD
Diagnosis
History and Physical
A thorough history and physical examination, including all systems, habits, medications, allergies, present acute and chronic illnesses and previous illnesses, significant injuries and surgeries, and a meticulous family medical-surgical history with multigeneration family cancer history, engaging cancer genetics counseling 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
This is the next step when there are abnormal findings on transvagianl 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]
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.