gynecology and obstetrics
Endometrial Cancer
Diagnosis of Endometrial Cancer
Endometrial biopsy The following suggest endometrial cancer: Postmenopausal bleeding Abnormal bleeding in premenopausal women (intermenstrual bleeding, ovulatory dysfunction), particularly in women > 45 years A routine Papanicolaou (Pap) test showing endometrial cells in postmenopausal women A routine Pap test showing atypical endometrial cells in any woman 4 mm and results are inconclusive ( Diagnosis references ). If biopsy results are inconclusive or suggest precancer (eg, complex hyperplasia with atypia) or cancer, dilation and curettage (D & C), often with hysteroscopy, is done. Once endometrial cancer is diagnosed, pretreatment evaluation includes a complete blood count (CBC) and other blood tests (serum electrolytes, kidney, and liver). A chest x-ray is done. If an abnormality is seen on chest x-ray, CT should be done. The following should be considered: Pelvic MRI to determine the origin of the tumor (cervix or uterus) and local extension For high-grade carcinomas, chest, abdomen, and pelvic CT If metastatic disease is suspected based on physical examination or blood tests, positive emission tomography (PET)-CT Because endometrial cancer sometimes results from an inherited mutation, genetic counseling and/or testing should be considered if patients are < 50 years or have a significant family history of endometrial cancer, ovarian cancer, or colorectal cancer or known Lynch syndrome (HNPCC). Staging of endometrial cancer is based on non-aggressive versus aggressive histology; extent of spread, including invasion depth, extension to surrounding structures, and extrauterine or lymph node metastases; lymphovascular space invasion; and molecular classification (see table). Staging is surgical and includes exploration of the abdomen and pelvis, biopsy or excision of suspicious extrauterine lesions, total abdominal hysterectomy, and, in patients with high-risk features (grade 1 or 2 cancer plus deep myometrial invasion, grade 3 cancer, all cancers with high-risk histology), pelvic and para-aortic lymphadenectomy. Staging can be done via laparotomy, laparoscopy, or robotic-assisted surgery. If cancer appears to be confined to the uterus, an alternative to pelvic and para-aortic lymphadenectomy is sentinel lymph node mapping. When the molecular classification is known: FIGO Stages I and II are based on surgical/anatomical and histologic findings. ForPOLEmutor p53abn status, the FIGO stage is modified in the early stage of the disease. This is depicted in the FIGO stage by the addition of “m” for molecular classification, and a subscript is added to denotePOLEmutor p53abn status. MMRd or NSMP status do not modify early FIGO stages; however, these molecular classifications should be recorded for the purpose of data collection. When molecular classification reveals MMRd or NSMP, it should be recorded as Stage Im or Stage Im and Stage IIm or Stage IIm. FIGO Stages III and IV are based on surgical/anatomical findings. The stage category is not modified by molecular classification; however, the molecular classification should be recorded if known, as Stage IIIm or Stage IVm with the appropriate subscript for the purpose of data collection. For example, when molecular classification reveals p53abn, it should be recorded as Stage IIIm or Stage IVm. Sentinel lymph node (SLN) mapping can be considered for the surgical staging of cancer that appears confined to the uterus—stage I ( Diagnosis references ). In many centers, SLN mapping is currently the standard for cancers with high-risk histology—ie, papillary serous carcinoma, clear cell carcinoma, and carcinosarcoma ( (ICG) is highly accurate for the diagnosis of endometrial cancer metastases; it was recommended as a replacement for complete lymphadenectomy ( Diagnosis references ). SLN mapping is done as for Where to inject the tracer in patients with endometrial carcinoma has been controversial. Evidence suggests that in endometrial cancer, cervical injection with ICG results in a higher detection rate than hysteroscopic injection, and anatomic nodal distribution is similar ( Diagnosis references ). Dye is usually injected into the cervix both superficially (1 to 3 mm) and deep (1 to 2 cm) at 3 and 9 o’clock. With this technique, dye penetrates to the uterine lymphatic trunks (which meet in the parametria) and appears in the broad ligament leading to pelvic and occasionally para-aortic SLNs. If sentinel lymph nodes are identified bilaterally, no lymphadenectomy is indicated, regardless of tumor characteristics. If one side (or both) has no identified sentinel node, complete lymphadenectomy is necessary on that side. Whether dissection of the para-aortic nodes is necessary is left up to surgeon discretion. The most common locations of pelvic SLNs are Medial to the external iliac blood vessels Ventral to the internal iliac blood vessels In the superior part of the obturator region Less common locations are the iliac and/or presacral regions. A complete pelvic lymphadenectomy should be done when any of the following occur: Mapping does not detect any SLNs in patients with high-risk tumors. A hemipelvis cannot be mapped. There are any suspicious or grossly enlarged nodes, regardless of mapping. An ongoing phase III randomized trial (ENDO-3) is evaluating SLN biopsy with no retroperitoneal node dissection compared with no nodal dissection in clinical stage 1 FIGO grade 1 to 3 endometrioid, clear cell, serous, or carcinosarcoma ( Diagnosis references ). 1.ACOG (American College of Obstetricians and Gynecologists) Committee Opinion No. 734: The role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding.Obstet Gynecol131 (5):e124-e129, 2018. doi: 10.1097/AOG.0000000000002631 2.Cusimano MC, Vicus D, Pulman K, et al: Assessment of sentinel lymph node Biopsy vs lymphadenectomy for intermediate- and high-grade endometrial cancer staging.JAMA Surg156 (2):157–164, 2021. doi: 10.1001/jamasurg.2020.5060 3.Schlappe BA, Weaver AL, McGree ME, et al: Multicenter study comparing oncologic outcomes after lymph node assessment via a sentinel lymph node algorithm versus comprehensive pelvic and paraaortic lymphadenectomy in patients with serous and clear cell endometrial carcinoma.Gynecol Oncol156 (1):62–69, 2020. doi: 10.1016/j.ygyno.2019.11.002 4.Rossi EC, Kowalski LD, Scalici J, et al: A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): A multicentre, prospective, cohort study.Lancet Oncol18 (3):384–392, 2017. doi: 10.1016/S1470-2045(17)30068-2 5.Segarra-Vidal B, Dinoi G, Zorrilla-Vaca A, et al: Minimally invasive compared with open hysterectomy in high-risk endometrial cancer.Obstet Gynecol138 (6):828–837, 2021. doi: 10.1097/AOG.0000000000004606 6.Rossi EC, Jackson A, Ivanova A, Boggess JF: Detection of sentinel nodes for endometrial cancer with robotic assisted fluorescence imaging: cervical versus hysteroscopic injection.Int J Gynecol Cancer23 (9):1704–1711, 2013. doi: 10.1097/IGC.0b013e3182a616f6 7.Obermair A, Nicklin J, Gebski V, et al: A phase III randomized clinical trial comparing sentinel node biopsy with no retroperitoneal node dissection in apparent early-stage endometrial cancer - ENDO-3: ANZGOG trial 1911/2020.Int J Gynecol Cancer31(12):1595-1601, 2021. doi:10.1136/ijgc-2021-003029 