Obstetrics and Gynaecology

at a Glance

Fourth EditionErrol R. Norwitz, John O. Schorge

Case Studies

Case 5: Endometrial cancer

An obese, but otherwise healthy, 62-year-old woman presents to your office after having her “period” for the first time in over a decade.

  • 1. What is your differential diagnosis?

    Correct answer: Any episode of postmenopausal bleeding should prompt the physician to consider the diagnosis of endometrial cancer. It is the most common malignancy of the reproductive organs: women have a 2% lifetime risk. Fortunately, most etiologies of postmenopausal bleeding will have a benign etiology. Endometrial polyps are most common, but atrophic vaginitis, trauma, or other lesions of the genital tract (e.g, urethral prolapse) may be identified.

  • 2. What is the initial evaluation?

    Correct answer: Initially, a careful history may provide a sense of the duration, amount, and consistency of the bleeding. When “bleeding” consists only of pinkish staining on toilet paper noted on wiping, then it may suggest a benign estrogen-deficient diagnosis. In this patient, having heavier bleeding similar to her “period” is more concerning. A careful pelvic examination is required to rule out a vulvar cancer, vaginal trauma, cervical lesion, or some other obvious cause. An endometrial biopsy (see Chapter 4) should be performed to make the diagnosis. If the results are equivocal, a transvaginal ultrasound may be helpful, but dilation and curettage with diagnostic hysteroscopy may also be required.

  • 3. The biopsy demonstrates grade 1 endometrial cancer. What is the best management?

    Correct answer: The vast majority of patients should undergo systematic surgical staging with pelvic washings, hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic and para-aortic lymphadenectomy. Increasingly, minimally invasive laparoscopic surgery or robotic-assisted surgery has replaced open laparotomy for treatment of this malignancy.

    Rarely, young women with grade 1 endometrioid adenocarcinoma associated with atypical endometrial hyperplasia, who wish to preserve fertility, may be treated with high-dose progestins. Women at increased risk of mortality secondary to comorbidities can be treated primarily by radiation.

    Preoperatively, only a physical examination and a chest radiograph are required for the clinical stage I patient with usual (grade 1 endometrioid) histology.

    Criteria for referral to gynecologic oncologist
    • The ability to completely and adequately surgically stage the patient is not readily available at the time of the initial procedure
    • Preoperative histology (grade 3, papillary serous, clear cell, carcinosarcoma) suggests a high risk for extrauterine spread
    • The final pathology result reveals an unexpected endometrial cancer after hysterectomy performed for other indications
    • There is evidence for cervical or extrauterine disease
    • The pelvic washings are positive for malignant cells
    • Recurrent disease is diagnosed or suspected
    • Non-surgical therapy is contemplated
  • 4. Her final pathology demonstrates a grade 13 tumor with 70% depth of invasion into the myometrium, negative lymph nodes, no cervical extension or lymph vascular invasion, and normal pelvic washings. What is her stage and does she need postoperative therapy?

    Correct answer: This patient would be assigned as a stage IB, grade 13 endometrial cancer. Her surgical–pathologic findings are considered to be “intermediate risk.” Most clinicians would refer her for consideration of vaginal brachytherapy to reduce her risk of local relapse.

  • 5. What is the appropriate follow-up for patients with endometrial cancer?

    Correct answer: Monitoring for recurrent endometrial cancer depends on the stage and treatment of the original diagnosis. Routine Pap tests have not proven that helpful during follow-up visits, are not cost-effective, and are probably not necessary. For those women who have not received radiation therapy, pelvic examinations every 3–4 months for 2 years, then twice-yearly after surgical treatment of endometrial cancer, are recommended.

See Chapters 4 and 32.

Print Answers | « Previous Case | Next Case »

twitter