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Q: What is endometrial cancer?
A: Endometrial cancer is a cancer that starts in the inner lining of the womb
(uterus). This lining is called the endometrium. The pictures below show where
the uterus is found.
The picture below shows the uterus and its adjacent structures. The uterus is a hollow organ, about the size and shape of a medium-sized pear. It has 2 main parts. The lower part, which extends into the vagina, is called the cervix. The upper part is the body of the uterus, also known as the corpus. The body of the uterus has three layers. The innermost layer is called the endometrium. During a woman's menstrual cycle the endometrium changes. In the early part of the cycle, it gets thicker in case the woman becomes pregnant. If she does not become pregnant, the tissue is shed from the uterus and becomes the menstrual flow. This cycle repeats throughout a woman's life until the time of menopause. Nearly all cancers of the uterus start in the endometrium. They are called endometrial carcinomas. Most carcinomas are cancers that start in the cells that form glands in the lining of the uterus. They are called adenocarcinomas. The most common type of endometrial cancer is called endometrioid adenocarcinoma. Other rare types include squamous cell and undifferentiated. About 80% of endometrial cancers are typical adenocarcinomas, also known as endometrioid. These cancers are made up of cells in glands that look much like the normal uterine lining (endometrium). Some of them contain squamous cells (squamous cells are flat, thin cells that can be found on the outer surface of the cervix), as well as glandular cells. A cancer with both types of cells is called an adenocarcinoma with squamous differentiation. There are other types of endometrioid cancers, such as secretory carcinoma, ciliated carcinoma, and mucinous adenocarcinoma. The grade of an endometrioid cancer is based on how much the cancer forms glands that look similar to the glands found in normal, healthy endometrium. Grade 1 tumors have 95% or more of the cancerous tissue forming glands.
Grade 2 tumors have between 50% and 94% of the cancerous tissue forming
Grade 3 tumors have less than half of the cancerous tissue forming glands.
They are called "high-grade", tend to be aggressive, and have a poorer
prognosis than low grade cancers (grades 1 and 2).
Some less common forms of endometrial adenocarcinoma are clear-cell
carcinoma, serous carcinoma (also called papillary serous carcinoma), and
poorly differentiated carcinoma. These cancers are more aggressive than most
endometrial cancers. They tend to grow quickly and usually have spread outside
the uterus at the time of diagnosis.
Endometrial carcinomas may be classified into 2 types based on their prognosis
and underlying causes. "Type 1" cancers are thought to be secondary to an
excess estrogen. They are usually not very aggressive and are slow to spread to
other tissues. Grades 1 and 2 endometrioid cancers belong to this type. A small
number of endometrial cancers are "Type 2." The exact cause of these cancers
is still unknown, although they have not been associated with unopposed
estrogen. Serous carcinoma, clear-cell carcinoma, poorly differentiated
carcinoma, and grade 3 endometrioid carcinoma are all type 2 cancers. They
appear differently from a normal endometrium and thus are called "poorly
differentiated" or "high-grade". They are more likely to grow and spread outside
of the uterus and are thus associated with poorer prognosis (than type 1
cancers).
Q: What are the key statistics about endometrial cancer?
A: In the United States, cancer of the endometrium is the most common cancer
of the female reproductive organs. The American Cancer Society estimates
there will be 40,100 new cases of cancer of the body of the uterus (uterine
corpus) diagnosed in the United States during 2008. Most of these occur in the
endometrium. The American Cancer Society also estimates that about 7,470
women in the United States will die from cancers of the uterine body during 2008.
In the Philippines, cancer of the corpus uteri has been identified as the 9th
leading site of cancer among Filipino women, with an incidence of 3.2%. There
is an estimated 4.3 new cancer cases per 100,000 women in 2005. About 546
Filipino women afflicted with this disease died in 2005.
This cancer is rare in women under the age of 45. Most cases are found in
women who are 55 years old and over, with more than half of all endometrial
cancer cases diagnosed in the 55 to 74 age group. The average chance of a
woman being diagnosed with this cancer during her lifetime is about one in 41.
There are over 500,000 women who are survivors of this cancer. This cancer is
more common in white women, but black women are more likely to die from it.
The 5-year relative survival rate from endometrial cancer is about 88%. Majority
of these cancers are found at an early stage, with a 5-year survival rate of more
than 95%. However, the prognosis for any single woman depends on the stage
of her cancer as well as several other factors.
Q: What are the risk factors for endometrial cancer?
A: The cause of most cases of endometrial cancer is still unknown. However,
there are certain risk factors that are linked to the development of this disease. A
risk factor is anything that increases a person's chance of getting a disease such
as cancer. Different cancers have different risk factors. A person can have
several risk factors and still not get the disease. On the other hand, not having
any risk factor does not mean that a woman will never have the disease. The
following have been identified as risk factors for the development of endometrial
cancer:
Hormone levels – A woman's hormonal balance plays a part in most
endometrial cancers. Many of the risk factors for endometrial cancer affect
estrogen levels. Before menopause, the ovaries are the main source of the 2
main types of female hormones – estrogen and progesterone. The balance
between these two hormones changes during a woman's menstrual cycle each
month. A shift in the balance of these 2 hormones toward more estrogen
increases a woman's risk for getting endometrial cancer. After menopause, the
ovaries cease producing these hormones, but a small amount of estrogen is still
made naturally in fat tissue. This estrogen has a bigger impact after menopause
than it does before menopause. Female hormones are also available as birth
control pills to prevent pregnancy, and hormone therapy to treat menopausal
symptoms.
Estrogen therapy – Using estrogen to treat symptoms of menopause is known
as estrogen replacement therapy or hormone replacement therapy. Estrogen is
available in various forms, such as pills, skin patches, creams, and vaginal rings.
It can reduce hot flashes, improve vaginal dryness, and help prevent the
weakening of bones (osteoporosis) that can occur with menopause. Using
estrogen alone (without progesterone) had been associated with the
development of endometrial cancer. Progesterone-like drugs must be given
along with estrogen in order to avoid this increased risk. This approach is called
combination hormone therapy.
Total number of menstrual cycles (periods) – Having more periods during a
woman's lifetime raises her risk for endometrial cancer. Starting menstrual
period (menarche) before age 12, or going through menopause late, raises the
risk. Starting periods early is less a risk factor for women with early menopause.
Likewise, late menopause may not lead to a higher risk in women whose periods
began later in their teens.
Pregnancy – During pregnancy, the hormonal balance shifts toward more
progesterone. Therefore, having several pregnancies reduces endometrial
cancer risk. Women who have never been pregnant (nulliparity) have a higher
risk, especially if they were also infertile (unable to become pregnant).
Obesity – Most of a woman's estrogen is produced by the ovaries, but fat tissue
can change some other hormones into estrogens. Having more fat tissue thus
can increase a woman's estrogen levels and, as a result, increase her
endometrial cancer risk. In comparison with women who maintain a healthy
weight, endometrial cancer is twice as common in overweight women, and more
than three times as common in women who are obese.
Tamoxifen – Tamoxifen is a drug that is used to treat women with breast cancer.
It is also used to reduce the risk in women who are at high risk of getting breast
cancer. The drug, unfortunately, acts like estrogen in the uterus. It can cause
the uterine lining to grow thereby increasing the risk of endometrial cancer in
women taking this drug. The risk of getting endometrial cancer in women taking
tamoxifen is very small (about 1 in 500). It must be balanced against the benefit
obtained from taking the drug in treating breast cancer and reducing the chances
of the woman getting cancer in the other breast.
Ovarian tumors – A certain type of ovarian tumor, the granulosa-theca cell
tumor, often produces estrogen. However, the control mechanism by which
estrogen is released by one of these tumors is different from that produced by
the ovaries, which can sometimes lead to high estrogen levels. This may result
to hormone imbalance which can stimulate the endometrium and may lead to
endometrial cancer. In fact, sometimes vaginal bleeding from endometrial
cancer is the first symptom of one of these tumors.
Polycystic ovarian syndrome – Women with polycystic ovarian syndrome
(PCOS) have hormonal imbalance such as higher estrogen levels and lower
levels of progesterone. The increase in estrogen compared to progesterone can
increase a woman's chance of getting endometrial cancer.
Age – The risk of endometrial cancer increases as a woman gets older.
Diabetes – Diabetes occurs more commonly among people who are overweight.
This could be the reason why diabetes is a risk factor for endometrial cancer.
Endometrial cancer may be as much as four times more common in women with
diabetes. Although diabetes is more common in people who are overweight,
even diabetics with normal body weight have a higher risk of developing
endometrial cancer. Some studies suggest that diabetes by itself could also be a
risk factor.
Family history – Endometrial cancer tends to run in some families with an
inherited tendency to develop colon cancer, a disorder called hereditary
nonpolyposis colon cancer (HNPCC), or Lynch syndrome. In most cases, this
disorder is secondary to a defect in either the gene MLH1 or the gene MSH2. At
least 5 other genes can cause HNPCC, namely MLH3, MSH6, TGBR2, PMS1,
and PMS2. An abnormal copy of any one of these genes reduces the body's
ability to repair any damage to its DNA, resulting in a very high risk of colon
cancer, as well as a high risk of endometrial cancer. Women with this syndrome
have a 40% to 60% risk of developing endometrial cancer some time during their
lives. The risk of ovarian cancer is also increased. A person who has a family
history of colon cancer or endometrial cancer may opt to have genetic counseling
and testing for HNPCC to determine whether the individual is at high risk for the
development of endometrial cancer. The American Cancer Society guidelines
recommend that women with known or suspected (based on family history)
HNPCC consider beginning endometrial sampling at age 35, and that their
physicians offer this test and explain its benefits, risks, and limitations. Another
option for a woman who has (or may have) HNPCC is to have the uterus
removed (prophylactic hysterectomy) once childbearing has been completed.
Breast or ovarian cancer – Women who have had breast cancer or ovarian
cancer may have a higher risk of getting endometrial cancer. Some of the risk
factors for breast and ovarian cancer also increase endometrial cancer risk.
Endometrial hyperplasia – Endometrial hyperplasia is an increased growth of
the endometrium. Mild or simple hyperplasia, the most common type, has a very
small risk of becoming cancerous. It may spontaneously resolve without
treatment, or may need hormone therapy. If the hyperplasia is called "atypical", it
has a higher chance of becoming cancer. Simple atypical hyperplasia develops
into cancer in about 8% of cases if not treated. Complex atypical hyperplasia, on
the other hand, has a risk of becoming cancerous in up to 29% of cases in the
absence of treatment.
Q: What causes endometrial cancer?
A: The exact cause of most cases of endometrial cancer is still unknown. A
great deal of research is currently ongoing in order to learn more about the
disease. Most endometrial cancer cells contain estrogen and/or progesterone
receptors on their surfaces. Somehow, interaction of these receptors with their
hormones leads to increased growth of the endometrium, particularly if hormonal
imbalance occurs. This can mark the beginning of the development of cancer.
Q: Can endometrial cancer be prevented?
A: Most cases of endometrial cancer cannot be prevented. However, there are
several ways to lower one’s risk of developing this disease. One is to change the
risk factors whenever possible. Weight loss may reduce the risk of this type of
cancer in women who are obese. A healthy diet and regular exercise can also
lower endometrial cancer risk. Women who exercise on a daily basis can
decrease their risk into half compared to women who do not exercise.
Controlling diabetes, if present, may also help reduce the risk. Estrogen is
available in many different forms to treat the symptoms of menopause, such as
pills, skin patches, creams, and vaginal rings. Prior to using this hormone for
menopausal symptoms, one should consult her physician first to discuss how this
will affect one’s risk of endometrial cancer. Although the additional use of
progestins can reduce the risk of endometrial cancer in women taking estrogen
therapy, this combination had been found to case an increase in the risk of
breast cancer. Also, obtaining prompt treatment for pre-cancerous disorders of
the endometrium is another way to lower the risk of endometrial cancer. Most
endometrial cancers develop over a period of years. Many are known to follow
and possibly start from less serious abnormalities of the endometrium called
endometrial hyperplasia. Some cases of hyperplasia will resolve spontaneously
without treatment. Other types will require treatment with hormones or even
surgery. Treatment with progestins and a dilation and curettage (D & C) or
hysterectomy can prevent hyperplasia from becoming cancerous. Abnormal
vaginal bleeding is the most common symptom of endometrial pre-cancers and
cancers, and it needs to be reported and evaluated right away.
Q: Can endometrial cancer be detected early?
A: In most cases, being alert to any signs and symptoms of endometrial cancer,
such as abnormal vaginal bleeding or discharge, and seeking immediate consult
allows the disease to be diagnosed at an early stage. Early detection improves
the chances of successful treatment. However, some endometrial cancers may
reach an advanced stage before signs and symptoms are evident.
Women at average endometrial cancer risk – At present, there are no tests or
exams that can detect endometrial cancer early in women who are at average
risk and have no symptoms. The American Cancer Society recommends that, at
the time of menopause, all women should be informed of the risks and symptoms
of endometrial cancer and strongly encouraged to report any vaginal bleeding or
spotting to their physician. Women should talk to their physicians about having
regular pelvic exams. Although the pelvic exam can find some cancers, including
some advanced uterine cancers, it is not very effective in finding early
endometrial cancers. Although the Pap test can find some early endometrial
cancers, it is not a good test for this type of cancer.
Women at increased endometrial cancer risk – The American Cancer Society
recommends that most women at increased risk should be informed of their risk
and advised to see their physician whenever there is any abnormal vaginal
bleeding. This includes women whose risk of endometrial cancer is increased
due to increasing age, late menopause, never giving birth (nulliparous), infertility,
obesity, diabetes, hypertension, estrogen treatment, or tamoxifen therapy.
Women who have (or may have) hereditary nonpolyposis colon cancer (HNPCC)
have a very high risk of endometrial cancer. These women should be offered
yearly testing for endometrial cancer with endometrial biopsy beginning at the
age of 35. This includes women known to carry HNPCC-linked gene mutations,
women who are likely to carry such a mutation (those with a mutation known to
be present in the family), and women from families with a tendency to get colon
cancer where genetic testing has not been done. Another option for a woman
who has (or may have) HNPCC is to have a hysterectomy once childbearing has
been completed. One study found that none of 61 women who had prophylactic
hysterectomies developed endometrial cancer, while 1/3 of the women who did
not undergo surgery eventually had endometrial cancer.
Q: How is endometrial cancer diagnosed?
A: There is no screening test that has been recommended in order to detect this
cancer before symptoms develop (except for women at high risk). Routine pelvic
exams rarely discover this disease. Most women are diagnosed once they have
symptoms.
Signs and symptoms of endometrial cancer

Unusual bleeding, spotting, or other discharge – A menopausal woman
should seek immediate consultation for any unusual vaginal bleeding, spotting, or
discharge. About 90% of patients diagnosed with endometrial cancer have
abnormal vaginal bleeding such as bleeding between periods (intermenstrual
bleeding) or after menopause. Non-bloody vaginal discharge may also be a sign
of endometrial cancer, which can be found in about 10% of cases.
Pelvic pain and/or mass and weight loss – These symptoms are more
common in the advanced stages of the disease. Still, any delay in seeking
medical help may allow the disease to progress even further, thus lowering the
chances for successful treatment.
Seeing a specialist

If the physician is highly considering the presence of endometrial cancer, the
woman must be examined by a gynecologist, a doctor qualified to diagnose and
treat diseases of the female reproductive system. Specialists in treating cancers
of the endometrium and other female reproductive organs are called gynecologic
oncologists.
Sampling endometrial tissue

To find out whether endometrial hyperplasia or endometrial cancer is present, the
doctor must remove some tissue so that these can be examined under a
microscope. Endometrial tissue can be obtained through either an endometrial
biopsy, or by dilation and curettage (D & C).
Endometrial biopsy – An endometrial biopsy is the most commonly performed
test for endometrial cancer. It can be done in the office or clinic without any form
of anesthesia. A very thin flexible tube is inserted into the uterus through the
cervix. Using suction, a small amount of endometrium is removed through the
tube. Others use a rigid instrument to scrape a little amount of the endometrial
lining. The discomfort is similar to menstrual cramps and can be diminished with
intake of a nonsteroidal anti-inflammatory drug such as ibuprofen before the
procedure.
Dilation and curettage (D & C) – If the endometrial biopsy sample does not
provide enough tissue, or if the biopsy suggests cancer but the results are
uncertain, a D & C must be performed. This procedure requires general
anesthesia or conscious sedation, performed in an outpatient surgery area of a
clinic or hospital. The opening of the cervix is enlarged (dilated) and a special
instrument is inserted into the uterine cavity to scrape tissue from the endometrial
lining. Most women have little discomfort after this procedure.
Testing of endometrial tissue
Endometrial tissue samples removed by biopsy or D & C are examined under the
microscope. Endometrial cancer is graded based on how much it looks like a
normal endometrium. It is called grade 1 if 95% or more of the cancer forms
glands similar to those of normal endometrial tissue. Grade 2 tumors have
between 50% and 94% gland formations. Cancers with less than half of the
tissue forming glands are given a grade of 3. Women with lower grade cancers
are less likely to have advanced disease or recurrences.
Tests for endometrial cancer
Transvaginal ultrasound – Ultrasound uses sound waves to obtain images of
parts of the body. For a transvaginal ultrasound, a probe that gives off sound
waves is inserted into the vagina, creating images of the uterus and other pelvic
organs. These images often help demonstrate the character and thickness of the
endometrial lining, whether a tumor is present, or whether it is growing into the
muscle layer of the uterus (myometrium), or adjacent structures.
Cystoscopy and proctoscopy – If a woman experiences symptoms that
suggest the cancer has spread to the bladder or rectum, the lining of these
organs can be visualized through a lighted tube. In cystoscopy, the tube is
placed into the bladder through the urethra. In proctoscopy, the tube is inserted
into the rectum. Small tissue samples can also be obtained during these
procedures for pathologic (microscopic) testing if suspicious or abnormal areas
are noted.
Computed tomography (CT) – The CT scan is an x-ray procedure that creates
detailed, cross-sectional images of the body. It is not used to diagnose
endometrial cancer, but may be used to delineate spread of the disease to other
organs. It can also be utilized in detecting tumor recurrence after treatment. A
CT scan can also be used to precisely guide a biopsy needle into a suspected
area of cancer spread.
Magnetic resonance imaging (MRI) – MRI scans use radio waves and strong
magnets instead of x-rays. The energy from the radio waves is absorbed and
then released in a pattern formed by the type of tissue and by certain diseases.
A computer translates the pattern of radio waves given off by the tissues into a
very detailed image of parts of the body, creating cross sectional slices of the
body like a CT scanner. It also produces slices that are parallel with the length of
the body. This procedure is particularly helpful in detecting tumors within the
brain, spinal cord, and other soft tissue structures such as lymph nodes.
Positron emission tomography (PET) – In this test, radioactive glucose (sugar)
is administered to the patient to look for cancer cells. Because cancers use
glucose (sugar) at a higher rate than normal tissues, the radioactivity will tend to
concentrate in the tumor. A scanner is used to spot the radioactive deposits.
This test can be helpful for locating small foci of cancer cells. However, PET
scans are not routinely ordered, and their role in endometrial cancer is still under
investigation.
Chest x-ray – This test can show whether the cancer has spread to the lungs. It
may also be used to look for serious lung or heart problems, particularly prior to
surgery.
Intravenous pyelogram (IVP) – This is an x-ray of the urinary system taken
after injecting a special dye into a vein. This dye is removed from the
bloodstream by the kidneys and passes through the ureters into the bladder (the
ureters are the tubes that connect the kidneys to the bladder). It is useful in
detecting abnormalities of the urinary tract, such as changes caused by spread of
cancer to the pelvic lymph nodes, which may compress or block a ureter. IVP is
rarely used in the initial evaluation of patients with endometrial cancer.
CA 125 blood test – CA 125 is a substance released into the blood stream by
many, but not all, endometrial and ovarian cancers. An elevated CA 125 level
suggests that an endometrial cancer has probably spread beyond the uterus.
Some physicians will utilize this in deciding whether surgery should be done by a
gynecologic oncologist. Furthermore, if levels are elevated prior to surgery,
serial measurements can be obtained post-operatively and during adjuvant
treatment in order to determine how well the treatment is working (levels will drop
after surgery if treatment is effective). Follow-up measurements can also be
requested after completion of treatment to detect early tumor recurrences.
Q: How is endometrial cancer staged?
A: Staging is a universal system used to describe how far the cancer has spread.
The stage of an endometrial cancer is the most important factor in choosing a
treatment plan. The main system used to stage endometrial cancer is called the
FIGO (International Federation of Gynecology and Obstetrics) system. This is a
surgical staging system, and is based on examination of the tissues removed
during the operation. Although several tests may be requested prior to the
surgery (ultrasound, MRI, CT scan) to detect spread of the tumor to distant sites,
this information can be helpful in planning surgery and other treatment and
cannot be used for staging the disease.
The staging system looks at how far the cancer has spread. It can spread locally
to other parts of the uterus. It can also spread regionally to nearby lymph nodes
found in the pelvis and along the aorta. Finally, the cancer can spread
(metastasize) to distant lymph nodes or organs such as lung, liver, bone, brain,
and other organs. Below is the 1988 FIGO surgical staging system for
endometrial cancers:
Tumor confined to the body of the uterus Tumor invades up to less than half of myometrium Tumor invades to more than one half of myometrium Tumor invades the cervix but does not extend beyond uterus Local and/or regional spread as specified in IIIA, B, C Tumor involves serosa and/or adnexa (direct extension or metastasis) and/or cancer cells in ascites or peritoneal washings Vaginal involvement (direct extension or metastasis) Metastasis to pelvic and/ or para-aortic lymph nodes Tumor has spread to the bladder and/or bowel mucosa or to Tumor invasion of bladder and/ or bowel mucosa Distant metastasis (excluding metastasis to vagina, pelvic serosa, or adnexa, including metastasis to intra-abdominal lymph nodes other than para-aortic and/or inguinal nodes)
Survival by stage

The 5-year survival rate refers to the percentage of patients who live at least 5
years after a diagnosis of malignancy has been made. These rates are used to
create a standard way of discussing prognosis. However, many of these patients
live much longer than 5 years from the time of diagnosis. Improvements in
treatment may result in a better treatment outcome for recently diagnosed
patients. Relative 5-year survival rates by stage for endometrial adenocarcinoma
are as follows:

Q: How is endometrial cancer treated?
A: The choice of treatment depends largely on the type of cancer and stage of
the disease at the time of diagnosis. Other factors that are taken into
consideration in choosing the best treatment plan include the patient’s age,
overall state of health, plans for future childbearing, and other personal
considerations. There are four basic types of treatment for women with
endometrial cancer: surgery, radiation therapy, chemotherapy and hormonal
therapy. Surgery is the main treatment for most women afflicted with this
disease. In certain situations, however, a combination of these treatments may
be used.
SURGERY
Hysterectomy – The main treatment for endometrial cancer is an operation to
remove the uterus and cervix (called a hysterectomy). When the uterus is
removed through an incision in the abdomen, it is called a simple or total
abdominal hysterectomy (TAH). If the uterus is removed through the vagina, it is
known as a vaginal hysterectomy. A radical hysterectomy is done when
endometrial cancer has spread to the cervix or the area around the cervix (the
parametrium). In this type of operation, the entire uterus, the tissues adjacent to
the uterus (parametrium and uterosacral ligaments), and the upper part of the
vagina (next to the cervix) are all removed.
Bilateral salpingo-oophorectomy – This operation removes both fallopian
tubes and both ovaries. This procedure is usually done at the same time the
uterus is removed (either by simple hysterectomy or radical hysterectomy) to
treat endometrial cancers. Removal of both ovaries will lead to menopause if the
patient has not done so already.
Lymph node surgery

Pelvic and para-aortic lymph node dissection – This operation removes
lymph nodes from the pelvis and the area adjacent to the aorta to detect
cancer cells that have spread from the endometrial tumor. This procedure is
usually done at the same time as the operation to remove the uterus. If the
patient is having an abdominal hysterectomy, the lymph nodes can be
removed through the same incision. In women who have had a vaginal
hysterectomy, these lymph nodes may be removed by laparoscopic surgery.
In a lymph node dissection, most or all of the lymph nodes in a certain area
are removed. When only a few of the lymph nodes in an area are removed, it
is called lymph node sampling.

Laparoscopic lymph node sampling – Laparoscopy is a technique that
allows the surgeon to inspect the abdominopelvic cavity through tubes
inserted into very small incisions. Small surgical instruments can be
controlled through the tubes, allowing the surgeon to remove lymph nodes.
This approach avoids the need for a large incision in the abdomen, and so
can shorten the time needed for recovery from surgery. This procedure is
done when hysterectomy is accomplished via the vaginal route. Studies are
in progress to determine whether sampling lymph nodes by laparoscopy is
comparable with the usual operations for endometrial cancer. Meanwhile,
many oncologists feel that laparoscopic lymph node sampling is as effective,
and are offering this procedure as an option to their patients. In early studies
with short-term follow-up, women who underwent laparoscopic surgery have
had the same cure rate as those who had abdominal surgery, with reduced
side effects and complications from the operation.

Pelvic washings – In this procedure, the surgeon "washes" the abdominal and
pelvic cavities with salt water (saline) and sends the fluid to the laboratory to
determine if it contains cancer cells.
Other procedures that may be used for staging
Omentectomy – The omentum is a layer of fatty tissue that covers the
abdominal contents like an apron. When this tissue is removed, it is called an
omentectomy. This procedure is sometimes performed to determine tumor
spread into the omentum. In cases where the endometrial cancer has
metastasized to the adnexa, omentectomy may also be done.
Peritoneal biopsies – The tissue lining the pelvis and abdomen is called the
peritoneum. Peritoneal biopsies involve removing small pieces of this lining to
check for cancer cells.
Tumor debulking – If cancer has spread throughout the abdomen, the surgeon
may attempt to remove as much of the tumor as possible. This is called
debulking. Debulking a cancer can facilitate a more efficient delivery of other
treatments, like radiation or chemotherapy.
Recovery after surgery
For an abdominal hysterectomy, the hospital stay is usually from 3 to 7 days.
The average hospital stay after a radical hysterectomy is about 5 to 7 days.
Complete recovery can take about 4 to 6 weeks. A laparoscopic procedure and
vaginal hysterectomy usually require a hospital stay of 1 to 2 days and 2 to 3
weeks for recovery. Complications are unusual but could include excessive
bleeding, wound infection, and damage to the urinary or intestinal systems.
Side effects
Any hysterectomy causes infertility. For those who were premenopausal before
surgery, removing the ovaries will lead to early menopause. This can cause the
appearance of symptoms such as hot flashes, night sweats, and vaginal dryness.
RADIATION THERAPY
Radiation therapy is the use of high-energy radiation (such as x-rays) to kill
cancer cells. It may be administered by placing radioactive materials inside the
body near the tumor, called internal radiation therapy or brachytherapy. Another
option is to deliver radiation from a machine outside the body in a procedure that
is much like having an x-ray, called external beam radiation therapy. In some
cases, both brachytherapy and external beam radiation therapy are given. The
stage and grade of the cancer help determine what areas need to be exposed to
radiation therapy and which methods are used.
Brachytherapy – For vaginal brachytherapy, a cylinder containing a source of
radiation is inserted into the vagina about 4 to 6 weeks after hysterectomy. With
this method, the radiation mainly affects the area in contact with the cylinder,
such as the vaginal cuff (the upper third of the vagina). Nearby structures such
as the bladder and rectum receive less radiation exposure than the area in
contact with the cylinder. There are 2 types of brachytherapy used for
endometrial cancer, low-dose rate (LDR) and high-dose rate (HDR).
In LDR brachytherapy, the pellets are usually left in place for about 3 days. The
patient needs to stay immobile to keep the pellets from moving during treatment,
and so she is usually kept in the hospital during the treatment.
In HDR brachytherapy, the radiation is more intense. Each dose takes a very
short period of time (usually less than an hour), and the patient can return home
the same day. For endometrial cancer, HDR brachytherapy is often given weekly
or even daily for at least 3 doses.
External beam radiation therapy – In this type of treatment, the radiation is
delivered from a source outside of the body. This is often given 5-days-a-week
for 4 to 6 weeks. The skin covering the treatment area is carefully marked with
permanent ink or injected dye similar to a tattoo. A special mold of the pelvis and
lower back is custom made to ensure that the woman is placed in the exact same
position for each treatment. Each treatment takes less than a half-hour.
Side effects of radiation therapy
Common side effects of radiation therapy include tiredness, upset stomach, or
loose bowels. Serious fatigue, which may not occur until about 2 weeks after
treatment begins, is a common side effect. Diarrhea is likewise common, but can
usually be controlled with over-the-counter medicines. Nausea and vomiting may
also occur, but can be treated with medication. Side effects tend to be worse
when chemotherapy is administered concurrent with the radiation.
Skin changes are also common, with the skin in the treated area looking and
feeling sunburned. As the radiation passes through the skin to the cancer, it may
damage the skin cells, thus causing irritation ranging from mild temporary
redness to permanent discoloration. The skin may also release fluid, which can
subsequently lead to infection.
Radiation can irritate the bladder, and problems with urination may occur. This is
called radiation cystitis, and can result in discomfort and an urge to urinate often.
Radiotherapy can also lead to low blood counts, causing anemia (low red blood
cells) and leukopenia (low white blood cells). The blood counts usually return to
normal once radiation is discontinued.
Pelvic radiation therapy may cause scar tissue to form in the vagina. This scar
tissue can make the vagina shorter or more narrow (called vaginal stenosis),
which can make sexual intercourse painful. A woman can help prevent this
problem by stretching the walls of her vagina several times a week through
frequent intercourse 3 to 4 times per week, or by using a vaginal dilator (a plastic
or rubber tube used to stretch out the vagina). Still, vaginal dryness and pain
with intercourse can be long-term side effects from radiation. Pelvic radiation
can damage the ovaries, resulting in premature menopause. However, this is not
an issue for most women who are being treated for endometrial cancer, since
majority are already postmenopausal, either naturally or as a result of surgery to
treat the cancer (hysterectomy and removal of the ovaries).
Radiation to the pelvis can also weaken the bones, leading to fractures of the
hips or pelvic bones.

CHEMOTHERAPY
Chemotherapy is the use of cancer-fighting drugs administered into a vein or
taken by mouth. These drugs enter the bloodstream and reach all areas of the
body, making this treatment potentially useful for cancer that has spread beyond
the endometrium. If this treatment is chosen, a combination of drugs is usually
given. Combination chemotherapy sometimes works better than a single drug
alone in the treatment of cancer.
Drugs used in treating endometrial cancer may include doxorubicin, cisplatin,
carboplatin, and paclitaxel. Most often, 2 or more drugs are combined for
treatment. The most common combinations include cisplatin and doxorubicin,
paclitaxel and doxorubicin, and cisplatin/paclitaxel/doxorubicin.
These drugs kill cancer cells but can also damage some normal cells, which in
turn can cause side effects. Side effects of chemotherapy depend on the specific
drugs, the amount taken, and the length of time of treatment. Common side
effects include nausea and vomiting, loss of appetite, mouth and vaginal sores,
and hair loss. Also, most chemotherapy drugs can damage the blood-producing
cells of the bone marrow, resulting in low blood cell counts, such as low white
blood cells (leukopenia) which increases the risk of infection, low platelet counts
which can cause bleeding or bruising after minor cuts or injuries, and low red
blood cells (anemia) which can cause problems like fatigue and shortness of
breath.
Most of the side effects of chemotherapy stop when the treatment is over, but
some can last a long time. Different drugs can cause different side effects. For
example, the drug doxorubicin can damage the heart muscle over time. The
chance of heart damage increases as the total cumulative dose of the drug
increases, such that there is only a limit or maximum dose of doxorubicin that a
patient can receive. Cisplatin can cause kidney damage. Giving large amounts
of fluid before and after chemotherapy can help protect the kidneys. Both
cisplatin and paclitaxel can cause nerve damage (called neuropathy), leading to
numbness, tingling, or even pain in the hands and feet.
HORMONE THERAPY
Progestins – The main hormone treatment for endometrial cancer uses
progesterone-like drugs called progestins. The 2 most commonly used
progestins are medroxyprogesterone acetate (Provera – injection or pill) and
megestrol acetate (Megace – a pill). These act by slowing the growth of
endometrial cancer cells. Side effects can include increased blood sugar levels
in patients with diabetes. Hot flashes, night sweats, and weight gain (from fluid
retention and an increased appetite) can also occur. Rarely, serious blood clots
are seen in patients on progestins.
Tamoxifen – Tamoxifen, an anti-estrogen drug often used to treat breast cancer,
may also be used to treat advanced or recurrent endometrial cancer. The goal of
tamoxifen therapy is to prevent any estrogens circulating in the woman's body
from stimulating growth of the cancer cells. Even though tamoxifen may prevent
estrogen from nourishing the cancer cells, it acts like a weak estrogen in other
areas of the body. It does not cause bone loss, but can cause hot flashes and
vaginal dryness. People taking tamoxifen also have an increased risk of serious
blood clots in the leg.
Gonadotropin-releasing hormone agonists – Gonadotropin-releasing
hormone (GNRH) agonists are another way to lower estrogen levels. These
drugs switch off estrogen production by the ovaries in women who are
premenopausal. Examples include goserelin (Zoladex) and leuprolide (Lupron).
They are injected every 1 to 3 months. Side effects include any of the symptoms
of menopause, such as hot flashes and vaginal dryness. If they are taken for a
long time (years), these drugs can weaken the bones and lead to osteoporosis.
Aromatase inhibitors – Even if the ovaries are removed (or are not functioning),
estrogen can still be produced in fat tissue. Drugs called aromatase inhibitors
can halt estrogen production by this mechanism and lower estrogen levels even
further. Examples of aromatase inhibitors include letrozole (Femara),
anastrozole (Arimidex), and exemestane (Aromasin). These drugs are most
often used to treat breast cancer, but may be helpful in the treatment of
endometrial cancer. Side effects can include hot flashes and muscle pain. If
they are taken for a long time (years), they can weaken the bones and lead to
osteoporosis. These drugs are still being studied, and their role in endometrial
cancer treatment is not yet clear.
Q: What are the treatment options for endometrial cancer?
A: The following are some options that oncologists may suggest in the
management of endometrial cancer after initial biopsy:
STAGE I

An endometrial cancer is stage I if the cancer is limited to the body of the uterus
and has not spread to lymph nodes or distant sites. If the tumor is endometrioid,
standard treatment includes surgery to remove the tumor and stage the disease.
Treatment after surgery depends upon the surgicopathologic stage.
Treatment after complete staging

Stage IA endometrioid cancers are limited to the endometrium only and have not
infiltrated into the myometrium. These cancers most often do not need any
further treatment after surgery. If the tumor is grade 3, the oncologist may
recommend vaginal brachytherapy. Pelvic radiation may be given as well in rare
circumstances.
In Stage IB, the cancer has invaded less than halfway into the myometrium.
Many of these can be observed without further treatment after surgery. For high
grade tumors, oncologists are more likely to recommend radiation after surgery,
in the form of either vaginal brachytherapy or pelvic radiation.
In stage IC, the cancer has infiltrated more than halfway through the
myometrium. After surgery, the patient is usually offered pelvic radiotherapy.
Patients not staged with surgery
If endometrial cancer was an incidental finding after hysterectomy for a benign
disease, and the procedure performed was a THBSO, further adjuvant treatment
will depend on the stage and grade of tumor. For stage IA and IB well- or
moderately-differentiated endometrial cancer, no further treatment is necessary.
High-grade tumors, on the other hand, will require either vaginal brachytherapy
(for stage IA tumors), or pelvic radiation (for stage IB tumors). However, if the
tumor has invaded more than half of the myometrium (stage IC), pelvic
radiotherapy is usually administered post-operatively, regardless of tumor
differentiation. If lymphovascular space invasion (LVSI) was noted on the
hysterectomy specimen, an option of re-exploration and lymphadenectomy may
be entertained. Otherwise, adjuvant therapy may be instituted. On the other
hand, if the patient underwent hysterectomy (TH) alone, and the tumor is either
stage IA or IB, well- or moderately-differentiated, with no LVSI, the oncologist
may opt to do re-exploration to remove the adnexa and perform complete
surgical staging. Close observation with no further adjuvant treatment is also an
option. If the disease is either stage IC, or poorly differentiated, with no evidence
of LVSI or metastases, pelvic radiotherapy is usually administered. In the
presence of LVSI or distant metastasis, however, re-operation may be the best
option to allow adnexal removal and the performance of a comprehensive
surgical staging so that further adjuvant treatment may be tailored accordingly.
Conservative therapy in the form of high dose progestins may be used to treat
early stage endometrial cancer in women younger than 40, who are still desirous
of pregnancy. Medical treatment may only be offered to patients in whom the
cancer is well-differentiated and of favorable histologic type (endometrioid).
Lymphovascular space invasion must be absent on comprehensive microscopic
examination. Imaging with contrast-enhanced MRI must demonstrate no or
minimal invasion into the myometrium, and the absence of cervical or
extrauterine spread. Serum CA 125 levels must be within normal limits.
Furthermore, the couple must have no other concomitant problems that would
lead to infertility. Most importantly, the patient must be able to comply with the
treatment and should have good follow-up with her oncologist. Patients are
initially managed with a fractional curettage, followed by 3 months of high dose
progestins. Repeat curettage is performed after treatment to document tumor
regression, persistence or progression. If the lesion persists or progresses, then
medical treatment is considered a failure, and surgery should be performed.
However, patients need to understand that this is not a standard treatment and
may increase risk of spread or progression of the disease.
STAGE II
When a cancer is stage II, it has spread to the cervix but has not grown outside
of the uterus. Cervical involvement could either be occult/microscopic
(endocervical curettage shows the presence of tumor cells with histologic
continuity to normal endocervical tissue) or gross. Options of surgical treatment
for occult/microscopic cervical involvement include either an extrafascial or a
radical hysterectomy with a complete surgical staging procedure. The advantage
of performing a radical hysterectomy is that it will obviate the need for adjuvant
radiotherapy for surgical stage II disease since more parametrial tissues have
been resected. This surgical approach is preferred in areas with no facilities for
radiation. On the other hand, patients who underwent extrafascial hysterectomy
will require postoperative pelvic radiotherapy. For patients whose cervix is
grossly infiltrated by tumor, radical hysterectomy with surgical staging is also the
recommended procedure. However, for poor surgical risk patients, pre-operative
complete radiotherapy (pelvic radiation followed by vaginal brachytherapy)
followed by extrafascial hysterectomy and lymph node assessment is an
acceptable alternative. These latter patients are staged according to the 1971
FIGO clinical staging of endometrial cancer.
STAGE III
Stage III cancers have spread outside of the uterus, but the tumor is still confined
within the pelvis. Standard treatment even for advanced disease is still
hysterectomy and comprehensive surgical staging. In the presence of adnexal
involvement, the omentum is removed as well. Any remaining tumor is removed
during surgery to achieve optimal debulking.
Stage IIIA: If the cancer is confined to the uterus, but pelvic washings obtained
during laparotomy demonstrate the presence of cancer cells, the disease is stage
IIIA. In the absence of other poor prognostic factors (unfavorable histologic type,
poorly differentiated tumor, presence of LVSI, deep myometrial invasion), no
other treatment may be needed after surgery. On the other hand, if any of the
abovementioned prognostic factors is present, chemotherapy followed by pelvic
radiation is usually administered.
A cancer is also considered stage IIIA when it has spread to other tissues in the
pelvis like the fallopian tubes and the ovaries. When this occurs, treatment after
surgery may include a combination of chemotherapy followed by radiation.
Stage IIIB: In this stage, the cancer has spread to the vagina. After surgery,
stage IIIB patients may be treated with combination chemotherapy, pelvic
radiation, and vaginal brachytherapy.
Stage IIIC: When the cancer has spread to the lymph nodes in the pelvis or
around the aorta, it is stage IIIC. Treatment includes surgery, followed by
combination chemotherapy, extended field radiation (includes pelvic and para-
aortic fields) and vaginal brachytherapy.
STAGE IV
These cancers have grown into the bladder or bowel (stage IVA), or spread to
distant sites like liver, lungs, etc. or to lymph nodes outside of the pelvis or para-
aortic area (stage IVB). The patient may have the best chance if all grossly
visible tumor seen during laparotomy can be removed and biopsies of the
abdomen do not show cancer cells. This may be possible if the cancer has
spread to lymph nodes in the abdomen and pelvis only. However, in most cases
of stage IV endometrial cancer, the extensive spread of the disease makes a
surgical cure nearly impossible. Nevertheless, a hysterectomy and bilateral
salpingo-oophorectomy may still be performed in order to prevent excessive
bleeding. This is followed by chemotherapy and complete radiotherapy
(extended field radiotherapy followed by brachytherapy). When the cancer has
spread to other parts of the body, hormone therapy such as progestins and
tamoxifen, may be given as well.
Combinations of chemotherapy drugs may help for a time in some women with
advanced endometrial cancer. The drugs used most often are doxorubicin,
paclitaxel, and either cisplatin or carboplatin. These drugs are often used
together in combination. Women with stage IV endometrial cancer should
consider taking part in clinical trials of chemotherapy or other new treatments.
POOR HISTOLOGIC TYPES
Tumors of poor histologic types, such as papillary serous carcinoma or clear cell
carcinoma, are more likely to have spread outside of the uterus at the time of
diagnosis, and thus have poorer prognosis. The surgery may be more extensive
such that in addition to the TH/BSO and the pelvic and para-aortic lymph node
dissections, the omentum is often removed and peritoneal biopsies are obtained.
After surgery, both chemotherapy and radiation therapy are often given to help
keep the cancer from recurring. The chemotherapy usually includes the drugs
cisplatin and doxorubicin. Paclitaxel may be given as well.
RECURRENT ENDOMETRIAL CANCER
When a cancer has gone away with treatment, but then comes back later, it is
called recurrent. Treatment depends on the size of the lesion, and location of the
tumor. If the recurrent cancer is only in the pelvis, radiation therapy may provide
a cure. Women with more extensive recurrences are treated like those with
stage IV endometrial cancer. Either hormone therapy or chemotherapy is
recommended. Low-grade cancers containing progesterone receptors are more
likely to respond well to hormone therapy. Higher-grade cancers and those
without detectable receptors are less likely to shrink during hormone therapy, but
may respond to chemotherapy. Clinical trials of new treatments are another
option.

Q: What will happen after treatment for endometrial cancer?
A: An important part of the treatment plan is a specific schedule of follow-up
visits after surgery, chemotherapy, or radiation therapy. During the first 2 years
after treatment, follow-up visits are usually scheduled for every 3 to 4 months.
About 75% of endometrial cancer recurrences are found within the first 2 years of
follow-up. Later on, recurrence is less likely and follow-up visits are scheduled
less often, usually twice yearly. During each follow-up visit, it is important to
report any symptom (vaginal spotting, vaginal discharge, abdominal pain, weight
loss, anorexia, etc) that might suggest a tumor recurrence, as well as any side
effect of treatment. A pelvic exam is performed to detect any abdominal or
vaginal mass, or look for any enlarged lymph nodes in the groin area. A Pap test
may also be done to look for cancer cells in the vagina vault. If symptoms or
physical exam suggest a possible recurrence, imaging tests (CT scans,
ultrasound studies), a CA 125 blood test, and/or biopsies may be done. Studies
of patients with endometrial cancer show that in the absence of symptoms or
abnormal physical exam findings, routine blood tests and imaging tests are not
necessary.
Hormone therapy may be given to symptomatic women who have been treated
for endometrial cancer. Studies have shown that the absolute recurrence rate
after hormone replacement therapy for early stage (stage I and II) endometrial
cancers is only 2.1%, and the incidence of development of a new malignancy is
very low.
It is also helpful to adopt lifestyle modification during or after treatment. One of
the best things that can be done is to put healthy eating habits into place, like
increasing the variety of healthy foods. Eat five or more servings of vegetables
and fruits each day. Choose whole grain foods instead of white flour and sugars.
Limit meats that are high in fat. Cut back on processed meats like hot dogs,
bologna, and bacon. Limit alcohol intake. Adopt a regular exercise plan.
Studies have shown that patients who follow an exercise program tailored to their
personal needs feel physically and emotionally improved and can cope better.
Exercise can improve physical and emotional health by improving cardiovascular
(heart and circulation) fitness, strengthening the muscles, reducing fatigue, and
lowering anxiety and depression. The American Cancer Society, in its guidelines
on physical activity for cancer prevention, recommends that adults take part in at
least one physical activity for 30 minutes or more on 5 days or more of the week.
Children and teens are encouraged to try for at least 60 minutes a day of
energetic physical activity on at least five days a week.
Q: What happens if treatment is no longer working?
A: If cancer continues to grow after one kind of treatment, or if it returns, it is
often possible to try another treatment plan that might still cure the cancer, or at
least shrink the tumors enough to help the patient live longer and feel better. On
the other hand, when a woman has received several different medical treatments
and the cancer has not been cured, over time the cancer tends to become
resistant to all treatment. At this time it is important to weigh the possible limited
benefit of a new treatment against the possible disadvantages, including
continued doctor visits and treatment side effects.
Everyone has a different way of looking at a situation like this. Some patients
may want to focus on remaining comfortable during their limited time left,
especially if continuing treatment will not likely improve health or change the
prognosis or survival. In such cases, most oncologists recommend treatment
directed to any symptom that the patient might have, particularly pain. This type
of treatment is called "palliative" treatment. Palliative treatment helps relieve
these symptoms, but is not expected to cure the disease. It is primarily given to
improve a patient’s quality of life. Sometimes, the treatment to control symptoms
is similar to the treatments used to treat cancer. For example, radiation therapy
might be given to help relieve bone pain from bone metastasis. Or
chemotherapy might be given to help shrink a tumor and keep it from causing a
bowel obstruction. However, this is not the same as receiving treatment to try to
cure the cancer.
Q: What’s new in endometrial cancer research and treatment?
A:
Molecular pathology
Recent research has improved our understanding of how changes in certain
molecules can cause normal endometrial cells to become cancerous. It has
been known for several years that damaged or defective DNA (called mutations)
can alter important genes that regulate cell growth. If these genes are damaged,
out-of-control growth may result in cancer.
Some endometrial cancer and colon cancer cases may seem to "run in a family"
who have an inherited defect in certain genes that normally help repair damage
to DNA. If these repair enzymes are not working properly, damage to DNA is
more likely to persist and cause cancer. Similar DNA repair defects have also
been found in endometrial cancer cells from some patients without an inherited
tendency to develop this disease. One of the normal genes responsible for
suppressing tumor growth, called PTEN, is often abnormal in endometrial
cancers. Tests for this and other DNA changes may some day help detect
endometrial cancers early. Endometrial cancers without other tumor suppressor
genes (or with inactive ones), such as the retinoblastoma (Rb) gene and the p53
gene, tend to be more likely to recur after initial treatment. Tests for these and
other DNA changes may some day be used to help predict how aggressive the
cancer might be and to select the best treatment for each patient with this
disease. The long-range goal of this field of research is gene therapy that can
correct the DNA abnormalities that caused the endometrial cells to become
malignant.
Tumor markers
Molecules released by cancer cells to the circulation can help detect recurrence
of some types of cancer. For example, CA 125 is a useful marker in finding
recurrent ovarian cancer. Recent studies demonstrate that blood tests for CA
125 may also be helpful in finding recurrent endometrial cancer, before tumor
deposits are visible by CT or MRI scans. Measuring CA 125 levels in some
patients before surgery may also be helpful if it appears the cancer may have
spread.
New treatments
Researchers are examining new drugs, combinations of drugs and "targeted
therapies" in patients with advanced endometrial cancer. The use of adjuvant
chemotherapy, with or without radiation is also under investigation.

Source: http://www.sgop.org.ph/common/FAQ_endometrial_cancer.pdf