Endometrial Cancer

The endometrium is the innermost lining of the uterus. Uterus is a part of the female reproductive system, which is hollow and pear-shaped, and is situated in the pelvis. It is in the uterus, where the fetal growth takes place.

Cancer which develops in the innermost lining of the uterus (the endometrium), is known as endometrial cancer or uterine cancer.

Endometrium growth varies according to levels of two hormones secreted from ovaries. These two hormones are estogen and progesterone. Excess of Estrogen is responsible for proliferation of endometrium and can cause endometrial cancers.

Basically there are to types of causes for endometrium cancer

Non modifiable

• Age Chances of getting cancer increase with increasing age.
• Family history-About 5-10% of endometrium cancer are related to family history. When there is history of multiple members having colon cancer possibility of familial inheritance is high and it should be ruled out by genetic testing Lynch syndrome is known condition where chances of multiple cancers in multiple family members is high.
• Early menarche and late menopause increase the time period of menstruation in years. Thus, the exposure of endometrium to estrogen is more. Thus, chances of endometrial cancer is high.
• Estrogen secreting ovarian cancers can also cause endometrial cancer.

Modifiable causes

Most of these causes are related to excess of Estrogen by external cause.

• Obesity: once a woman stops menstruating her ovarian function stops but Estrogen hormone can be produced from fat cells known as adipose tissue of body. This is very common cause of endometrium cancer. Obesity, diabetes and high blood pressure are usually coexist in patients and known as triple syndrome of endometrial cancer. These conditions are responsible for excessive estrogen production in body.
• Diet and physical activity: High fat content in diet and sedentary life style are related to increased body weight and in turn are related to endometrial cancer.
• Polycystic ovarian syndrome: This condition is associated with estrogen and androgen hormone excess a related to endometrial cancer.
• Taking hormones, known as hormone replacement therapy to combat postmenopausal symptom, that contain Estrogen alone but not progesterone also leads to endometrial cancer.
• Hormone therapy for breast cancer: Tamoxifen which is an anti-cancer drug used for the treatment of breast cancer can cause endometrial hyperplasia (increase in thickness of endometrial lining).Association of tamoxifen with endometrial cancer has been demonstrated although it’s not very high and when measuring the risk benefit ratio tamoxifen is considered essential medicine for breast cancer hence use of same should not be stopped.

There are two types endometrial carcinoma

• Type I associated with estrogen excess. These are usually endometroid adenocarcinoma. These are less aggressive cancers which relatively spreads slowly.
• Type II are aggressive cancer these include serous carcinoma and clear cell carcinoma

There are many different types of endometrial cancers histo-pathologically

Adenocarcinoma, Uterine carcinosarcoma, Squamous cell carcinoma, Small cell carcinoma, Transitional carcinoma, Serous carcinoma.

Less common types are Clear cell carcinoma, Mucinous adenocarcinoma, Serous adenocarcinoma etc

Pathologically endometrial cancers divided in to different grade which is nothing but how the cancers cells are organised in comparison to normal endometrial cells.Grading is important plan the treatment. There are three grades 1,2and 3.

The most common symptom of endometrial cancer is abnormal vaginal bleeding. It can be

• Postmenopausal bleeding - once a woman has stop menstruating at least for one year any vaginal bleeding is abnormal.
• Heavy menstrual flow - it can happen due to hormonal disturbances too but should be investigated.
• Spotting in between menstrual periods
• Watery, excessive white discharge per vaginum
• Severe pain abdomen or back pain (in advanced stage)

Physical examination is the most important and a good history of health is the preliminary work to be done. An examination of the body to look for any lumps, any lymph nodes, or any signs of disease which is unusual. History of any past illness or treatment is essential.

Once any woman presents with it should be investigated with tests

Imaging

Ultrasonogram (USG):

Transabdominal ultrasonogram of abdomen and pelvis is very safe and simple way of detecting any abnormality in uterus and ovaries. Depending on the findings of USG next investigation is planned which is usually biopsy of any form.

Transvaginal ultrasound: It is commonly known as TVS. In a transvaginal ultrasound, an ultrasound transducer or a probe like structure is inserted into the vagina. This probe sends high energy sound waves to the internal tissues and organs. These organs are vagina, uterus, fallopian tubes and bladder.

CT scan: After confirming the diagnosis with biopsy if needed contrast enhanced CT scan abdomen is planned to know further details.

MRI: it is very good investigation to know the spread of disease in pelvic organ and it helps to plan the treatment. Usually MRI also is being done after confirming the diagnosis.

PETCT Scan: If initial investigations suggest very advance disease or if somebody already had endometrial cancer and presents with recurrence of disease PETCT scan can be done to know the spread of disease. Although it is not first investigation to be done.

Biopsy:

It is very important investigation to detect any abnormal uterine bleeding. Biopsy is usually taken from inner lining uterus.This tissue is checked under microscope by pathologist to check for any abnormal tissue PAP smear which is commonly done for cervix cancer screeningis not helpful because endometrial cancer starts inside the uterus. Therefore, a piece of endometrial tissue should be taken out and checked under the microscope for cancer cells. The following procedures are used to diagnose these cancers.

• Endometrialpipette biopsy: This is an office procedure and does not require any type ofanaesthesia.The thin and flexible tube is inserted through the cervix into the uterus and it gently scraps off a small amount of tissue from the endometrium. Usually this painless procedure but may cause mild discomfort.
• Dilatation and curettage: This are called D&C. This procedure usually requires mild form of anaesthesia. In this procedure, the cervix is dilated and a curette which is a spoon-shaped instrument is inserted into the uterus to remove the tissue. These samples are checked under a microscope for signs of the disease.
• Hysteroscopy: This is a procedure to look inside the uterus for abnormal tissues. It requires anaesthesia. This is done with a specialized instrument called a hysteroscope. This is a thin tube-like instrument with a light source and lens for viewing properly and has a tool attached to it which aids in the removal of the tissue samples. It is essentially like dilatation and curettage but procedure is under direct vision hence is better than D&C.

The treatment options for endometrial cancer are as follows:

Depending on the stage, age and fertility status endometrial carcinoma is treated. In young women when pregnancy is dsirous, fertility preservation options are available in the form of hormone treatment. If family is completed then following are the options for treatment.

• Surgery: Depending on the age, stage surgery is usually planned. surgery involves removal of uterus both the ovaries along with fallopian tubes along with lymph nodes removal. Minimal invasive (laparoscopic) surgery gives good results in the form of recovery and less pain. Both laparoscopic and open surgeries can be performed. After surgery removed specimen is send for detailed histopathological examination which guides for further treatment planning.
• Radiation therapy: Depending on the histopathology report need of radiation therapy is decided. For very early cancers no further treatment is needed. For Cancers which have gone deep in to the uterus brachytherapy is used. Brachy theapy is simple technique where radiation therapy is given to limited area by an instrument placed near the operated area for short duration. If histopathology reveals that cancer has spread to lymph nodes than external beam adiation therapy is given (EBRT), which includes radiation to nearby area to avoid recurrence.
• Chemotherapy: Chemotherapy is not required for all the patients Depending on final histopathological report if needed chemotherapy is given to avoid further spread of tumor.
• Hormone therapy: Endometrium cancer is hormone sensitive cancer. When surgical treatment is not possible due to various reasons hormone therapy can be offered. It is given in the form of tablets or intrauterine implants (device is placed inside the uterus.)

There is no defined screening protocol for endometrial cancer. Awareness is the best way to prevent the cancer. Any abnormal uterine bleeding, specially post-menopausal bleeding should not be ignored.

The following measures can be taken to reduce the risk of endometrial cancer:

• Healthy life style
• Weight reduction
• Periodic check ups