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P RACTICE BULLET IN
clinical management guidelines for obstetrician – gynecologists
Number 149, April 2015 (Replaces Practice Bulletin Number 65, August 2005)
Reaffirmed 2017
Endometrial Cancer
Endometrial carcinoma is the most commonly diagnosed gynecologic malignancy; almost every gynecologist will
encounter it. A thorough understanding of the epidemiology, pathophysiology, and diagnostic and management strate-
gies for this type of cancer allows the obstetrician–gynecologist to identify women at increased risk, contribute toward
risk reduction, and facilitate early diagnosis. The purpose of this document is to review the current understanding of
endometrial cancer and to provide guidelines for management that have been validated by appropriately conducted
outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are
presented.
Committee on Practice Bulletins—Gynecology and the Society of Gynecologic Oncology. This Practice Bulletin was developed by the Committee on
Practice Bulletins—Gynecology and the Society of Gynecologic Oncology’s Clinical Practice Committee with the assistance of William M. Burke, MD,
and Michael A. Gold, MD. The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These
guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs
of the individual patient, resources, and limitations unique to the institution or type of practice.
risk of carcinoma among women with nonatypical Table 1. Risk Factors for Type I Uterine Corpus Cancer ^
endometrial hyperplasia (8). Endometrial intraepithelial
Factors Influencing Risk Estimated Relative Risk*
neoplasia, however, is much more likely to progress to
cancer and may be found coexisting with an undiag- Older age 2–3
nosed endometrioid carcinoma in 30–50% of cases (9, Residency in North America or 3–18
10). In a prospective trial conducted by the Gynecologic Northern Europe
Oncology Group (GOG), 306 women in whom endo- Higher level of education or income 1.5–2
metrial intraepithelial neoplasia was diagnosed on pre- White race 2
operative biopsy underwent hysterectomy without first
Nulliparity 3
receiving medical treatment (9). On final pathology,
History of infertility 2–3
42.6% of the women were found to have invasive can-
cer. Although most of the identified cases of endometrial Menstrual irregularities 1.5
cancer were minimally invasive grade 1 tumors, 11% Late age at natural menopause 2–3
of the cases of endometrial cancer demonstrated deep Early age at menarche 1.5–2
myometrial invasion (9). When endometrial intraepi- Long-term use of unopposed estrogen 10–20
thelial neoplasia is treated conservatively, the 19-year
Tamoxifen use 2–3†
cumulative risk of developing endometrial carcinoma is
reported to be 27.5% (95% CI, 8.6–42.5%) (8). Obesity 2–5
Type II cancer is considered to be high grade and Estrogen-producing tumor >5
to have a significant risk of extrauterine disease and History of type 2 diabetes, hypertension, 1.3–3
a poorer prognosis than type I cancer. Uterine papil- gallbladder disease, or thyroid disease
lary serous carcinoma accounts for only approximately Lynch syndrome 6–20‡
10% of all cases of uterine cancer, but it is responsible
*Relative risks depend on the study and referent group employed.
for the deaths of almost 40% of patients with endome-
Data from Tamoxifen and uterine cancer. Committee Opinion No. 601. American
†
trial cancer (11). The precursor lesion is thought to be College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:1394–7.
endometrial intraepithelial carcinoma (12, 13). Serous ‡
Data from Bonadona V, Bonaiti B, Olschwang S, Grandjouan S, Huiart L, Longy
endometrial intraepithelial carcinoma may be associ- M, et al. Cancer risks associated with germline mutations in MLH1, MSH2,
ated with an extrauterine tumor at the time of diagnosis and MSH6 genes in Lynch syndrome. French Cancer Genetics Network. JAMA
and with risk of recurrence, spread, and eventual death 2011;305:2304–10.
from the tumor (14). Clear cell histology also is rare Modified from Gershenson DM, McGuire WP, Gore M, Quinn MA, Thomas G,
but is associated with a similarly poor prognosis (15). editors. Gynecologic cancer: controversies in management. Philadelphia (PA):
Elsevier Churchill Livingstone; 2004.
Carcinosarcoma, also known as malignant mixed mül-
lerian tumor of the uterus, is another histologic cell type
with a poor prognosis and may represent a subset of
increase in risk of endometrial cancer in individuals with
adenocarcinoma.
body mass index (BMI [calculated as weight in kilograms
divided by height in meters squared]) values higher than
Risk Factors
25 (17). A meta-analysis that evaluated women taking
Some of the more common risk factors for type I endo- hormone therapy (HT) showed that BMI is strongly asso-
metrial cancer are discussed in this section. Additional ciated with an increased risk of endometrial cancer, with
risk factors for type I endometrial cancer are listed in the association becoming stronger at BMI values greater
Table 1. than 27 and being particularly strong in women who have
never been exposed to HT (18). Type 2 diabetes mellitus
Unopposed Estrogen and hypertension are associated with an increased risk of
Prolonged exposure to unopposed estrogen, whether endo- endometrial cancer that may be related to concurrent obe-
genous or exogenous, is associated with most cases of sity (19, 20), although an independent association between
type I endometrial cancer. Unopposed endogenous estro- diabetes and endometrial cancer has been reported (21).
gen exposure occurs in chronic anovulation (eg, poly- Systemic unopposed estrogen therapy increases
cystic ovary syndrome), with estrogen-producing tumors, the risk of endometrial cancer by up to 20-fold, with
and with excessive peripheral conversion of androgens the increasing risk correlating with the duration of use
to estrone in adipose tissue. Obesity is associated with (22–26). Concomitant progestin administration mitigates
an increased incidence of endometrial cancer (16). Case– this risk. When progestins are administered continu-
control studies have demonstrated a 200–400% linear ously, intermittently (at least 10 d/mo), or through a
Selecting appropriate adjuvant therapy for patients with Is there a benefit from cytoreduction in
early-stage endometrial cancer is difficult. To date, no patients with advanced-stage or recurrent
level I evidence supports an overall survival advantage endometrial cancer?
for adjuvant therapy of any form in patients with early-
stage endometrial cancer. Further complicating the deci- Approximately 10–15% of all new cases of endometrial
sion process is the fact that patients with “early-stage” cancer will involve disease that has spread outside the
endometrial cancer actually comprise two types of uterus. These cases account for more than 50% of all
patients: 1) those who are comprehensively staged and uterine cancer-related deaths, with survival rates as low
have received appropriate nodal evaluation and 2) those as 5–15% (120, 121). These patients are treated with
who are not comprehensively staged. a multimodal approach that includes surgery, chemo-
The value of adjuvant radiation therapy in com- therapy, and radiation therapy, with cytoreduction being
prehensively staged patients who have risk factors the most crucial aspect. Optimal surgical cytoreduction
associated with disease relapse remains unclear. Several (variably defined as less than or equal to 1 cm or 2 cm)
randomized trials have demonstrated that adjuvant radia- has been found to improve progression-free and overall
tion for certain stage I or stage II endometrial carcino- survival rates in patients with advanced-stage or recur-
mas reduces the local recurrence rate but does not affect rent endometrial cancer.
overall survival (86, 112–115). A high-intermediate risk Five large retrospective studies have addressed the
group has been defined, however, in which adjuvant advantages of optimal cytoreductive surgery in patients
radiation therapy improves progression-free survival with stage III and stage IV endometrial adenocarci-
and decreases the risk of local recurrence (86). The fol- noma. Each study demonstrated a statistically significant
lowing risk factors were found to be associated with an progression-free and overall survival advantage when
increased rate of recurrence: grade 2 or grade 3 disease, optimal cytoreduction was achieved (122–126). All
the presence of lymphovascular space invasion, and five studies described cytoreduction as an independent
outer-third myometrial invasion. The high-intermediate prognostic factor for overall survival in the management
risk group included women 70 years or older with one of patients with advanced-stage endometrial cancer. For
of these risk factors, women 50 years or older with two those patients in whom the tumor was determined to
of these risk factors, and women of any age with all of be unresectable, the median survival was 2–8 months,
these risk factors (86). Conclusions from these trials are regardless of further treatment with radiation therapy,
limited, however, because of differences in inclusion chemotherapy, or both (124–126). The extent of residual
criteria and the allowance of vaginal brachytherapy in disease in advanced-stage endometrial cancer appears
the control groups. Among patients who have not had to have a direct influence on survival. In one study,
radiation therapy, salvage therapy at the time of recur- the median survival for patients who had less than
rence is most often curative (116–118). 1-cm residual disease was 15 months, compared with
Vaginal brachytherapy has been shown in one study 40 months among those who had microscopic disease
to be equivalent to whole pelvic irradiation in achieving (122). In another study, the median survival for patients
locoregional control and providing reasonable disease- with no residual disease was 40 months, compared with
specific and overall survival in patients with certain 19 months for those who had any residual disease (126).
high-intermediate risk factors for recurrent endome- Secondary cytoreductive surgery for recurrent
trial cancer: older than 60 years with stage IB grade 1 endometrial cancer also has been shown to improve
or grade 2 disease; older than 60 years with stage IA progression-free and overall survival, whether the
grade 3 disease with myometrial invasion; or any age recurrence is localized to the pelvis or disseminated
with endocervical glandular involvement and disease throughout the abdomen. Among women with recurrent
otherwise confined to the uterus, excluding those with endometrial cancer, survival seems to be dependent on
stage IB grade 3 disease (115). These findings apply to the type of recurrence (solitary recurrence versus car-
all patients regardless of whether they have undergone cinomatosis), the ability to achieve optimal cytoreduc-
a comprehensive surgical staging procedure. Vaginal tion, and the time from original treatment to recurrence
brachytherapy is associated with significantly fewer (127). Median overall survival after secondary cytore-
gastrointestinal toxic effects as well as a better quality ductive surgery ranges from 39 months to 57 months
of life (115, 119). Thus, vaginal brachytherapy should after surgery (122, 127–129). In patients with localized
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