Malignant diseases of the uterus: Endometrial Hyperplasia, Endometrial Carcinoma, Sarcoma: Diagnosis and Management

Key points

  • Endometrial carcinoma is the most common malignancy of the female genital tract. In the United States the lifetime risk of endometrial cancer is 3%.

  • Most women who develop endometrial cancer are aged 50 to 65 years.

  • Women with Lynch syndrome (hereditary nonpolyposis colorectal cancer syndrome) have a 40% to 60% lifetime risk of endometrial cancer, which is similar to their lifetime risk of colon cancer.

  • Chronic unopposed estrogen stimulation of the endometrium leads to endometrial hyperplasia and in some cases adenocarcinoma. Other important predisposing factors include obesity, nulliparity, late menopause, and diabetes.

  • The risk of a woman developing endometrial carcinoma is three times higher if her body mass index is greater than 30 kg/m 2 .

  • Tamoxifen use increases the risk of endometrial neoplasia two- to threefold.

  • The primary symptom of endometrial carcinoma is postmenopausal bleeding. Women with abnormal bleeding should undergo endometrial sampling to rule out endometrial pathologic conditions.

  • Cytologic atypia in endometrial hyperplasia is the most important factor in determining malignant potential.

  • Studies have found that there is a 40% concurrent rate of endometrial cancer in patients with a preoperative diagnosis of complex atypical hyperplasia.

  • Prognosis in endometrial carcinoma is related to tumor grade, tumor stage, histologic type, and degree of myometrial invasion.

  • Older patients with atypical hyperplasia are at increased risk of malignant progression compared with younger patients.

  • A key determinant of the risk of nodal spread of endometrial carcinoma is depth of myometrial invasion, which is often related to tumor grade.

  • Well-differentiated (grade 1) endometrial carcinomas usually express steroid hormone receptors, whereas poorly differentiated (grade 3) tumors usually do not express receptors.

  • Uterine serous carcinoma is an aggressive histologic subtype associated with metastatic disease even in the absence of myometrial invasion.

  • Ninety percent of recurrences of adenocarcinoma of the endometrium occur within 5 years.

  • Overall survival rates for patients with adenocarcinoma of the endometrium by stage are as follows: stage I, 86%; stage II, 66%; stage III, 44%; stage IV, 16% (overall 72.7% 5-year survival rate combining clinical and operative staging systems).

  • Histologic variants of endometrial carcinoma with a poor prognosis include uterine serous carcinoma and clear cell carcinoma.

  • The most common sites of distant metastasis of adenocarcinoma of the endometrium are the lung, retroperitoneal nodes, and abdomen.

  • Primary treatment of endometrial cancer includes hysterectomy, bilateral salpingo-oophorectomy, lymph node assessment, and resection of all disease. The exceptions include young premenopausal women with stage I and grade 1 endometrial carcinoma associated with endometrial hyperplasia and women with increased risk of mortality secondary to medical comorbidities.

  • Postoperative adjuvant radiation has not been shown to improve overall survival.

  • Patients with high-stage or recurrent disease should be treated with a multimodal approach including chemotherapy, radiation, and/or hormone therapy.

  • Uterine sarcomas comprise less than 5% of uterine malignancies.

  • Uterine sarcomas are treated primarily by operation including removal of the uterus, tubes, and ovaries.

  • Endometrial stromal sarcomas are low-grade sarcomas with an indolent course.

  • Multiagent chemotherapeutic regimens are usually prescribed for metastatic sarcomas; complete responses are rare and usually temporary.

Endometrial carcinoma is the most common malignancy of the lower female genital tract in the United States. Lifetime risk for endometrial cancer is 3%, and approximately 61,880 new cases develop in the United States each year, according to 2019 figures from the American Cancer Society. The rising rates of obesity in the United States correlate with rising rates of endometrial cancer. Approximately 12,000 deaths occurred annually in women with uterine cancer, more than for cervical cancer (4250) and fewer than the estimated 14,000 for ovarian cancer.

This chapter reviews the clinical and pathologic features of endometrial hyperplasias and carcinomas, the factors that contribute to the development of these diseases, and the appropriate methods of management. Sarcomas of the uterus and their clinical behavior and therapy are also presented.


Adenocarcinoma of the endometrium affects women primarily in the perimenopausal and postmenopausal years and is most often diagnosed in those between ages 50 and 65; however, these cancers can also develop in young women during their reproductive years. Approximately 5% of the cases are diagnosed in women younger than 40 and approximately 10% to 15% in women younger than age 50. Women diagnosed before age 50 years are also at risk for synchronous ovarian cancer ( ). Fig. 32.1 plots a typical age–incidence curve for cancers of the endometrium. The curve rises sharply after age 45 and peaks between 55 and 60; then there is a gradual decrease.

Fig. 32.1

Incidence curve for carcinoma of the endometrium by age.

(From Elwood JM, Cole P, Rothman KJ, Kaplan SD: Epidemiology of endometrial cancer. J Natl Cancer Inst. 1977;59:1055.)

Complex atypical hyperplasia, also referred to as endometrial intraepithelial neoplasia (EIN), is a precursor to endometrioid endometrial cancer. Some endometrial cancers develop without previous hyperplasia. These non–estrogen-related carcinomas with serous histology tend to be poorly differentiated and clinically more aggressive.

Multiple factors increase the risk of developing endometrial carcinoma ( Box 32.1 ). Obesity is a strong risk factor for endometrial cancer. Women who are obese (body mass index > 30) have a two- to threefold increased risk, and this risk increases with increasing weight. The association is believed to be due in part to increased circulating estrogen levels that result from conversion of androstenedione to estrone in the adipose tissue, decreased sex hormone-binding globulin, and other factors, including insulin resistance. Although more historical than clinically relevant, unopposed estrogen stimulation is strongly associated with endometrial cancer, increasing the risk four to eight times for a woman using estrogen alone for menopausal replacement therapy. The risk increases with higher doses of estrogen (>0.625 mg conjugated estrogens) and more prolonged use but can be markedly reduced with the use of progestin (see Chapter 42 , Menopause). Similarly, combination (progestin-containing) oral contraceptives decrease the risk, as noted by Grimes and Economy, with most studies showing a relative risk reduction to approximately 0.5 ( ). The protection begins after 1 year of use and lasts approximately 15 years after discontinuation. Other conditions leading to long-term estrogen stimulation of the endometrium, including the polycystic ovary syndrome (Stein-Leventhal syndrome) and the much more rare feminizing ovarian tumors, are also associated with increased risk of endometrial carcinoma.

BOX 32.1

Endometrial Carcinoma Risk Factors

Increases the risk

  • Obesity (2-5 times)

  • Nulliparity (2-3 times)

  • Diabetes (2.8 times)

  • Lynch syndrome

  • Insulin resistance

  • Estrogen-secreting ovarian tumors

  • Polycystic ovary syndrome

  • Tamoxifen therapy for breast cancer

  • Unopposed estrogen stimulation

  • Unopposed menopausal estrogen (4-8 times) replacement therapy

Diminishes the risk

  • Ovulation

  • Progestin therapy

  • Combination oral contraceptives

  • Menopause before 49 years

  • Multiparity

Patients who receive the selective estrogen receptor modulator (SERM) tamoxifen are also at increased risk of developing endometrial carcinoma. In the National Surgical Adjuvant Bowel and Breast P-1 trial examining tamoxifen as a chemopreventive agent, risk of endometrial cancer was elevated 2.5-fold. Risk increased with duration of use. The majority of endometrial cancers that developed in tamoxifen users had endometrioid histology and were of low grade and stage; however, high-grade endometrial cancers and sarcomas have also been reported in women taking tamoxifen. There is a high false-positive rate with transvaginal ultrasonography as a screening technique because tamoxifen causes subendometrial cyst formation, which makes the endometrial stripe appear abnormally thick. Women taking tamoxifen should be counseled about the increased risk of endometrial cancer, and all women on tamoxifen who have irregular vaginal bleeding (if premenopausal) or any vaginal bleeding (if postmenopausal) should undergo endometrial sampling or dilation and curettage (D&C).

Various other factors increase the risk of endometrial cancer. Nulliparity is associated with a twofold increased risk in endometrial cancer. Diabetes increases the risk by 2.8-fold and has been found to be an independent risk factor. Hypertension is often related to obesity and diabetes but is not considered an independent risk factor. Insulin resistance or metabolic syndrome has also been recognized as a risk factor for endometrial cancer. Regarding racial factors, the incidence of endometrial cancer among white women is approximately twice the rate in black women; however, studies of Hill and coworkers demonstrated that black women tend to develop a much higher percentage of poorly differentiated tumors. The National Cancer Database report by Partridge and colleagues confirmed that patients who are black and have a low income do present at an advanced stage and have a poor survival compared with non-Hispanic white patients. The difference in survival between black and non-Hispanic white women does not appear to be solely based on access to care issues, and there are likely biologic differences that account for the disparity in survival.

Lynch syndrome, or hereditary nonpolyposis colorectal cancer (HNPCC) syndrome, is an autosomal dominant hereditary cancer susceptibility syndrome caused by a germline defect in a DNA mismatch repair gene ( MLH1, MSH2, MSH6, or PMS2 ). Women with MLH1 or MSH2 mutations have a 40% to 60% lifetime risk for developing endometrial cancer, a 40% to 60% lifetime risk of developing colon cancer, and a 12% lifetime risk of developing ovarian cancer. This contrasts sharply with the general population risk of 3% for endometrial cancer, 5% for colon cancer, and 1.7% risk of ovarian cancer. Women with MSH6 mutations have a high rate of endometrial cancer, but the occurrence is often at a later age. Endometrial cancers in Lynch syndrome can be of any histology and grade. Broaddus and Lu reported that although most endometrial cancers in women with Lynch syndrome were early stage, approximately one-fourth were high grade, high stage, or of a poor histologic type ( ). Given that there are few longitudinal cohort studies, screening recommendations for gynecologic cancers are based on expert opinion and can include endometrial biopsy every 1 to 2 years. Schmeler reported on the efficacy of prophylactic hysterectomy and salpingo-oophorectomy to decrease endometrial and ovarian cancer risk ( ). Women with Lynch syndrome should be offered this option after childbearing is complete. Lynch syndrome is likely to account for approximately 2% of all endometrial cancers. Women with endometrial cancer and a family history of colon, endometrial, or ovarian cancer should be referred for genetic evaluation and colonoscopy. In addition, women who have a personal history of both endometrial and colon cancer have a significant risk for Lynch syndrome and should be referred. Although synchronous endometrial and ovarian cancers are fairly common, Soliman and colleagues estimated the risk of Lynch syndrome in this cohort to be less than 10% ( ).

In 2013 the Cancer Genome Atlas Program published a comprehensive genomic analysis on more than 300 endometrial cancers ( ). Four molecular subtypes emerged: polymerase-epsilon (POLE) ultramutated, microsatellite instability high (MSI-H), copy number low, and copy number high. Copy number–low tumors include most low-grade, estrogen receptor–positive endometrial cancers, which contain defects in the PTEN and KRAS pathways. Copy number–high tumors include endometrial cancers of serous histologic type, which contain p53 mutations, and high-grade endometrioid cancers. MSI-H tumors can occur in women with Lynch syndrome; more commonly, they result from somatic hypermethylation of the MLH1 promoter. Finally, a small subset of endometrial cancers with mutations in POLE are associated with a large number of mutations and have an improved clinical outcome.

Endometrial hyperplasia

The normal morphologic changes that occur in the endometrium during the menstrual cycle are reviewed in Chapter 4 , Reproductive Endocrinology. Endometrial hyperplasia is believed to result from an excess of estrogen or an excess of estrogen relative to progestin, such as occurs with anovulation. In 2014 the World Health Organization changed its categorization of endometrial hyperplasias. There are two important separate categories: hyperplasia without atypia and hyperplasia with atypia, often referred to as complex atypical hyperplasia or EIN.

Hyperplasia without atypia

Hyperplasia without atypia encompasses the older terms simple hyperplasia and complex hyperplasia without atypia. The endometrium may have dilated glands with some outpouching and abundant endometrial stroma ( Fig. 32.2 ). Alternatively, the glands may demonstrate crowding with very little endometrial stroma, a very complex gland pattern, and outpouching formations but no cytologic atypia ( Fig. 32.3 ).

Fig. 32.2

Benign simple hyperplasia.

(From Kurman RJ, Kaminski PF, Norris HJ. Behavior of endometrial hyperplasia: a long-term study of “untreated” hyperplasias in 170 patients. Cancer. 1985;56:403.)

Fig. 32.3

Complex hyperplasia characterized by crowded back-to-back glands with complex outlines.

(From Kurman RJ, Kaminski PF, Norris HJ. Behavior of endometrial hyperplasia: a long-term study of “untreated” hyperplasias in 170 patients. Cancer. 1985;56:403.)

Hyperplasia with atypia

Hyperplasia with atypia refers to hyperplasias that contain glands with cytologic atypia and are considered premalignant. There is an increase in the nuclear/cytoplasmic ratio with irregularity in the size and shape of the nuclei ( Fig. 32.4 ). The term complex atypical hyperplasia can also be used, as well as the term endometrial intraepithelial neoplasia (EIN ).

Fig. 32.4

Severely atypical hyperplasia (complex) of the endometrium with marked irregularity of nuclei (original magnification ×720).

(From Welch WR, Scully RE: Hum Pathol. 1977;8:503, 1977.)

Natural history

The rate at which endometrial hyperplasia progresses to endometrial carcinoma has not been accurately determined because many of the studies have been retrospective and were based on the 1994 classification of endometrial hyperplasia. Kurman and associates studied 170 patients with endometrial hyperplasia diagnosed by D&C at least 1 year before hysterectomy. Overall, complex atypical hyperplasias had the highest risk of progression to carcinoma. Simple hyperplasia had a 1% rate of progression to cancer, complex hyperplasia without atypia had a 3% rate of progression to cancer, and complex atypical hyperplasia had a 29% rate of progression to cancer. Lacey found up to 27.5% cumulative risk of endometrial cancer in women with atypical hyperplasia, compared with a 4.6% cumulative risk of endometrial cancer in women with nonatypical hyperplasia ( ). In addition to possible progression to cancer, 42% of women who undergo hysterectomy for complex atypical hyperplasia have a concurrent endometrial cancer in their hysterectomy specimen. This high rate of cancer suggests that complex atypical hyperplasia often may be present with low-grade endometrial cancer and that endometrial sampling may not identify an endometrial cancer when admixed with a complex atypical hyperplasia. Clearly there is a spectrum of histologic types that make a definitive diagnosis of atypical hyperplasia/EIN difficult, and the clinician must be aware of this fact when planning management strategies.

Diagnosis and endometrial sampling

Abnormal vaginal bleeding is the most common symptom of endometrial hyperplasia. In younger patients, hyperplasia may develop during anovulatory cycles and may be detected after prolonged periods of oligomenorrhea or amenorrhea. It can occur at any time during the reproductive years but is most common with abnormal bleeding in the perimenopausal period. Premenopausal women with irregular vaginal bleeding and postmenopausal women with any vaginal bleeding should be evaluated with an office endometrial sampling or a D&C. The office sampling instruments, such as a thin plastic Pipelle, are introduced through the cervical os into the endometrial cavity and can provide sufficient tissue for accurate histologic diagnoses. Studies have had conflicting results regarding whether a D&C provides more sensitivity in detecting cancer compared with an office Pipelle procedure. Importantly, both modalities still miss a significant number of cancers. Suh-Bergmann reported that preoperative D&C lowered the risk of an unrecognized cancer in women with complex atypical hyperplasia from 45% to 30%.

Transvaginal ultrasonography has been evaluated as an adjunct for the diagnosis of endometrial hyperplasia and cancer. In postmenopausal women with any vaginal bleeding, Gull and colleagues found that an endometrial stripe of less than 4 mm had a 100% negative predictive value. A finding of endometrial thickness less than 4 mm is a reasonable predictor of lack of endometrial pathologic changes, even in a postmenopausal patient with bleeding; however, persistent vaginal bleeding should lead to endometrial sampling regardless of the ultrasound findings. In addition, measurement of endometrial stripe in a premenopausal woman is not clinically useful.


The therapy employed for endometrial hyperplasia depends on the patient’s age, desire for future childbearing, comorbidities, and the type of hyperplasia. For younger women with benign endometrial hyperplasia, the risk of developing endometrial cancer is extremely low and patients can be treated with progestins or combination oral contraceptive agents. For patients with hyperplasia with atypia/EIN, the risk of developing endometrial cancer may be close to 30%.

For patients who do not desire future childbearing, hysterectomy is the definitive treatment. Oophorectomy can be considered, but long-term risks and benefits should be discussed with the patient. Because of the 40% risk of a concomitant cancer, many surgeons send the uterus for frozen section evaluation intraoperatively, with staging as needed.

Women who desire preservation of childbearing function or who are poor surgical candidates are treated with progestin therapy, usually megestrol acetate 40 mg four times a day. A common alternative is the use of a progestin-eluting intrauterine device (IUD), which has the benefit of local delivery to the endometrium with minimal systemic side effects and which has an overall response rate for women with complex atypical hyperplasia of 80% ( ). One study found a higher rate of regression in patients treated with a progestin-eluting IUD compared with those treated with oral progestins (Gallos, 2013). Patients require long-term follow-up and periodic sampling. In these patients the risk factors that led to the development of hyperplasia with atypia/EIN are likely to remain. In those for whom progestin therapy is ineffective, hysterectomy should be considered.

Endometrial carcinoma

Symptoms, signs, and diagnosis

Postmenopausal bleeding, abnormal premenopausal bleeding, and perimenopausal bleeding are the primary symptoms of endometrial carcinoma.

The diagnosis of endometrial carcinoma is established by histologic examination of the endometrium. Initial diagnosis often can be made on an outpatient basis, with an office endometrial biopsy. A routine cytologic examination (Papanicolaou [Pap] smear) from the exocervix, which screens for cervical neoplasia, detects endometrial carcinoma in only approximately 50% of the cases.

If adequate outpatient evaluation cannot be obtained or if the diagnosis or cause of the abnormal bleeding is not clear from the tissue obtained, a hysteroscopy and D&C should be performed. If cervical involvement is suspected, the endocervix should be sampled first, followed by hysteroscopy to visualize the endometrial cavity and then a complete uterine curettage.

Histologic types

The various types are listed in Box 32.2 . Fig. 32.5 illustrates typical adenocarcinomas of the endometrium and demonstrates varying degrees of differentiation (G1, well differentiated; G2, intermediate differentiation; G3, poorly differentiated). Grading is determined by the percentage of solid components found in the tumor: Grade 1 has less than 5% solid components, grade 2 has 6% to 50% solid components, and grade 3 has more than 50% solid components.

BOX 32.2

Endometrial Primary Adenocarcinomas

  • Typical endometrioid adenocarcinoma

  • Adenocarcinoma with squamous elements *

  • Clear cell carcinoma

  • Serous carcinoma

  • Secretory carcinoma

  • Mucinous carcinoma

  • Squamous carcinoma

* Previously termed adenoacanthoma or adenosquamous carcinoma.

Fig. 32.5

A, Well-differentiated adenocarcinoma of the endometrium. The glands are confluent. (Original magnification ×130.) B, Moderately differentiated adenocarcinoma of the endometrium. The glands are more solid, but some lumens remain. (Original magnification ×100.) C, Poorly differentiated adenocarcinoma of the endometrium. The epithelium shows solid proliferation with only a rare lumen. (Original magnification ×100.)

(From Kurman RJ, Norris HJ. Endometrial neoplasia: hyperplasia and carcinoma. In Blaustein A, ed. Pathology of the Female Genital Tract. 2nd ed. New York: Springer-Verlag; 1982.)

Squamous epithelium commonly coexists with the glandular elements of endometrial carcinoma. Previously the term adeno-acanthoma was used to describe a well-differentiated tumor and adenosquamous carcinoma to describe a poorly differentiated carcinoma with squamous elements. More recently, the term adenocarcinoma with squamous elements has been used with a description of the degree of differentiation of both the glandular and squamous components. Zaino and colleagues, in a Gynecologic Oncology Group (GOG) study of 456 cases with squamous elements, showed that prognosis was related to the grade of the glandular component and the degree of myometrial invasion. They suggested the term adenocarcinoma with squamous differentiation, and this has been generally adopted.

Uterine serous carcinomas are a highly virulent and a less common histologic subtype of endometrial carcinomas (5% to 10%). These tumors histologically resemble papillary serous carcinomas of the ovary ( Fig. 32.6 ). Slomovitz and associates evaluated 129 patients with uterine serous carcinoma (USC) and found a high rate of extrauterine disease even in cases without myometrial invasion. They recommend a thorough operative staging (see the next section) with all cases of these tumors because of the high risk of extrauterine disease even in cases where the tumor is admixed with other histologic types (endometrial and/or clear cell).

Fig. 32.6

Serous carcinoma characterized by a complex papillary architecture resembling serous carcinoma of the ovary.

(From Kurman RJ. Blaustein’s Pathology of the Female Genital Tract. 3rd ed. New York: Springer-Verlag; 1987.)

Clear cell carcinomas of the endometrium are less common (<5%). Histologically they resemble clear cell adenocarcinomas of the ovary, cervix, and vagina; they tend to develop in postmenopausal women and carry a prognosis much worse than typical endometrial adenocarcinomas. Survival rates of 39% to 55% have been reported, much less than the 65% or better usually recorded for endometrial carcinoma. When diagnosed at an early stage, however, prognosis can be favorable. Armbruster and colleagues reviewed 112 cases of clinical early stage clear cell cancer of the uterus. Patient with pure clear cell or mixed tumors with more than 50% clear cell type had an overall survival approaching 10 years. Women older than 70 years had the worst prognosis


In 2009, a revised International Federation of Gynecology and Obstetrics (FIGO) surgical staging classification was introduced in which the staging was modified to better define clinically relevant risk strata based on the FIGO Annual Report and other supporting publication ( Table 32.1 ).

TABLE 32.1

Revised FIGO Staging for Endometrial Cancer (adopted 2009)

Stages Characteristic
I * Tumor confined to the corpus uteri
IA * No or less than half myometrial invasion
IB * Invasion equal to or more than half of the myometrium
II * Tumor invades cervical stroma but does not extend beyond the uterus
III * Local and/or regional spread of the tumor
IIIA * Tumor invades serosa of the corpus uteri and/or the adnexae
IIIB * Vaginal and/or parametrial involvement
IIIC * Metastases to pelvic and/or paraaortic lymph nodes
IIIC1 * Positive pelvic nodes
IIIC2 * Positive paraaortic lymph nodes with or without positive pelvic lymph nodes
IV * Tumor invades bladder and/or bowel mucosa and/or distant metastasis
IVA * Tumor invades bladder and/or bowel mucosa
IVB * Distant metastases, including intraabdominal and/or inguinal lymph nodes

FIGO, International Federation of Gynecology and Obstetrics.

* Either G1, G2, or G3.

Endocervical glandular involvement only should be considered stage I and no longer stage II.

Positive cytologic testing has to be reported separately without changing the stage.

Prognostic factors

Many variables affect the behavior of endometrial adenocarcinomas. These variables can be divided into clinical and pathologic factors. The clinical determinants are patient age at diagnosis, race, and clinical tumor stage. The pathologic determinants are tumor grade, histologic type, tumor size, depth of myometrial invasion, microscopic involvement of vascular spaces in the uterus by tumor, and spread of tumor outside the uterus to the retroperitoneal lymph nodes, peritoneal cavity, or uterine adnexa.

Clinical factors

Older patients have tumors of a higher stage and grade compared with younger patients. White patients have a higher survival rate than black patients, a finding partially explained by higher-stage and higher-grade tumors among black women. In addition, black women are more likely to develop USCs. In the series reported by Aziz and coworkers, the 10-year survival of 136 black patients was 40% compared with 72% for 135 white patients.

Pathologic factors

Tumor stage is a well-recognized prognostic factor for endometrial carcinoma ( Table 32.2 ). Fortunately, most cases are diagnosed in stage I, which provides a favorable prognosis.

TABLE 32.2

Carcinoma of the Corpus Uteri: Patients Treated in 1990-1992: Survival by 1988 FIGO Surgical Stage, N = 5562

Modified from Pecorelli S, Creasman WT, Pettersson F, et al. FIGO annual report on the results of treatment in gynaecological cancer. Vol 23. Milano, Italy. J Epidemiol Biostat. 1998.

Stage 5-Year Survival Rate
IA 90.9%
IB 88.2%
IC 81.0%
II 71.6%
III 51.4%
IV 8.9%

FIGO, International Federation of Gynecology and Obstetrics.

The histologic grade of the tumor is a major determinant of prognosis. Endometrial carcinomas are divided into three grades: grade 1, well differentiated; grade 2, intermediate differentiation; and grade 3, poorly differentiated. Fig. 32.7 shows the survival of 895 patients studied by the GOG that relates endometrial carcinoma survival to tumor grade and demonstrates the worsening of prognosis with advancing grade.

Fig. 32.7

Recurrence-free interval by histologic grade.

(Redrawn from Morrow CP, Bundy BN, Kurman RJ, et al. Relationship between surgical-pathologic risk factors and outcome in clinical stage I and II carcinoma of the endometrium: a Gynecologic Oncology Group study. Gynecol Oncol. 1991;40:55.)

The histologic type of the endometrial carcinoma is also related to prognosis, with the best prognosis associated with endometrioid adenocarcinomas, in particular well-differentiated tumors. Approximately 80% of all endometrial carcinomas fall into the favorable category. Histologic types that carry poor prognoses are serous carcinoma, clear cell carcinoma, carcinosarcoma, and poorly differentiated carcinoma with or without squamous elements.

The degree of myometrial invasion correlates with the risk of tumor spread outside the uterus, but the higher-grade and higher-stage tumors in general are more likely to have deep myometrial penetration ( Fig. 32.8 ). In a study by Schink and colleagues, tumor size greater than 2 cm was also found to be prognostic. Only 4% of those with tumors 2 cm or less had lymph node metastases. The rate increased to 15% for those with tumors greater than 2 cm and to 35% when the entire endometrial cavity was involved. Table 32.3 summarizes the clinical and pathologic factors affecting outcomes in patients with early-stage tumors. Peritoneal cytologic characteristics have been studied as a prognostic factor, and the results are conflicting. In a study of 567 surgical stage I cases, Turner and associates found that positive peritoneal cytologic evaluation was an independent prognostic factor. In contrast, Grimshaw and coworkers evaluated 322 clinical stage I cases and found that positive peritoneal cytology was an adverse prognostic factor, but they did not find it to be an independent risk factor when other variables were considered. In 2018 Seagle and colleagues evaluated 16,851 women though the National Cancer Database and found that positive washings were associated with decreased survival among women with stage I/II endometrial cancer, including those with low-grade tumors. In addition, treatment of women with positive cytology with adjuvant chemotherapy was associated with increased survival. Although these large database studies have limitations, this is something to consider. In the 2009 revised FIGO surgical staging, positive cytology is no longer classified as stage IIIA.

Fig. 32.8

A, Technique for intraoperative assessment of the depth of myometrial invasion. B, Cross section of uterine wall demonstrating superficial myometrial invasion. Arrow shows the tumor–myometrial junction.

(From Doering DL, Barnhill DR, Weiser EB, et al. Intraoperative evaluation of depth of myometrial invasion in stage I endometrial adenocarcinoma. Obstet Gynecol. 1989;74:930.)

TABLE 32.3

Surgical Stage I and II Tumors: The Proportional Hazards Modeling of Relative Survival Time

Modified from Zaino RJ, Kurman RJ, Diana KL, Morrow CP. Pathologic models to predict outcome for women with endometrial adenocarcinoma. Cancer. 1996;77:1115.

Variable Regression Coefficient Relative Risk Significance Test * ( P value)
Grade 1 1.0
Grade 2 0.28 1.3 2.7 (.1)
Grade 3 0.56 1.8
Endometrioid with squamous differentiation 0.1 (.7)
Grade 1 0.20 1.2
Grade 2 –0.01 1.0 0.3 (.6)
Grade 3 0.22 0.8
Villoglandular 2.2 (.1)
Grade 1 –4.91 0.01
Grade 2 –0.59 0.5 10.4 (.001)
Grade 3 3.73 41.9
Endometrium only 1.0
Superficial 0.39 0.5
Middle 1.20 3.3 19.6 (.0002)
Deep 1.53 4.6
Age 0.17
Age –0.000837 20.7 (.0001)
45 (arbitrary reference) 1.0
55 0.85 2.3
65 1.52 4.6
75 2.03 7.6
Vascular space involvement 0.32 1.4 1.2 (.3)

P value for grading is for overall grade within cell type.

* Wald x 2 test.

Patterns of spread of endometrial carcinoma.

Plentl and Friedman noted four major channels of lymphatic drainage from the uterus that serve as sites for extrauterine spread of tumor: (1) a small lymphatic branch along the round ligament that runs to the inguinal femoral nodes; (2) branches from the tubal and (3) ovarian pedicles (infundibulopelvic ligaments), which are large lymphatics that drain into the paraaortic nodes; and (4) the broad ligament lymphatics that drain directly to the pelvic nodes. The pelvic and paraaortic node drainage sites (2, 3, and 4) are the most important clinically. In addition, direct peritoneal spread of tumor can occur through the uterine wall or via the lumen of the fallopian tube. Therefore the clinician must assess the retroperitoneal nodes, the peritoneal cavity, and the uterine adnexa for the spread of endometrial carcinoma ( Fig. 32.9 ).

Fig. 32.9

Spread of endometrial carcinoma. The major pathways of tumor spread are illustrated (see text).

Extensive studies by the GOG have elucidated both the frequency of lymph node metastases in endometrial carcinoma and the pathologic factors that modify this risk in stage I disease. Tumor grade, size of the uterus, and degree of myometrial invasion were studied. Table 32.4 illustrates the frequency of lymph node metastases according to tumor grade and depth of myometrial invasion. The frequency of nodal involvement becomes much greater with high-grade tumors and with greater depth of myometrial invasion. The risk of lymph node involvement appears to be negligible for endometrial carcinoma involving only the endometrium. With invasion of the inner third of the myometrium, there is minimal risk of node involvement for grade 1 and 2 cases. If the outer third of the myometrium is involved, the risk of nodal metastases is greatly increased. These data emphasize the importance of myometrial invasion and tumor spread, providing the basis for the FIGO Surgical Staging System. Tables 32.5 and 32.6 summarize the risk of nodal metastases based on the GOG studies published by Creasman and colleagues. Mariani and colleagues at the Mayo Clinic found that tumor size could also be incorporated into a staging paradigm to identify patients at highest risk for nodal spread. They found that in grade 1 and 2 tumors with less than 50% invasion and tumor size less than 2 cm, the risk of lymph node involvement was virtually zero ( ).

TABLE 32.4

Grade, Depth of Myometrial Invasion, and Node Metastasis—Stage I

Adapted from Creasman WT, Morrow CP, Bundy BN, et al. Surgical pathologic spread patterns of endometrial cancer. Cancer 1987;60:2035.

Depth of Invasion G1 n = 180 G2 n = 288 G3 n = 153
Endometrium only (n = 86) 0 (0%) 1 (3%) 0 (0%)
Inner (n = 281) 3 (3%) 7 (5%) 5 (9%)
Middle (n = 115) 0 (0%) 6 (9%) 1 (4%)
Deep (n = 139) 2 (11%) 11 (19%) 23 (34%)
Endometrium only (n = 86) 0 (0%) 1 (3%) 0 (0%)
Inner (n = 281) 1 (1%) 5 (4%) 2 (4%)
Middle (n = 115) 1 (5%) 0 (0%) 0 (0%)
Deep (n = 139) 1 (6%) 8 (14%) 15 (23%)

G, grade.

TABLE 32.5

FIGO Staging and Nodal Metastasis

From Creasman WT, Morrow CP, Bundy BN, et al. Surgical pathologic spread patterns of endometrial cancer. Cancer. 1987;60:2035.

Staging Pelvic Aortic
IA G1 (n = 101) 2 (2%) 0 (0%)
G2 (n = 169) 13 (8%) 6 (4%)
G3 (n = 76) 8 (11%) 5 (7%)
IB G1 (n = 79) 3 (4%) 3 (4%)
G2 (n = 119) 12 (10%) 8 (7%)
G3 (n = 77) 20 (26%) 12 (16%)

FIGO, International Federation of Gynecology and Oncology; G, grade.

TABLE 32.6

Risk Factors for Nodal Metastases—Stage I

Adapted from Creasman WT, Morrow CP, Bundy BN, et al. Surgical pathologic spread patterns of endometrial cancer. Cancer. 1987;60: 2035.

Factor Pelvic Aortic

  • Low risk

  • Grade 1

  • Endometrium only

  • No intraperitoneal spread

0/44 (0%) 0/44 (0%)

  • Moderate risk

  • Grade 2 or 3

  • Invasion to middle third

15/268 (6%) 6/268 (2%)

  • High risk

  • Invasion to outer third

21/116 (18) 17/118 (15%)

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Aug 8, 2021 | Posted by in GYNECOLOGY | Comments Off on Malignant diseases of the uterus: Endometrial Hyperplasia, Endometrial Carcinoma, Sarcoma: Diagnosis and Management
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