Endometrial cancer is the most common malignant disease of the female reproductive system and the fourth most common cancer in women after breast, colon and lung cancer.
Worldwide in 2020 over 420,000 women were diagnosed with endometrial cancer. For 2022, it is estimated that approximately 14,000 women will lose their lives due to this disease.
Endometrial cancer usually occurs in women who are over the age of 50 and are therefore in menopause. However, more than 25% of cases can occur before menopause.
Risk factors
Risk factors for endometrial cancer include prolonged hyperestrogenism, which can be caused by early menarche, late menopause, alopecia, obesity, or hormone therapy.
Undoubtedly, the increasing age of the population and the increase in obesity rates in the modern population belong to the modern challenges we have to face in relation to endometrial cancer. Obese women may have up to 4 times the risk of developing the disease. This implies an expected increase in new cases of endometrial cancer, an increase which in the United States of America has already been observed. By 2040, endometrial cancer is expected to surpass colon cancer as the third most common cancer in women.
Signs of endometrial cancer
The most common sign of endometrial cancer is vaginal bleeding. After menopause, there should be no vaginal bleeding. Therefore, the presence of bleeding is not normal. Before menopause, bleeding between periods or unusual heavy vaginal bleeding during menstruation should also alert women to consult their doctor. However, the absence of pain symptoms, which in other diseases can sound the alarm bell and sensitize patients, often prevents women from seeking medical help in time.
Diagnosis
The diagnosis of endometrial cancer is made histologically after taking an endometrial biopsy. The biopsy is usually obtained with the help of hysteroscopy and scraping of the endometrium.
However, the biggest revolution in the better understanding and treatment of endometrial cancer came about with the help of the Cancer Gene Atlas and started in 2013. According to the Cancer Atlas, endometrial cancer is classified into four different molecular groups, each of which has its own behavior and needs a different treatment:
1. Polymerase epsilon ultra-mutated (POLE)
2. hypermutated microsatellite instability (MSI)
3. copy-number alternations low
4. copy-number alternations high (p53)
Therefore, after taking the biopsy, the attending physician must, with the help of the pathologist, classify the endometrial cancer into one of the above categories. These data must be evaluated by an experienced gynecologist-oncologist in order for the patient to proceed with the appropriate treatment.
Treatment
Treatment of endometrial cancer is primarily surgical. Radiotherapy and chemotherapy given after surgery are called adjuvant treatments, meaning they are given in conjunction with surgery. The surgery involves removing the uterus, both fallopian tubes and the ovaries. In some histological types (e.g. serous, clear cell, carcinosarcoma) the removal of the tissue (the so-called epiplexy) from the peritoneal cavity is also required. At the same time, the probability of lymph node metastasis in all FIGO stages is about 15%. This fact highlights the importance of lymphadenectomy for the correct treatment of endometrial cancer.
In recent years, the usefulness of the Sentinel Lymph Node has been confirmed. The latest guidelines of the European Society of Gynecological Oncology (ESGO) published in January 2021 accepted the usefulness of finding the Sentinel Lymph Node using indocyanine green (ICG) in the surgical staging of endometrial cancer. Existing data suggest that the use of Lymphaden-Guard is associated with similar oncological outcomes as systemic lymphadenectomy but also with a significant reduction in complications. Its use is now the treatment of choice for the staging and treatment of endometrial cancer, and should be practiced by every gynecologist-oncologist.
Numerous studies have shown that the survival expectancy of patients with gynecological cancer increases dramatically when they are treated by a specialized surgical team. In addition, the presentation of these cases to Oncology Councils ensures a personalized treatment of each patient in accordance with international guidelines.
Written by:
Sklavounos Panagiotis
Obstetrician gynecologist
Director of the 2nd Clinic of Gynecological Oncology MITERA
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