If the patient is not having postmenopausal bleeding, if she should get an ultrasound done by her internist that shows an endometrial stripe of 9 mm, she does not need to be sampled unless she becomes symptomatic, and I want to make one point here, that atypical hyperplasia and cancer, in many institutions, if you show a slide of atypical hyperplasia to 20 pathologists, 10 will report it out as well differentiated cancer and 10 will report it out as atypical hyperplasia, atypical hyperplasia is felt e a premalignant condition and in anywhere from 35 to 50% of cases, when you finally get the final hysterectomy specimen, they will be diagnosed with a cancer, and these are several studies that have been done that have demonstrated that on the D&C or office biopsy was atypical hyperplasia, and when they finally got the final hysterectomy specimen, indeed about 50% had cancer, so atypical hyperplasia, particularly in the post menopausal women is better out than left in. There are several prognostic factors in dealing with endometrial cancer, as with any cancer, the stage of the disease, pretty much predicts how the patient is going to do. The problem with endometrial cancers is 75% of your patient’s present with stage I disease, you need to have other prognostic factors that are going to divide up those stage I patient’s to tell you which patient’s are at risk for recurrent and which patient’s are don’t need any further treatment. The most important prognostic factor are the most sensitive prognostic factor, when dealing with endometrial cancer, is tumor differentiation and the reason for that is the higher the grade of the tumor, the worse the patient is going to be, because the higher the grade of the tumor, the higher the stage of the disease can potentially be, the higher the myometrial invasion rate, and therefore the probability of lymph node metastases.
So if we look at endometrial cancer again, the higher the stage, is usually associated with higher grade lesions. As a GYN oncologist, of course I see all spectrum and I see people who have well differentiated cancers who walk in the door with a stage III disease simply because they let their disease process go. I am briefly going to review the staging of endometrial cancer, this is something you will need to study on your own, briefly, stage I is confined to the fundus, stage II has cervical involvement, stage III has adnexal involvement or lymph node involvement and then stage IV is distal metastases. You will have to take some time to go over the one, two, three’s and the ABCs, but in general if you just keep it in mind, one fundus, two cervix, three, adnexal lymph nods, four distal. That will help you on your exam. The distribution of endometrial cancer as I said, 75% of the patient’s who walk in are postmenopausal, 75% are stage I, so it’s not very helpful in treating these people with adjunctive therapy unless you can divide up your stage I patient’s to decide who needs further treatment and who doesn’t. The higher the stage of the cancer, it’s rare to pick them up, also, their survival is not very good.
The most important prognostic factor when dealing with endometrial cancer is the grade of the tumor, it’s also the histology of the tumor. If you read in your review courses, you are going to find five different histologies. What I would like to do is take about two minutes to break those down. Adenocarcinoma is the most common and is the garden variety cancer that we see, this is the lady who is obese, hypertension, diabetic, and she walks in the door and she has an adenocarcinoma, that makes up about 60%. Adenocanthoma is a benign variant of adenocarcinoma, it means there are squamous components that are not malignant, and you grade the tumor based on the adeno component, therefore you can say now that 80% of your patient’s walk in the door, have the garden variety adenocarcinoma. Adeno squamous back in the olden days was felt to have a worse prognosis than adenocarcinoma and adenocanthoma. However, and this is because the squamous component is invasive. If you just grade the adeno component and if you look at just the grade of the adeno, that is what makes the prognosis of an adeno squamous a poor prognosis, almost virtually all patient’s who have adeno squamous carcinoma of the endometrium also have a grade III tumor, so they behave as a grade III tumor.