CLINICAL CASE
Unit 5: Neoplasia
Objective 54: Endometrial Carcinoma
A 49-year-old 1001 woman presents for evaluation of irregular vaginal bleeding. She
states that, at this time, she has been bleeding or spotting on almost a daily basis for
two or three months. She has a long-standing history of irregular menstrual cycles.
She will frequently go for long periods of time with no menses, and then have episodes
of heavy and irregular bleeding. She received clomiphene citrate to conceive her child
16 years ago. She has not seen a physician since then.
Physical Examination
Physical examination reveals a 5 foot, 4 inch, 286-pound woman with a blood
pressure of 154/102. Acanthosis nigricans is noted. The remainder of her general
examination is normal.
Pelvic examination reveals a normal cervix with a small amount of blood in the
vaginal vault. The uterus is anteverted and appears normal in size. Ovaries are nonpalpable secondary to body habitus.
Laboratory
Fasting blood sugar 142. CBC is normal.
Pelvic ultrasound reveals a top-normal sized uterus. Ovaries are not visualized with
transabdominal ultrasound. Utilizing transvaginal ultrasound, the ovaries are normal
size. Transvaginal measurement of the endometrial thickness is 6 mm.
Endometrial biopsy performed at the time of the first office visit revealed a welldifferentiated adenocarcinoma.
Diagnosis
1.
2.
3.
4.
5.
Adenocarcinoma of the endometrium
Long-standing history of anovulation
Hypertension
Diabetes mellitus
Obesity
Management
The patient was taken to the operating room, where a TAH/BSO was performed. The
frozen section at the time of the surgery revealed myometrial invasion to be less than
50%. This was confirmed on histological evaluation. Because of the low grade of
disease, pelvic and periaortic lymph node dissection is not performed. The patient has
been followed for two years, with examination and CT scanning. No evidence of
recurrence is noted.
Teaching Tips
1.
The relationship between unopposed estrogen, either from anovulation or
hormonal therapy and endometrial carcinoma, is well documented.
2.
Perimenopausal bleeding that is more frequent should not be considered
normal and needs to be evaluated for endometrial carcinoma.
3.
The use of oral contraceptives lowers the lifetime risk of endometrial cancer
by 50%.
4.
Some feel that there are two pathogenic types of adenocarcinoma of the
endometrium. The first occurs in younger women with a history of
unopposed estrogen. It tends to be low grade and low stage, and bleeds
early in the course of disease. These patients tend to do well. The second
type occurs in older women with no history of unopposed estrogen. It is of
higher stage and grade, and these women have poorer outcomes.
5.
Atypia occurring in endometrial hyperplasia is a precursor of
adenocarcinoma of the endometrium.
6.
Depth of myometrial invasion is an indication of the virulence of the
disease.
Adenocarcinoma of the endometrium tends to be associated with diabetes and
hypertension. It is likely that obesity is an underlying factor for all three diseases.