Endometrial Cancer Diagnosis

# Diagnosis
History and Physical
A complete medical and family history and physical examination, engaging cancer genetics counseling and are crucial in narrowing down a diagnosis. 
Abnormal uterine bleeding is the most common symptom of endometrial cancer.  
Occasionally, cervicovaginal cytology or abnormal vaginal discharge may lead to the diagnosis of endometrial cancer. Pap smears taken within 6 months prior to the diagnosis of endometrial cancers were reported to be abnormal 38% of the time, consistent with adenocarcinoma 21% of the time, and in 13% of cases showed atypical glandular cells. 
The definitive diagnosis of endometrial cancer is accomplished by the use of histology. However, the personal and family history of the patient together with a complete physical examination are instrumental. Intrauterine pregnancy should be considered in women of reproductive age with abnormal uterine bleeding or amenorrhea unless post-menopausal status has been confirmed. If suspicious symptoms, signs, and/or family history are present, basic laboratory evaluation, cervical-vaginal Pap smear, and transvaginal ultrasound generally are considered. Patients with an abnormal Pap smear should undergo further investigation regardless of age. 
Transvaginal Ultrasound
This is often the next step when suspicious history or physical findings are seen. In some cases, abdominal ultrasound may also be used. In women aged 35 years or younger who are diagnosed with benign gynecologic conditions or non-gynecologic etiologies and are determined to be of low risk for endometrial pathology, transvaginal ultrasound can be skipped. However, if there is a subsequent failure of medical management, transvaginal ultrasound should be performed. 
Transvaginal ultrasound should be performed in younger women with recurrent abnormal uterine bleeding and anovulatory bleeding in women over the age of 35 years together with examination under anesthesia  with dilation and curettage or endometrial sampling in an outpatient setting. Any suspicious findings warrants further investigation.
Currently, the cut-off for endometrial thickness that requires further investigation in patients with abnormal uterine bleeding is 5 mm in post-menopausal women as measured by transvaginal ultrasound.  However, a recent meta-analysis and systematic review recommended that the cut-off for exclusion of endometrial cancer in women with post-menopausal bleeding be changed to 3 mm.  
Endocervical Sampling and Endocervical Curettage
Endocervical sampling[ of endocervical curettage is sometimes done before endometrial sampling so determine if there is involvement of the cervix. Biopsies should be taken of any unusual findings and these may prove useful in planning patient management.
Hysteroscopy
Hysteroscopic examination can be used in detection of endometrial polyps, which can be associated with endometrial cancer particularly among post-menopausal women.  When used in conjunction with dilation and curettage, hysteroscopy can be used in the removal of these polyps and detection of focal lesions.   Hysteroscopy can also be used to detect submucosal myomas.
Endometrial Biopsy
When there are abnormal findings on transvaginal ultrasound such as endometrial thickness of 5 mm or any abnormal uterine or adnexal findings in women with post-menopausal bleeding, .
Other Diagnostic Methods
- If there is recurrent post-menopausal bleeding or the results of an endometrial biopsy is equivocal, evaluation under anesthesia and fractional dilation and curettage should be performed, and the diagnosis may be enhanced by hysteroscopy for the detection of focal lesions.  
- Chest X-ray can be done pre-operatively to evaluate patients for metastasis.
- MRI can be performed in difficult cases when ovarian tumors, adnexal involvement, or parametrial invasion is suspected. 
- In patients that are Lynch syndrome mutation carriers, it is advisable to perform sonographic imaging, cystourethroscopy, and colonoscopy due to their increased risk of ovarian, urothelial, and colorectal cancer.  
Staging
Management of endometrial cancer and its precursor lesions depends upon the histotype and differentiation[[, extent of disease and status of the patient. The extent of endometrial carcinoma is surgically-pathologically classified, or "staged," according to International Federation of Gynecology and Obstetrics (FIGO) criteria published in 2009 as:
Stage I: Tumor confined to the corpus uteri
- IA: No invasion or invasion into less than half of the myometrium
- IB: Invasion equal into or more than half of the myometrium
Stage II: Tumor invades cervical stroma but does not extend beyond the uterus
Stage III: Local and/or regional spread of tumor
- IIIA: Tumor invades the serosa or corpus and/or adnexa
- IIIB: Vaginal and/or parametrial involvement
- IIIC: Metastases to pelvic and/or para-aortic nodes
IIIC1: Positive pelvic nodes
IIIC2: Positive para-aortic nodes with or without pelvic nodes
- IIIC1: Positive pelvic nodes
- IIIC2: Positive para-aortic nodes with or without pelvic nodes
Stage IV: Tumor invades bladder and/or bowel mucosa or distant metastases
- IVA: Tumor invasion of bladder and/or bowel mucosa
- IVB: Distant metastases, including intra-abdominal and/or inguinal nodes
Although positive peritoneal cytology does not change FIGO staging, this finding is associated with other factors that portend a poor prognosis. 
It is important to understand that staging is a means of coding and reporting the extent of disease and not a formula for managing endometrial cancer. Current FIGO classification by stage depends upon both surgical and pathological findings. Generally, preinvasive neoplastic lesions are diagnosed clinically and pathologically without resort to surgery. Sometimes, it is necessary to clinically and pathologically "stage" cancers when surgery is incomplete or precluded because of co-morbidity or other forbidding reasons.
References
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