Uterine Cancer
Screening & Diagnosis
Screening
- Pelvic examination: The doctor feels the uterus, vagina, ovaries, and rectum to check for any unusual findings.
- Transvaginal ultrasound: This test uses sound waves to create a picture of the uterus so that the doctor can look for abnormalities in the uterine lining. If the endometrium looks too thick, the doctor may decide to perform a biopsy.
- Endometrial biopsy: This procedure involves removing a sample of endometrial tissue for laboratory analysis. This can usually be completed in the doctor’s office.
- Hysteroscopy: For this imaging procedure, a thin, flexible, lighted tube (hysteroscope) is inserted through the vagina and cervix into the uterus. A lens on the hysteroscope allows direct visualization of the uterus and the endometrium.
- Dilation and curettage (D&C): If the biopsy does not yield enough tissue or if the laboratory results are unclear, a procedure called dilation and curettage (D&C) can be performed. During D&C, tissue is scraped from the lining of the uterus and examined under a microscope for cancer cells. A D&C is often done in combination with a hysteroscopy.
- More advanced screening can include a CT scan to produce 3D cross-sectional images of the uterus, and an MRI to look at the various layers of the uterine wall.
Stages, Grades and Types
Stages & Grades
Once uterine cancer is diagnosed, doctors will evaluate the size of the tumor and how far it has spread from where it originated. This classification, or staging, is a significant factor in determining the best treatment approach and predicting how successful it will be.
There are two systems used to stage uterine cancer – the FIGO (International Federation of Gynecology and Obstetrics) system and the AJCC (American Joint Committee on Cancer) TNM (tumor, node, metastasis) system. Both systems use basically the same information to stage uterine cancer:
- The size of the tumor and how deeply it goes into the muscle wall of the uterus.
- Whether the cancer has spread to any nearby lymph nodes.
- Whether the cancer has spread to distant lymph nodes or other parts of the body (metastasized).
- There are 4 main stages of endometrial cancer and uterine sarcoma. Early diagnosis is typically, but not always, associated with better outcomes.
Cancer is usually staged twice. The first rating is called the clinical (baseline stage), based on tissue and images obtained before treatment. The second rating is done after treatment, such as surgery, and is called the pathologic stage.
In 2023, FIGO published important changes to the staging system. The updated 2023 staging of endometrial cancer includes the various histological types, tumor patterns, and molecular classification to better reflect the improved understanding of the complex nature of the several types of endometrial carcinoma and their underlying biologic behavior. The changes incorporated in the 2023 staging system should provide a more evidence-based context for treatment recommendations.
Endometrial Cancer Stages
Stage I: Confied to the uterine corpus and ovary
- IA1: non-aggressive histological type of endometrial carcinoma limited to a polyp or confined to the endometrium;
- IA2: non-aggressive histological types of endometrium involving less than 50% of the myometrium with no or focal lymphovascular space invasion (LVSI)
- IA3: low-grade endometrioid carcinomas limited to the uterus with simultaneous low-grade endometrioid ovarian involvement
- IB: non-aggressive histological types involving 50% or more of the myometrium with no LVSI or focal LVSI
- IC: aggressive histological types, i.e. serous, high-grade endometrioid, clear cell, carcinosarcomas, undifferentiated, mixed, and other unusual types without any myometrial invasion.
Stage II: Invasion of cervical stroma without extrauterine extension OR with substantial LVSI OR aggressive histological types with myometrial invasion
- IIA: non-aggressive histological types that infiltrate the cervical stroma.
- IIB: non-aggressive histological types that have substantial LVSI.
- IIC: aggressive histological types with any myometrial invasion.
Stage III: Local and/or regional spread of the tumor of any histological subtype
- IIIA: differentiating between adnexal versus uterine serosa infiltration
- IIIB: infiltration of vagina/parametria and pelvic peritoneal metastasis
- IIIC: refinements for lymph node metastasis to pelvic and para-aortic lymph nodes, including micrometastasis and macrometastasis.
Stage IV: Spread to the bladder mucosa and/or intestinal mucosa and/or distance metastasis
- IVA: locally advanced disease infiltrating the bladder or rectal mucosa
- IVB: extrapelvic peritoneal metastasis
- IVC: distant metastasis
The performance of complete molecular classification (POLEmut, MMRd, NSMP, p53abn) is encouraged in all endometrial cancers. If the molecular subtype is known, this is recorded in the FIGO stage by the addition of “m” for molecular classification, and a subscript indicating the specific molecular subtype. When molecular classification reveals p53abn or POLEmut status in Stages I and II, this results in upstaging or downstaging of the disease (IICmp53abn or IAmPOLEmut).
Endometrial Cancer Grades
Grade X
Grade 1
Grade 2
Grade 3
Uterine Sarcoma Stages
Stage I
- IA: Tumor is 5 cm across (about 2 inches) or smaller.
- IB: Tumor is larger than 5 centimeters (about 2 inches) across.
Stage II
- IIA: Cancer extends to the ovaries or fallopian tubes.
- IIB: Cancer has spread to other tissues in the pelvis.
Stage III
- IIIA: Cancer has spread into abdominal tissues in 1 place only.
- IIIB: Cancer is growing into abdominal tissues in 2 or more places
- IIIC: Cancer has spread to nearby lymph nodes.
Stage IV
- IVA: Cancer has spread to the bladder or rectum, but not distant sites.
- IVB: Cancer has spread to distant sites, such as the lungs, bones, or liver.
Uterine Cancer: Histologic Subtypes
Uterine cancers can be categorized into different subtypes based on key characteristics of individual cells under the microscope (histology).
Endometrial cancer originates in the endometrium, or inner lining of the uterus. The most common cancer cell type is endometrioid (80%). Certain less-common cell types are considered high-risk because they tend to grow more rapidly and are harder to treat. These include serous carcinoma, clear cell carcinoma, carcinosarcoma (also known as malignant mixed Müllerian tumor [MMMT]), and undifferentiated/dedifferentiated carcinoma.
Uterine sarcoma starts in the supporting tissues or muscles of the uterus. Cancer cell types include uterine leiomyosarcoma (uLMS), endometrial stromal sarcoma (ESS), and undifferentiated uterine sarcoma (UUS).
Molecular Subtypes
The Cancer Genome Atlas (TCGA) has identified four molecular subtypes of endometrial cancer with distinct genetic profiles. Molecular subtyping is important for patient management and clinical trial design because it has prognostic and therapeutic implications. This slide shows the four different subyptes. For further explanation of each subtype, you can watch our video presentation here. \
Insert Dr. Myers slide:
Depending on your specific type of uterine cancer, there may be other factors to discuss with your medical team which may help to determine treatments etc. These include estrogen receptor (ER) status, progesterone receptor (PR) status, and HER2/neu expression status.
If you receive a diagnosis of uterine cancer, SHARE is here to support you. You can join us for one of our support groups or call our Uterine Cancer Support Line at 844-582-6005.
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