:,
..
..
..
~ ~ ~ ~ ~ ~ ~ ~ ~ . .; ,:
~~~~.:: ~
j, ~
..
................
Diagnosis and Management of Early Carcinoma of the Endometrium Leslie A. Walton, MD Chapel Hill, North Carolina
Early (stage I) carcinoma of the endometrium is increasing in frequency. Outpatient diagnostic methods play a role in this increase. Prognostic factors such as histologic grade, uterine size, myometrial invasion, age, lymph node involvement, and cervical spread are important in determining five-year survival. Therapeutic options for early-stage disease are discussed.
Carcinoma of the endometrium has superceded carcinoma of the cervix as the primary cancer on many large gynecologic services in many areas of the country. The feeling that corpus cancer is a good cancer is not true. Kottmeier,' in a 1974 review of 18,000 corpus cancer cases throughout the world, noted a 62 percent five-year survival rate. In the past few years five-year survival figures approaching
Presented at the 82nd Annual Convention of the National Medical Association, Los Angeles, California, August 1-4, 1977. Requests for reprints should be addressed to Dr. Leslie A. Walton, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC 27514.
90 to 95 percent2 have been obtained in treating early-stage disease. It is claimed that the incidence of this disease is increasing. Factors affecting this increase include usage of estrogens and oral contraceptives, delayed menopause, increasing longevity of women, and the increasing use of diagnostic methods. If the yield from a large series of outpatient diagnostic techniques is collated, an average yield would be as documented in Table 1. As can be seen, methods involving direct sampling of the endometrium on an outpatient basis are usually reasonably accurate. Combination of some of these methods increases the accuracy to 100 percent. Once an outpatient diagnosis is made, plans for hospitalization can be simplified. The only other diagnostic uterine study needed, in addition to measurement of the uterine canal, is a thorough curettage of the endocervical canal. This can usually be
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
accomplished without anesthesia and without dilating the endocervix. The lower uterine segment should be studiously avoided in this sampling. Outpatient negative-pressure aspiration curettage has a good yield. However, factors such as cervical stenosis, obesity, enlarged uterus, uncooperative patient, and distortion of the endometrial cavity might necessitate hospitalization for diagnostic purposes. Thirty-two patients7 (Table 2) could not undergo outpatient curettage for reasons listed above. Before considering treatment of stage I carcinoma of the endometrium, certain factors are of important prognostic significance in planning therapy (Table 3). A review of a large series8 (Table 4) gives us some idea of the distribution of histologic grade. There is a slight predominance of grade 1 (welldifferentiated adenocarcinoma) histology but 57 percent of stage I patients 309
Table 1. Outpatient Detection of Endometrial Carcinoma3-6 Method
Accuracy (percentage)
Vaginal aspiration Pap smear Cervical scraping Endometrial brush sampling Endometrial aspiration
47
50 55 62 76
Gravlee jet wash Endometrial biopsy Vacuum aspiration
87-92 88-90 95-97
Table 2. Comparison of Results Using Aspiration Curettage and Sharp Curettage (300 Patients)7
Pathology
Endometrial cancer Hyperplasia Endometrial polyps (small) Endometrial polyps (large) Decidua Tissue insufficient for diagnosis Other benign lesions Total
have varying degrees of differentiation, ie, grade 2 or grade 3. In a collected series of 1,558 patients, there was an 81 percent five-year survival for patients with grade I tumor, 74 percent for grade 2, and 50 percent for grade 3 tumors.9 Tumor invasion of the myometrium carries a serious prognostic sign. While uterine enlargement may signify myometrial involvement, other conditions, eg, myomas and adenomyomas, may contribute to increased uterine size. Hysterography has been useful in localizing cavity tumors and recently has been shown to correlate with myometrial involvement. 10 This involvement is of extreme importance in planning therapy because the deeper the involvement of the myometrium, 310
Number of Patients Outpatient Hospital Aspiration Curettage (Sharp)
23
6 24
4
2
0
1
6
5
6
35
28
194 268
202 268
the lower the five-year survival. Also, the more undifferentiated the tumor, the greater the incidence of myometrial spread. In a large series (Table 5), it was shown that 28 percent of patients are expected to have significant myometrial involvement and require further treatment. Size of uterus is tremendously important. The International Federation of Gynecology and Obstetrics (FIGO) classification labels as enlarged, a uterus whose depth via measurement is greater than 8 cm. Patients with an enlarged uterus have a poorer prognosis. However, many studies question the contribution of uterine size to prognosis. Spread to the cervix, as determined by endocervical curettage, is important
in that the five-year survival rate drops by about 50 percent once the disease, which is normally found high in the fundus on the posterior wall, grows downward and begins to involve the endocervix, because now the potential for spread is different. Fundal disease can spread via the infundibulo-pelvic vessels to the aortic nodes without involving the pelvic nodes, or via the uterine and broad ligament lymphatics to the pelvic nodes. Corpus adenocarcinoma can spread to the cervix. When the cervix is involved the incidence of pelvic node involvement rises from 10.6 to 36.5 percent.8 Age at the time of diagnosis influences prognosis.11,12 Younger patients with carcinoma of the endometrium have a more favorable prognosis than
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
Table 3. Virulence Factors of Endometrial Carcinoma
Table 4. Endometrial Adenocarcinoma (Stage l): Grade Distribution8 Grade Distribution
Histologic grade of the tumor Involvement of the myometrium Size of the uterus Involvement of the cervix Advancing age Lymph node metastasis
Year
1
2
3
Gusberg, et al Roman, et al
1960 1967
204 47
85 106
Wade, et al Cheon Lewis, et al
1967 1969 1970
59
132
65 113 39
354 266 230
201 36
68 50
60 19
329
547 (42.6%)
441 (34.3%)
296
1,284
(23.1%)
(% of Total)
older patients because the older patients have tumors that are more poorly differentiated13 and, thus, have greater myometrial involvement. Lymph node involvement carries a worsening prognosis. The more undifferentiated the tumor, the greater the myometrial spread and the higher the incidence of pelvic and aortic node involvement (Table 6).1114,15 Lymph node involvement beyond the pelvis can help explain the low five-year survival rate previously mentioned.
Treatment
Total Cases
Author
105
Table 5. Endometrial Adenocarcinoma (Stage I): Incidence of Myometrial Invasion8 Author
Year
Gusberg, et al Hirabyashi and Graham Austin and MacMahon Sall, et al Lewis, et al Lewis
1960
Number of Patients
1968 1969 1970 1970 1972
Total
Myometrial Moderate and deep invasion invasion
(%)
(%)
87 (29.7) 54 (23.2)
131
195 (66.6) 174 (74.7) 402 (75.1) 125 (51.4) 91 (85.0) 84 (64.1)
1,542
1,071 (69.4)
293 233 535 243 107
163 (30.5) 50 (20.6) 50 (46.7) 31 (23.7)
435 (28.2)
The argument as to how patients with stage I carcinoma of the en-
dometrium should be treated is gradually being resolved in favor of using some form of preoperative irradiation followed by hysterectomy and salpingo-oophorectomy. In most centers, this involves a short-interval radium system followed by a simple extra-fascial hysterectomy with careful pathological sectioning of the uterus to confirm the degree of differentiation and ascertain the degree of myometrial involvement. At the time of hysterectomy, pelvic and para-aortic nodes should be carefully palpated and any enlarged nodes biopsied and sent for pathologic examination. Radiopaque clips should mark the biopsy site.
Methods of Treatment Vaginal hysterectomy has been used in stage Ia, grade 1 patients with good
results (100 patients, Mayo Clinic)-an 89 percent five-year survival.17 Vaginal hysterectomy is indicated in obese patients, patients with prolapse, elderly patients, or the poor medical risk patient. Disadvantages are that the ovary is left behind (five to ten percent of patients with endometrial carcinoma have ovarian metastasis); the abdomen cannot be explored and the status of pelvic and para-aortic nodes is unknown. The abdominal route is the surgical route of choice. Removal of the vaginal cuff at the time of hysterectomy does not decrease the incidence of vaginal metastases. Radical hysterectomy has been used but when pelvic nodes are positive the five-year survival is low and in patients with negative nodes, the five-year survival is no better than with lesser radi-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
cal surgery. Also the morbidity is greater because the patients are older, obese, diabetic, etc. Preoperative radium or cesium (Table 7), followed by hysterectomy in stage I disease, is indicated if the uterus sounds to 8 cm or less, if tumor is grade 1 or grade 2, or if adequate pelvic anatomy exists. Hysterectomy as initial treatment is indicated in patients with stage Ia (uterus 8 cm or less), grade 1 or grade 2 disease; if there is unfavorable pelvic anatomy due to small vagina, bicornuate uterus, conical vagina; if there exist medical problems such as preexisting thrombophlebitis, massive obesity (prolonged bed rest to be avoided); and if an adnexal mass is present. There is no significant difference in survival in the early well-differentiated 311
Table 6. Stage and Grade by Pelvic and Aortic Node Metastasis (140
Table 7. Survival Rates With Stage I Endometrial Adenocarcinoma as Related to Method of Therapy16
Patients)"5
Stage IA, Gl IA, G2 IA, G3 IB, Gl IB, G2 IB, G3
2.6 6.9 16.7 3.9 14.3 54.0
2.6
3.5 8.3 0.0 4.8 46.0
lesion if hysterectomy is utilized first.2 The advantages of this method are no delay for surgery, one less hospitalization, and one less anesthesia. Preoperative radium or cesium is preferred because it decreases the incidence of vaginal recurrence. In a collected series of 770 patients9 the incidence of vaginal recurrence was 10.3 percent if surgery alone was used, 4.6 percent when adjunctive preoperative radium was given, and 5.2 percent when postoperative radium was used. Postoperative cuff irradiation can be given via vaginal ovoids or lucite molds. Preoperative external irradiation and radium is indicated in patients whose uterine cavity measures more than 8 cm, and in patients with tumors of varying degrees of differentiation such as adenosquamous tumors, clear cell tumors, squamous cell tumors, and undifferentiated tumors. This form of therapy can also be used if the uterus is perforated at the time of dilatation and curettage (D & C), if there is cervical spread, or as complete therapy in patients in whom surgery is contraindicated. 312
Five-Year Survival Rates Gross (%/oJ Corrected(%)
Treatment
Number of Patients
Simple hysterectomy Radical hysterectomy and nodes Radical hysterectomy alone Preoperative radiation Postoperative radiation Radiation alone Other Totals
166
65
127 76 61 42 24 42 538
80 82 82 43 38 70 70
Percentage Aortic Pelvic
Conclusion Early endometrial carcinoma should not be considered a benign disease because of its poorer prognosis with undifferentiated disease, myometrial involvement, and lymph node spread. Abdominal hysterectomy is the mainstay of therapy after careful diagnostic evaluation. Adjunctive radiation therapy in the form of preoperative radium or cesium and external irradiation definitely improves the five-year survival rate.
Literature Cited 1. Kottemier HR (ed): Annual report on the results of treatment in carcinoma of the uterus, vagina, and ovary. Radiumhemmet, Stockholm,
vol 15(1974)
2. Keller D, Kempson RL, Levine G, et al: Management of the patient with early endometrial carcinoma. Cancer 33:1108-1116, 1974 3. Ng ABP: The cellular detection of endometrial carcinoma and its precursors. Gynecol Oncology 2:162-179, 1974
72 82 86 88 46 45 77 76
4. Anderson DG, Eaton CJ, Galinkin LT, et al: The cytologic diagnosis of endometrial adenocarcinoma. Am J Obstet Gynecol 125:376-383, 1976 5. Alfonso JF: Value of the Gravlee jet washer in the diagnosis of endometrial cancer. Obstet Gynecol 46:141-146, 1975 6. Creasman WT, Weed JC: Screening techniques in endometrial cancer. Cancer 38 (July suppl):436-440, 1974 7. Walters D, Robinson D, Park RC, et al: Diagnostic outpatient aspiration curettage. Obstet Gynecol 46:160-164, 1975 8. morrow CP, DiSaia PJ, Townsend DE: Current management of endometrial carcinoma. Obstet Gynecol 42:399-406, 1973 9. Jones HW Ill: Treatment of adenocarcinoma of the endometrium. Obstet Gynecol 30:147-169, 1975 10. Tak WK, Anderson B, Vardi JR, Beecham JB, et al: Myometrial invasion and hysterography in endometrial carcinoma. Obstet Gynecol 50:159-165, 1977 11. Nilsen PA, Koller 0: Carcinoma of the endometrium in Norway 1957-1960 with special reference to treatment results. Am J Obstet Gynecol 105:1099-1109, 1969 12. Frick HD II, Munnell EW, Richart RM, et al: Carcinoma of the endometrium. Am J Obstet Gynecol 115:663-676, 1973 13. Ng ABP: Mixed carcinoma of the endometrium. Am J Obstet Gynecol 102:506-515, 1968 14. Lewis BV, Stallworthy JA, Cowdell R: Adenocarcinoma of the body of the uterus. J Obstet Gynecol Br Comm 77:343-348, 1970 15. Creasman WT, Boronow RC, Morrow CP, et al: Adenocarcinoma of the endometrium: Its metastatic lymph node potential. Gynecol Oncology 4:239-243, 1976 16. Homesley H, Boronow R, Lewis JL: Treatment of adenocarcinoma of the endometrium at Memorial-James Ewing Hospital, 1949-1965. Obstet Gynecol 47:100-105, 1976 17. Pratt JH, Symmonds RE, Welch JS: Vaginal hysterectomy for carcinoma of the fundus. Am J Obstet Gynecol 98:663-674, 1967
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION,
VOL. 70, NO. 5,
1978
..
..
..
~ ~ ~ ~ ~ ~ ~ ~ ~ . .; ,:
~~~~.:: ~
j, ~
..
................
Diagnosis and Management of Early Carcinoma of the Endometrium Leslie A. Walton, MD Chapel Hill, North Carolina
Early (stage I) carcinoma of the endometrium is increasing in frequency. Outpatient diagnostic methods play a role in this increase. Prognostic factors such as histologic grade, uterine size, myometrial invasion, age, lymph node involvement, and cervical spread are important in determining five-year survival. Therapeutic options for early-stage disease are discussed.
Carcinoma of the endometrium has superceded carcinoma of the cervix as the primary cancer on many large gynecologic services in many areas of the country. The feeling that corpus cancer is a good cancer is not true. Kottmeier,' in a 1974 review of 18,000 corpus cancer cases throughout the world, noted a 62 percent five-year survival rate. In the past few years five-year survival figures approaching
Presented at the 82nd Annual Convention of the National Medical Association, Los Angeles, California, August 1-4, 1977. Requests for reprints should be addressed to Dr. Leslie A. Walton, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC 27514.
90 to 95 percent2 have been obtained in treating early-stage disease. It is claimed that the incidence of this disease is increasing. Factors affecting this increase include usage of estrogens and oral contraceptives, delayed menopause, increasing longevity of women, and the increasing use of diagnostic methods. If the yield from a large series of outpatient diagnostic techniques is collated, an average yield would be as documented in Table 1. As can be seen, methods involving direct sampling of the endometrium on an outpatient basis are usually reasonably accurate. Combination of some of these methods increases the accuracy to 100 percent. Once an outpatient diagnosis is made, plans for hospitalization can be simplified. The only other diagnostic uterine study needed, in addition to measurement of the uterine canal, is a thorough curettage of the endocervical canal. This can usually be
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
accomplished without anesthesia and without dilating the endocervix. The lower uterine segment should be studiously avoided in this sampling. Outpatient negative-pressure aspiration curettage has a good yield. However, factors such as cervical stenosis, obesity, enlarged uterus, uncooperative patient, and distortion of the endometrial cavity might necessitate hospitalization for diagnostic purposes. Thirty-two patients7 (Table 2) could not undergo outpatient curettage for reasons listed above. Before considering treatment of stage I carcinoma of the endometrium, certain factors are of important prognostic significance in planning therapy (Table 3). A review of a large series8 (Table 4) gives us some idea of the distribution of histologic grade. There is a slight predominance of grade 1 (welldifferentiated adenocarcinoma) histology but 57 percent of stage I patients 309
Table 1. Outpatient Detection of Endometrial Carcinoma3-6 Method
Accuracy (percentage)
Vaginal aspiration Pap smear Cervical scraping Endometrial brush sampling Endometrial aspiration
47
50 55 62 76
Gravlee jet wash Endometrial biopsy Vacuum aspiration
87-92 88-90 95-97
Table 2. Comparison of Results Using Aspiration Curettage and Sharp Curettage (300 Patients)7
Pathology
Endometrial cancer Hyperplasia Endometrial polyps (small) Endometrial polyps (large) Decidua Tissue insufficient for diagnosis Other benign lesions Total
have varying degrees of differentiation, ie, grade 2 or grade 3. In a collected series of 1,558 patients, there was an 81 percent five-year survival for patients with grade I tumor, 74 percent for grade 2, and 50 percent for grade 3 tumors.9 Tumor invasion of the myometrium carries a serious prognostic sign. While uterine enlargement may signify myometrial involvement, other conditions, eg, myomas and adenomyomas, may contribute to increased uterine size. Hysterography has been useful in localizing cavity tumors and recently has been shown to correlate with myometrial involvement. 10 This involvement is of extreme importance in planning therapy because the deeper the involvement of the myometrium, 310
Number of Patients Outpatient Hospital Aspiration Curettage (Sharp)
23
6 24
4
2
0
1
6
5
6
35
28
194 268
202 268
the lower the five-year survival. Also, the more undifferentiated the tumor, the greater the incidence of myometrial spread. In a large series (Table 5), it was shown that 28 percent of patients are expected to have significant myometrial involvement and require further treatment. Size of uterus is tremendously important. The International Federation of Gynecology and Obstetrics (FIGO) classification labels as enlarged, a uterus whose depth via measurement is greater than 8 cm. Patients with an enlarged uterus have a poorer prognosis. However, many studies question the contribution of uterine size to prognosis. Spread to the cervix, as determined by endocervical curettage, is important
in that the five-year survival rate drops by about 50 percent once the disease, which is normally found high in the fundus on the posterior wall, grows downward and begins to involve the endocervix, because now the potential for spread is different. Fundal disease can spread via the infundibulo-pelvic vessels to the aortic nodes without involving the pelvic nodes, or via the uterine and broad ligament lymphatics to the pelvic nodes. Corpus adenocarcinoma can spread to the cervix. When the cervix is involved the incidence of pelvic node involvement rises from 10.6 to 36.5 percent.8 Age at the time of diagnosis influences prognosis.11,12 Younger patients with carcinoma of the endometrium have a more favorable prognosis than
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
Table 3. Virulence Factors of Endometrial Carcinoma
Table 4. Endometrial Adenocarcinoma (Stage l): Grade Distribution8 Grade Distribution
Histologic grade of the tumor Involvement of the myometrium Size of the uterus Involvement of the cervix Advancing age Lymph node metastasis
Year
1
2
3
Gusberg, et al Roman, et al
1960 1967
204 47
85 106
Wade, et al Cheon Lewis, et al
1967 1969 1970
59
132
65 113 39
354 266 230
201 36
68 50
60 19
329
547 (42.6%)
441 (34.3%)
296
1,284
(23.1%)
(% of Total)
older patients because the older patients have tumors that are more poorly differentiated13 and, thus, have greater myometrial involvement. Lymph node involvement carries a worsening prognosis. The more undifferentiated the tumor, the greater the myometrial spread and the higher the incidence of pelvic and aortic node involvement (Table 6).1114,15 Lymph node involvement beyond the pelvis can help explain the low five-year survival rate previously mentioned.
Treatment
Total Cases
Author
105
Table 5. Endometrial Adenocarcinoma (Stage I): Incidence of Myometrial Invasion8 Author
Year
Gusberg, et al Hirabyashi and Graham Austin and MacMahon Sall, et al Lewis, et al Lewis
1960
Number of Patients
1968 1969 1970 1970 1972
Total
Myometrial Moderate and deep invasion invasion
(%)
(%)
87 (29.7) 54 (23.2)
131
195 (66.6) 174 (74.7) 402 (75.1) 125 (51.4) 91 (85.0) 84 (64.1)
1,542
1,071 (69.4)
293 233 535 243 107
163 (30.5) 50 (20.6) 50 (46.7) 31 (23.7)
435 (28.2)
The argument as to how patients with stage I carcinoma of the en-
dometrium should be treated is gradually being resolved in favor of using some form of preoperative irradiation followed by hysterectomy and salpingo-oophorectomy. In most centers, this involves a short-interval radium system followed by a simple extra-fascial hysterectomy with careful pathological sectioning of the uterus to confirm the degree of differentiation and ascertain the degree of myometrial involvement. At the time of hysterectomy, pelvic and para-aortic nodes should be carefully palpated and any enlarged nodes biopsied and sent for pathologic examination. Radiopaque clips should mark the biopsy site.
Methods of Treatment Vaginal hysterectomy has been used in stage Ia, grade 1 patients with good
results (100 patients, Mayo Clinic)-an 89 percent five-year survival.17 Vaginal hysterectomy is indicated in obese patients, patients with prolapse, elderly patients, or the poor medical risk patient. Disadvantages are that the ovary is left behind (five to ten percent of patients with endometrial carcinoma have ovarian metastasis); the abdomen cannot be explored and the status of pelvic and para-aortic nodes is unknown. The abdominal route is the surgical route of choice. Removal of the vaginal cuff at the time of hysterectomy does not decrease the incidence of vaginal metastases. Radical hysterectomy has been used but when pelvic nodes are positive the five-year survival is low and in patients with negative nodes, the five-year survival is no better than with lesser radi-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
cal surgery. Also the morbidity is greater because the patients are older, obese, diabetic, etc. Preoperative radium or cesium (Table 7), followed by hysterectomy in stage I disease, is indicated if the uterus sounds to 8 cm or less, if tumor is grade 1 or grade 2, or if adequate pelvic anatomy exists. Hysterectomy as initial treatment is indicated in patients with stage Ia (uterus 8 cm or less), grade 1 or grade 2 disease; if there is unfavorable pelvic anatomy due to small vagina, bicornuate uterus, conical vagina; if there exist medical problems such as preexisting thrombophlebitis, massive obesity (prolonged bed rest to be avoided); and if an adnexal mass is present. There is no significant difference in survival in the early well-differentiated 311
Table 6. Stage and Grade by Pelvic and Aortic Node Metastasis (140
Table 7. Survival Rates With Stage I Endometrial Adenocarcinoma as Related to Method of Therapy16
Patients)"5
Stage IA, Gl IA, G2 IA, G3 IB, Gl IB, G2 IB, G3
2.6 6.9 16.7 3.9 14.3 54.0
2.6
3.5 8.3 0.0 4.8 46.0
lesion if hysterectomy is utilized first.2 The advantages of this method are no delay for surgery, one less hospitalization, and one less anesthesia. Preoperative radium or cesium is preferred because it decreases the incidence of vaginal recurrence. In a collected series of 770 patients9 the incidence of vaginal recurrence was 10.3 percent if surgery alone was used, 4.6 percent when adjunctive preoperative radium was given, and 5.2 percent when postoperative radium was used. Postoperative cuff irradiation can be given via vaginal ovoids or lucite molds. Preoperative external irradiation and radium is indicated in patients whose uterine cavity measures more than 8 cm, and in patients with tumors of varying degrees of differentiation such as adenosquamous tumors, clear cell tumors, squamous cell tumors, and undifferentiated tumors. This form of therapy can also be used if the uterus is perforated at the time of dilatation and curettage (D & C), if there is cervical spread, or as complete therapy in patients in whom surgery is contraindicated. 312
Five-Year Survival Rates Gross (%/oJ Corrected(%)
Treatment
Number of Patients
Simple hysterectomy Radical hysterectomy and nodes Radical hysterectomy alone Preoperative radiation Postoperative radiation Radiation alone Other Totals
166
65
127 76 61 42 24 42 538
80 82 82 43 38 70 70
Percentage Aortic Pelvic
Conclusion Early endometrial carcinoma should not be considered a benign disease because of its poorer prognosis with undifferentiated disease, myometrial involvement, and lymph node spread. Abdominal hysterectomy is the mainstay of therapy after careful diagnostic evaluation. Adjunctive radiation therapy in the form of preoperative radium or cesium and external irradiation definitely improves the five-year survival rate.
Literature Cited 1. Kottemier HR (ed): Annual report on the results of treatment in carcinoma of the uterus, vagina, and ovary. Radiumhemmet, Stockholm,
vol 15(1974)
2. Keller D, Kempson RL, Levine G, et al: Management of the patient with early endometrial carcinoma. Cancer 33:1108-1116, 1974 3. Ng ABP: The cellular detection of endometrial carcinoma and its precursors. Gynecol Oncology 2:162-179, 1974
72 82 86 88 46 45 77 76
4. Anderson DG, Eaton CJ, Galinkin LT, et al: The cytologic diagnosis of endometrial adenocarcinoma. Am J Obstet Gynecol 125:376-383, 1976 5. Alfonso JF: Value of the Gravlee jet washer in the diagnosis of endometrial cancer. Obstet Gynecol 46:141-146, 1975 6. Creasman WT, Weed JC: Screening techniques in endometrial cancer. Cancer 38 (July suppl):436-440, 1974 7. Walters D, Robinson D, Park RC, et al: Diagnostic outpatient aspiration curettage. Obstet Gynecol 46:160-164, 1975 8. morrow CP, DiSaia PJ, Townsend DE: Current management of endometrial carcinoma. Obstet Gynecol 42:399-406, 1973 9. Jones HW Ill: Treatment of adenocarcinoma of the endometrium. Obstet Gynecol 30:147-169, 1975 10. Tak WK, Anderson B, Vardi JR, Beecham JB, et al: Myometrial invasion and hysterography in endometrial carcinoma. Obstet Gynecol 50:159-165, 1977 11. Nilsen PA, Koller 0: Carcinoma of the endometrium in Norway 1957-1960 with special reference to treatment results. Am J Obstet Gynecol 105:1099-1109, 1969 12. Frick HD II, Munnell EW, Richart RM, et al: Carcinoma of the endometrium. Am J Obstet Gynecol 115:663-676, 1973 13. Ng ABP: Mixed carcinoma of the endometrium. Am J Obstet Gynecol 102:506-515, 1968 14. Lewis BV, Stallworthy JA, Cowdell R: Adenocarcinoma of the body of the uterus. J Obstet Gynecol Br Comm 77:343-348, 1970 15. Creasman WT, Boronow RC, Morrow CP, et al: Adenocarcinoma of the endometrium: Its metastatic lymph node potential. Gynecol Oncology 4:239-243, 1976 16. Homesley H, Boronow R, Lewis JL: Treatment of adenocarcinoma of the endometrium at Memorial-James Ewing Hospital, 1949-1965. Obstet Gynecol 47:100-105, 1976 17. Pratt JH, Symmonds RE, Welch JS: Vaginal hysterectomy for carcinoma of the fundus. Am J Obstet Gynecol 98:663-674, 1967
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION,
VOL. 70, NO. 5,
1978
