What is the management approach for an endometrial mass?

Management of Endometrial Mass

The standard management for an endometrial mass is total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO), preferably using a minimally invasive approach, with appropriate surgical staging based on risk factors. 1, 2

Diagnostic Evaluation

• Initial diagnosis requires histopathological confirmation:

  • Dilatation and curettage (D&C) is superior to pipelle biopsy for accurate tumor grading 1
  • Hysteroscopy with directed biopsy is an alternative approach 2
  • Histological diagnosis should be reviewed by an expert gynaecopathologist 1

• Imaging for staging:

  • Pelvic MRI is the preferred imaging modality to assess myometrial invasion and adnexal involvement 1, 2
  • Expert ultrasound can be considered as an alternative 1
  • CT scanning is optimal for evaluating para-aortic nodal involvement 2

Management Algorithm

1. For Standard Cases (Non-Fertility Preserving)

• Surgical approach:

  • Total hysterectomy with bilateral salpingo-oophorectomy 1, 2
  • Minimally invasive approach (laparoscopic or robotic) when feasible 2
  • Peritoneal fluid collection/washings during surgery 1
  • Thorough exploration of abdominal cavity and nodal areas 1

• Lymph node assessment:

  • Sentinel lymph node mapping for apparent uterine-confined disease 2
  • Complete lymphadenectomy if sentinel mapping is unavailable or positive 2
  • Systematic pelvic and para-aortic lymphadenectomy for high-risk disease 2

• Adjuvant therapy based on risk stratification:

  • Low risk (Stage Ia/Ib, grade 1-2, endometrioid): No adjuvant therapy 1
  • Intermediate risk: Pelvic radiotherapy reduces local recurrence 1
  • High risk: Pelvic radiotherapy plus consideration of chemotherapy 1

2. For Fertility-Preserving Cases

• Strict eligibility criteria:

  • Limited to patients with atypical hyperplasia/endometrial intraepithelial neoplasia (AH/EIN) or grade 1 endometrioid endometrial carcinoma (EEC) 1
  • No evidence of myometrial invasion on MRI 1
  • Patient must be referred to specialized centers 1

• Treatment options:

  • Medroxyprogesterone acetate (MPA; 400–600 mg/day) or megestrol acetate (MA; 160–320 mg/day) 1, 3
  • Levonorgestrel-releasing intrauterine device (LNG-IUD) with or without GnRH analogues is an alternative 1
  • Assessment of response at 6 months with repeat D&C and imaging 1

• Follow-up and management:

  • If complete response: Encourage conception and refer to fertility clinic 1
  • If no response after 6 months: Standard surgical treatment 1
  • After completion of childbearing: Standard treatment with hysterectomy and salpingo-oophorectomy 1, 2

Special Considerations

• Response rates with conservative management: Approximately 75%, but recurrence rates are 30-40% 1

• Risk factors for poor outcomes:

  • Grade 3 histology
  • Deep myometrial invasion (>50%)
  • Cervical involvement
  • Lymphovascular space invasion
  • Non-endometrioid histology 1

• Pitfalls to avoid:

  • Inadequate initial histological sampling leading to undergrading
  • Omitting expert pathology review
  • Failure to perform appropriate imaging for staging
  • Using tamoxifen for hormonal treatment (may be pro-estrogenic) 1
  • Delaying standard treatment after failed conservative management

Follow-up Recommendations

• For standard treatment: Clinical evaluations every 3-4 months for first 3 years, then every 6 months for years 4-5, and annually thereafter 1

• For fertility-preserving treatment: Endometrial sampling every 3-6 months 2

The management of endometrial masses requires a systematic approach with proper diagnosis, staging, and risk stratification to guide treatment decisions. While fertility preservation is possible in select cases, the standard of care remains surgical management with appropriate adjuvant therapy based on risk factors.