What are the diagnostic and treatment approaches for uterine tumors?

Diagnostic and Treatment Approaches for Uterine Tumors

The primary approach to diagnosing uterine tumors requires endometrial biopsy for epithelial tumors and advanced imaging for mesenchymal tumors, with treatment determined by tumor type, staging, and patient factors. 1

Initial Diagnostic Evaluation

• About 90% of patients with endometrial carcinoma present with abnormal vaginal bleeding, most commonly in the postmenopausal period 1

• Initial evaluation should include:

  • Endometrial biopsy (office procedure with 10% false-negative rate) 1, 2
  • If office biopsy is negative in a symptomatic patient, fractional dilation and curettage (D&C) under anesthesia is required 1
  • Hysteroscopy may be helpful for evaluating lesions like polyps in cases of persistent or recurrent bleeding 1
  • Chest imaging (chest X-ray) 1

• For mesenchymal tumors (sarcomas), endometrial biopsy may not be accurate; imaging is essential 1, 3

Imaging Recommendations

• Transvaginal ultrasound is the initial imaging modality for evaluating uterine tumors 2, 4
• MRI is preferred for characterizing uterine masses, especially for:
  • Distinguishing between benign and malignant tumors 5
  • Assessing depth of myometrial invasion 1
  • Evaluating disease limited to the endometrium in fertility-sparing cases 1
• CT scan and/or PET/CT may be used to assess disease extent and evaluate for metastatic disease 1, 3
• Suspicious ultrasound features for leiomyosarcoma include irregular tumor border, loss of normal myometrium, necrosis, and cystic degeneration 4

Laboratory Testing

• Serum CA-125 may be helpful in monitoring clinical response in patients with extrauterine disease 1
  • Note: CA-125 can be falsely elevated with peritoneal inflammation/infection or radiation injury 1
• Consider genetic testing for patients <50 years of age or those with significant family history of endometrial and/or colorectal cancer 1

Classification of Uterine Tumors

Epithelial Tumors

• Pure endometrioid adenocarcinoma
• Uterine serous adenocarcinoma
• Clear cell adenocarcinoma
• Carcinosarcoma (malignant mixed Müllerian tumor) 1

Stromal/Mesenchymal Tumors

• Endometrial stromal sarcoma (ESS)
• High-grade (undifferentiated) endometrial sarcoma
• Uterine leiomyosarcoma (uLMS) 1
• Benign leiomyomas (fibroids) - most common, affecting up to 80% of women 5, 6

Staging

• FIGO staging system is most commonly used 1
• Clinical staging is inaccurate in 15-20% of patients 1
• Surgical/pathologic staging provides more accurate assessment of:
  • Histologic grade
  • Myometrial invasion
  • Extent and location of extrauterine spread 1

Treatment Approaches

Endometrial Carcinoma

Early-Stage Disease (Confined to Uterus)

• Primary treatment: Total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO) and surgical staging 1
• Fertility-sparing options may be considered if ALL criteria are met:
  • Well-differentiated (grade 1) endometrioid adenocarcinoma
  • Disease limited to the endometrium on MRI or transvaginal ultrasound
  • No suspicious or metastatic disease on imaging
  • No contraindications to medical therapy 1

Suspected Cervical Involvement

• Total hysterectomy or radical hysterectomy with surgical staging 1
• External beam radiation therapy (EBRT) + brachytherapy ± systemic therapy 1

Medically Inoperable Patients

• Tumor-directed radiotherapy or hormone therapy in select patients 1

Uterine Sarcomas

• Primary treatment is surgical with total hysterectomy and BSO 1
• For low-grade endometrial stromal sarcoma (ESS):
  • Conservative surgery may be appropriate in young patients with stage I disease 1
• For high-grade sarcomas and leiomyosarcoma:
  • More aggressive surgical approach with complete staging 1
• Adjuvant therapy:
  • Platinum-based chemotherapy for advanced stage or recurrent disease 1
  • BEP regimen (bleomycin, etoposide, cisplatin) is commonly used 1

Special Considerations

Lynch Syndrome

• Women with Lynch syndrome have up to 60% lifetime risk for endometrial cancer 1
• Recommendations:
  • Yearly endometrial biopsy for screening 1
  • Prophylactic hysterectomy/BSO after childbearing is complete 1
  • Annual colonoscopy for colorectal cancer screening 1

Preoperative Diagnosis of Suspected Sarcomas

• Ultrasound-guided needle biopsy may be helpful for uterine tumors with suspected malignancy on MRI 7
• Sensitivity of 91.7% and specificity of 100% for detecting malignancy 7

Monitoring and Surveillance

• Physical examination every 3-6 months for 2 years, then every 6 months or annually 1
• Vaginal cytology every 6 months for 2 years, then annually 1
• Annual chest X-ray 1
• CT/MRI as clinically indicated 1