Carcinoma of the endometrium

The incidence of endometrial cancer is highest among relatively affluent Ca ucasians. Although it has a comparatively low mortality rate compared with other gynaecological cancers, it is capable of aggressive behaviour. Endome trial cancer is uncommon in premenopausal women. The incidence rises with a ge and is significantly increased when there is exposure to unopposed estro gen, including hormone replacement therapy (HRT). Even when HRT is given in the form of estrogen and cyclical progesterone there is probably some incr eased risk. The long term use of tamoxifen for breast cancer is also associ ated with an increased incidence of endometrial cancer. Transvaginal ultrasound and pipelle or hysteroscopy endometrial biopsies ar e tending to replace the traditional dilation and curettage in establishing a diagnosis. 90% of endometrial tumours are surgically resectable on presentation. This remains the first line management - minimally, a total abdominal hysterecto my and bi-lateral salpingo oophorectomy. Prognostic factors include the his tological grade, the depth of invasion of the myometrium, the presence or a bsence of lymph-vascular space invasion and involved regional nodes, tumour volume, and the presence or absence of involvement of the cervix. The pelv is is a major anatomical site at risk of recurrence, and since cytotoxic ch emotherapy and hormone therapies have limited effectiveness, radiotherapy i s the adjuvant therapy of choice where adverse prognostic factors are prese nt. A move towards more radical surgery - the addition of lymphadenectomy with a total abdominal hysterectomy and bi-lateral salpingo oophorectomy, may mo dify the value of adjuvant therapy and has highlighted the need to demonstr ate the exact place of post operative radiotherapy in the management of end ometrial cancer. The ASTEC trial in the UK, run by the Medical Research Cou ncil, has the dual aims of determining the benefit of lymphadenectomy and o f post operative adjuvant radiotherapy in patients with endometrial cancer confined to the corpus. Patients who are not medically fit for surgery or who have inoperable disea se are managed with radical radiotherapy but the results in both these grou ps are inferior to those obtained with radical surgery. Spread outside the pelvis to paraaortic nodes may still be salvaged with local irradiation, bu t systemic disease is incurable and treatment is largely palliative includi ng consideration of local irradiation, hormone therapy or chemotherapy for symptomatic relief. As reliable techniques for diagnosis are refined an even larger proportion of patients will be diagnosed with early disease. This, together with the d evelopment of new cytotoxic agents and sophisticated radiotherapy technique s to reduce normal tissue morbidity, will require the establishment of furt her clinical trials to refine optimal management.