Endometriosis

Disease Description (Causes and Symptoms)

• Definition and pathophysiology: Endometrial cancer is a malignant tumor arising from the endometrium, which lines the inside of the uterus. It is commonly called “cancer of the uterine corpus,” and it often develops through endometrial hyperplasia → malignant transformation (type I, endometrioid) caused mainly by persistent stimulation of the endometrium by estrogen (unopposed estrogen). In contrast, cell types associated with older age and non-hormonal pathophysiology (serous, clear cell, etc., type II) are often unrelated to estrogen and have a poor prognosis.
• Main causes and risk factors:
  • Atypical endometrial hyperplasia
  • Early menarche and late menopause (increased estrogen exposure)
  • Obesity, insulin resistance/diabetes
  • Exogenous estrogen alone (without progesterone protection)
  • Tamoxifen use (a breast cancer treatment)
  • Nulliparity (infertility), late menopause, thyroid disease, family history (particularly associated with Lynch syndrome)
• Main symptoms:
  • Postmenopausal vaginal bleeding (the most common symptom)
  • Abnormal uterine bleeding (heavy menstrual bleeding, irregular bleeding, amenorrhea)
  • Pelvic pain, lower abdominal discomfort, increased vaginal discharge
• Clinical features: Most cases are diagnosed at an early stage (stage I, confined to the uterus), so the treatment prognosis is relatively favorable.

Treatment Methods and Precautions

• Standard treatment (localized and early-stage disease)
  • Surgery: Total hysterectomy + bilateral salpingo-oophorectomy is the standard.
  • Lymph node examination/dissection (pelvic and para-aortic lymph nodes): Considered in the following cases
    • Cases that are not low-grade (very poorly differentiated)
    • Tumor size ≥ 2 cm (when moderately differentiated)
    • High-risk non-endometrioid epithelial histologies (serous, clear cell, papillary serous, etc.)
    • Myometrial invasion of at least half the thickness of the endometrium
    • Suspected cervical involvement
• Adjuvant treatment
  • Radiation therapy: Pelvic radiation or intravaginal radiation (brachytherapy) is used to reduce the risk of recurrence or to treat lymph node metastasis. It is selectively administered after considering complications (bone marrow suppression, organ dysfunction, etc.).
  • Chemotherapy: For advanced/metastatic disease, the standard is usually combination therapy such as carboplatin + paclitaxel.
  • Hormone therapy: Progestins (medroxyprogesterone, mifepristone/high-dose progestins, etc.) may be used in patients who wish to preserve fertility or who have unresectable, hormone receptor-positive locally advanced disease.
  • Targeted and immunotherapy: Applied according to molecular markers
    • MSI-High/dMMR: Immune checkpoint inhibitors (e.g., pembrolizumab) may be considered
    • pMMR non-specific/advanced disease: Combination of lenvatinib + pembrolizumab (guidelines and insurance coverage must be confirmed)
    • HER2-positive histology (particularly serous): Targeted therapy such as trastuzumab may be considered
• Complications and precautions (including self-management)
  • Risk of infection, bleeding, and venous thromboembolism after surgery; possible intestinal or bladder injury
  • Chronic complications after radiation: intestinal obstruction, bladder and vaginal dysfunction, leg swelling, etc.
  • Systemic side effects of chemotherapy (vomiting, bone marrow suppression, neuropathy, etc.)
  • Monitoring for thrombotic risk, weight gain, etc. is needed during hormone therapy
  • Lifestyle management: Weight loss and control of blood glucose and blood pressure; smoking cessation is recommended

Checklist Before an Outpatient Visit (Items to Bring and Example Questions)

• Items to bring
  • A list of all medications and supplements currently being taken (including tamoxifen and hormone medications)
  • Past medical history (including a family history of breast cancer, colorectal cancer, Lynch syndrome, etc.) and surgical and biopsy reports, including pathology results
  • Recent imaging results (pelvic ultrasound, CT/MRI) and dates of the examinations
  • Results of recent blood tests (CBC, blood glucose, etc.), if available
  • A note recording menstrual history (timing of menarche and menopause) and the onset, pattern, and duration of bleeding
  • Whether you are pregnant and any pregnancy plans, if applicable
  • Weight, height (BMI), and lifestyle habits (smoking, alcohol consumption, exercise)
• Examples of questions patients may find useful to write down before the visit
  • The timing and pattern of the bleeding (how it differs from menstruation), and the location, intensity, and aggravating factors of the pain
  • Any previous gynecologic examinations or biopsies (history and dates)

Examples of General Questions to Ask the Doctor

• “What does my stage mean (the expected stage before and after surgery), and what is my overall prognosis?”
• “What are the expected benefits and major side effects of the treatment you recommended (surgery/radiation/chemotherapy/hormone therapy)?”
• “What is the recurrence rate after surgery, and what will the follow-up examinations involve (frequency and tests)?”
• “Do you recommend genetic testing (e.g., MSI/dMMR or Lynch-related testing) or molecular testing?”

Examples of Disease-Specific Questions

• “How should I interpret the cancer subtype (e.g., endometrioid vs. serous), grade, depth of myometrial invasion, and whether there is cervical involvement as shown in my biopsy (or pathology report)? How do these results affect the need for lymph node dissection and the prognosis?”
• “If I wish to become pregnant in the future, can conservative treatment (such as progestin therapy) be attempted? What are the possible conditions, recurrence risk, and follow-up methods?”

Note: Specific diagnosis and treatment plans, whether medications should be administered, and the need for examinations should be determined through consultation with the treating doctor.