Cancer involves abnormal cells growing uncontrollably, invading nearby tissues, and spreading to other parts of the body through metastasis.
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When a patient presents with postmenopausal bleeding or abnormal menstruation, the first diagnostic tool utilized is Transvaginal Ultrasound (TVUS). This non-invasive imaging modality allows the clinician to visualize the uterus and, critically, to measure the thickness of the endometrium (Endometrial Stripe). A probe is inserted into the vagina, placing the ultrasound transducer in proximity to the uterus for high-resolution images.
In postmenopausal women, the endometrial stripe is usually thin and atrophic due to estrogen deficiency. A thickness of 4 millimeters or less has a very high negative predictive value, indicating that cancer is extremely unlikely. If the stripe measures greater than 4 or 5 millimeters, or if the lining appears irregular, cystic, or fluid-filled, further tissue sampling is mandatory.
In premenopausal women, evaluation is more complex because endometrial thickness varies naturally throughout the menstrual cycle. In this population, ultrasound is used to look for focal masses (polyps), heterogeneity, or abnormal vascularity rather than a strict thickness cutoff. TVUS also helps evaluate the ovaries to rule out estrogen-producing ovarian tumors that could be causing the bleeding.
However, a blind biopsy can miss focal cancers (tumors growing in just one small spot) or may be impossible if the patient has cervical stenosis (a narrowed opening). If the office biopsy is non-diagnostic, inconclusive, or if symptoms persist despite a benign result, a Dilation and Curettage (D&C) with Hysteroscopy is performed under anesthesia.
Hysteroscopy involves inserting a camera into the uterus to inspect the cavity visually. This allows the surgeon to visualize the tumor directly and perform targeted biopsies of any suspicious lesions or polyps. This is the gold standard for diagnosis as it provides a visual map of the disease and ensures a representative sample is obtained. The tissue is then graded by a pathologist (Grade 1, 2, or 3) based on the extent to which the cancer cells have deviated from standard glandular architecture.
Once a diagnosis is confirmed, assessing the local and distant extent of the disease is crucial for surgical planning. Magnetic Resonance Imaging (MRI) of the pelvis with contrast is the superior modality for local staging. It provides excellent soft-tissue contrast, allowing radiologists to determine the depth of myometrial invasion (how deep the cancer has eaten into the muscle wall) and whether the cancer has spread downwards into the cervical stroma. Knowing the depth of invasion helps surgeons decide whether to remove lymph nodes.
Computed Tomography (CT) scans of the chest, abdomen, and pelvis are used to detect distant metastases to the lungs, liver, or abdominal lymph nodes. While less sensitive for the uterus itself, CT is vital for ruling out widespread disease.
Positron Emission Tomography (PET-CT) is increasingly utilized, particularly for high-grade tumors (serous or clear cell) or when recurrence is suspected. PET-CT detects metabolic activity, highlighting lymph nodes or peritoneal implants that might look normal on size criteria but contain active cancer cells.
Endometrial cancer is staged surgically according to the International Federation of Gynecology and Obstetrics (FIGO) system. This system correlates strongly with survival and dictates adjuvant treatment.
Stage I: The cancer is confined to the uterus.
Accurate staging requires a comprehensive surgery, including hysterectomy and often lymph node assessment. Pathological staging (examining the removed tissues) is final and determines the need for radiation or chemotherapy.
A significant advancement in surgical staging is Sentinel Lymph Node (SLN) mapping. Historically, surgeons performed a complete lymphadenectomy, removing all lymph nodes in the pelvis and along the aorta to check for spread. This caused significant morbidity, including lymphedema (chronic leg swelling).
SLN mapping involves injecting a fluorescent dye (Indocyanine Green) into the cervix at the beginning of the surgery. The dye travels through the lymphatic channels to the first draining nodes—the “sentinels.” The surgeon uses a near-infrared camera to find and remove just these specific nodes.
If the sentinel nodes are negative for cancer, it is statistically safe to assume the remaining nodes are also negative, sparing the patient a complete dissection. This technique provides accurate staging information with significantly lower risk of surgical complications and long-term lymphedema. “Ultra-staging” by the pathologist involves slicing these nodes very thinly to find even microscopic cancer cells (micrometastases).
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No. A thickened lining can be caused by many benign things, including polyps (benign fleshy growths), fibroids pushing into the cavity, or simple hyperplasia (overgrowth) that hasn’t turned into cancer yet. However, a biopsy is always needed to distinguish between the two.
Not always. For low-grade, early-stage cancers found on biopsy, surgeons may proceed directly to surgery. However, MRI is invaluable if the doctor suspects the cancer is advanced or if fertility-sparing treatment is being considered, to ensure the cancer hasn’t gone too deep.
“Grade” describes what the cancer cells look like under the microscope (how aggressive they look). “Stage” describes how far the cancer has spread in the body. You can have a high-grade (aggressive-looking) tumor that is caught at Stage I (hasn’t spread), or a low-grade tumor that is Stage IV. Both factors are essential.
Lymph fluid drains from the uterus into the lymph nodes in the pelvis. Cancer cells can detach and float into these nodes before they spread to other organs. Finding cancer in the nodes (Stage III) completely changes the treatment plan, requiring chemotherapy or radiation that wouldn’t be given otherwise.
The biomarker CA-125 is sometimes used. While it is an ovarian cancer marker, it can also be elevated in advanced or recurrent endometrial cancer, mainly if the cancer has spread outside the uterus. If it is high at diagnosis, it can be tracked later to check for the cancer coming back.
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