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Session13 - Endometrial Ca

Endometrial hyperplasia occurs when there is an excessive thickening of the endometrium due to an imbalance of estrogen and progesterone. It is usually caused after menopause when ovulation stops. Left untreated, endometrial hyperplasia can progress to endometrial cancer. Diagnosis involves endometrial biopsy and treatment depends on the histologic findings and patient factors. Endometrial cancer risk increases with age and long-term exposure to unopposed estrogen. Diagnosis is usually made after evaluation of postmenopausal bleeding and staging determines prognosis and treatment.

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288 views27 pages

Session13 - Endometrial Ca

Endometrial hyperplasia occurs when there is an excessive thickening of the endometrium due to an imbalance of estrogen and progesterone. It is usually caused after menopause when ovulation stops. Left untreated, endometrial hyperplasia can progress to endometrial cancer. Diagnosis involves endometrial biopsy and treatment depends on the histologic findings and patient factors. Endometrial cancer risk increases with age and long-term exposure to unopposed estrogen. Diagnosis is usually made after evaluation of postmenopausal bleeding and staging determines prognosis and treatment.

Uploaded by

CHALIE MEQU
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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Endometrial Hyperplasia

06/27/2021 Kindu.Y 1
Introduction
o Endometrium thickens every month in preparation for pregnancy.

o If pregnancy does not occur, the lining is shed-menstrual period or


menstruation.

o This entire process is controlled by estrogen & progesterone.

o Estrogen is responsible for building up the uterine lining, and


progesterone maintains and controls this buildup.

06/27/2021 Kindu.Y 2
o The endometrium measures b/n 8 & 12 mm by the end of the
follicular phase & 10 to 14 mm in the secretary phase.

o If the hormones are out of balance or not available- excessive


growth of the cells lining the uterus endometrial hyperplasia.

o An excessive or abnormal thickening of the endometrium


endometrial overgrowth.

o Most cases of endometrial hyperplasia are benign

06/27/2021 Kindu.Y 3
When does endometrial hyperplasia occur?
o Usually after menopause, when ovulation stops & progesterone is no
longer made.

o During perimenopause, when ovulation may not occur regularly.

o Estrogen therapy without taking progesterone

o Use of medications that act like estrogen

o Long-term use of high doses of estrogen after menopause

o Chronic diseases : DM, Obesity

06/27/2021 Kindu.Y 4
Risk factors of endometrial hyperplasia
o Age >35 years

o Late menopause and early menarche

o Cigarette smoking

o Unopposed estrogen exposure

o Hormone replacement therapy

o Obesity, Anovulation , PCOS

06/27/2021 Kindu.Y 5
Types of endometrial hyperplasia

 Simple or complex based on the absence or presence of architectural


abnormalities (glandular complexity & crowding).

o Simple hyperplasia - abnormally thickened endometrium with


histologic evidence of ↑ed ratio of glands to stroma; the glands are
cystically dilated & somewhat irregular with some infolding &
budding.

o Complex hyperplasia- glandular crowding with even less intervening


stroma, & the glands show significant infolding & budding.

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 Atypical if they demonstrate cytologic (i.e., nuclear) atypia.

o Atypical hyperplasia-either simple or complex architectural patterns.

o Most atypical hyperplasias have a complex architecture.

o Only atypical endometrial hyperplasias are clearly associated with


the subsequent development of adenocarcinoma

06/27/2021 Kindu.Y 7
06/27/2021 Kindu.Y 8
Clinical features
o The most common sign is abnormal uterine bleeding.

 Changes in menstrual periods-heavy or prolonged menstrual bleeding,


irregular menstrual periods ( menorrhagia ,metrorhagia)

 Any bleeding after menopause (Postmenopausal vaginal bleeding )

 Pain during sexual intercourse

06/27/2021 Kindu.Y 9
Diagnosis
o History + P/E + laboratory tests (hormone levels) + endometrial
biopsy.

o Endometrial biopsy- (97% sensitive) & indicated for AUB ≥35 years
with AUB nonresponding to medication.

o TVS for endometrial thickness

06/27/2021 Kindu.Y 10
Management

 Depends on histologic criteria predisposing factors, patient age, &


desire to maintain fertility.

o TAH and BSO for

 Atypical hyperplasia (about 40% risk of coexisting


adenocarcinoma and 29% malignant potential).
 A truly postmenopausal woman (last menses 2 or more years
ago)
o Progestin therapy: very poor surgical candidates or patients who
desire fertility
06/27/2021 Kindu.Y 11
Progestin therapy
o Reverse endometrial hyperplasia by activation of progesterone
receptors- stromal decidualization- thinning of the endometrium

o ↓ estrogen receptors

o Activate hydroxylase enzymes to convert estradiol to its less active


metabolite estrone.

o Progestin is given orally, in IUD, or as a vaginal cream.

06/27/2021 Kindu.Y 12
Complications of endometrial hyperplasia

1. Absenteeism from work or school

2. Anemia

3. Endometrial cancer

4. Infertility

5. AUB

06/27/2021 Kindu.Y 13
Endometrial Cancer

06/27/2021 Kindu.Y 14
Epidemiology
o Worldwide, 527,600 women were diagnosed with uterine cancer

o The mortality rate was 1.7 to 2.4 per 100,000 women

o Most common gynecologic malignancy in developed countries

o The incidence and mortality rate increases with age

06/27/2021 Kindu.Y 15
Risk factors
o Long time exposure to an opposed estrogen

o Obesity

o PCOS

o Early age of menarche

o Family history

o Late age of menopause

o Coexisting medical condition

o Smoking has protective effect ???


06/27/2021 Kindu.Y 16
Type of endometrial cancer

o Type I: is associated with either endogenous or


exogenous unopposed estrogen and usually consist
of a low grade or well differentiated tumor and good
prognosis.

o Type II: tumor grow independent of estrogen and are


associated with endometrial atrophy.

o The histopathology of this type is poorly


differentiated.

06/27/2021 Kindu.Y 17
Histopathology

Endometrioid carcinoma: is the most common type of EC,


accounting for 75 to 80 percent of cases.
 These tumors are stimulated by estrogen, are typically are
preceded by endometrial hyperplasia
 present at an early stage, and have a good prognosis

Mucinous carcinoma: these tumors are typically low grade with a


good prognosis.

 biopsy results of a mucinous EC may be difficult to interpret and


this tumor may confused with endocervical adenocarcinoma
06/27/2021 Kindu.Y 18
Serous carcinoma: is the 2nd most common type of EC but only accounts for
about 10% of cases.
 most serous endometrial carcinomas have a worse prognosis.

Clear cell carcinoma: is an uncommon histologic type (<5%) of EC.


 like serous carcinoma, this tumor is typically high grade and often
presents at an advanced stage.
 clear cell carcinomas are typically negative for estrogen receptor
protein.

Mixed cell tumors: mixed carcinoma with both endometrioid and high-
grade non-endometrioid patterns (usually serous) may occur.
06/27/2021 Kindu.Y 19
Diagnosis

 Signs and Symptoms

o Early diagnosis of endometrial cancer is almost entirely


dependent on the prompt recognition and evaluation of irregular
vaginal bleeding.

o In premenopausal women, a clinician must maintain a high index


of suspicion:
 for a history of prolonged, heavy menstruation or intermenstrual
spotting.
 because many other benign disorders give rise to similar symptoms.
06/27/2021 Kindu.Y 20
o Postmenopausal bleeding is particularly worrisome and carries a 5 to
10% likelihood of diagnosing endometrial carcinoma.

o Abnormal vaginal discharge may be another symptom in older


women.

o In more advanced disease, pelvic pressure and pain may reflect


uterine enlargement or extra-uterine tumor spread.

06/27/2021 Kindu.Y 21
Endometrial Sampling
o Office biopsy is preferred for the initial evaluation of women with
bleeding suspicious for malignancy.

o However, if sampling techniques fail to provide sufficient diagnostic


information or if abnormal bleeding persists, D & C may be required
to clarify the diagnosis.

o The ACOG considers hysteroscopy acceptable for AUB evaluation in


those without advanced-stage uterine or cervical cancer.

06/27/2021 Kindu.Y 22
Laboratory Testing
o The only clinically useful tumor marker in the management of
endometrial cancer is a serum CA125 level.

o Preoperatively, an elevated level indicates the possibility of more


advanced disease.

o In practice, it is most useful in patients with advanced disease or


serous subtypes to assist in monitoring response to therapy or during
post treatment surveillance.

06/27/2021 Kindu.Y 23
Stages of Endometrial Cancer

Stage I: Cancer that is confined to the uterus.

Stage II: Cancer that has spread to the cervix.

Stage III: Cancer that has spread to the vagina, ovaries, and/or lymph
nodes.

Stage IV: Cancer that has spread to the urinary bladder, rectum, or
organs located far from the uterus, such as the lungs or bones

06/27/2021 Kindu.Y 24
Management of low risk women

 Low-risk endometrial cancer is defined as


 cancer limited to the endometrium
 cancer that is not a high-risk histologic type (e.g., clear cell,
serous)
o Not require adjuvant therapy
o Reproductive-age women with low-risk endometrial carcinoma
are candidates for progestin therapy
o have an excellent prognosis with a low recurrence risk and
expected survival of ≥90%
06/27/2021 Kindu.Y 25
Management of high risk women

 Patients are classified as having high-risk endometrial


cancer if they have any of the following:
 Serous adenocarcinoma (any stage)
 Clear cell adenocarcinoma (any stage)
 deeply invasive endometrioid carcinoma
 pathologic stages III/IV disease

o Management will be Radiotherapy, chemotherapy or


surgery based on the stage
06/27/2021 Kindu.Y 26
THANK YOU

06/27/2021 Kindu.Y 27

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