Endometrial carcinoma
- 1. ENDOMETRIAL CARCINOMA Dr Sunita Samal Professor Dept of Obs & Gyn
- 2. A 60yr old postmenopausal obese women presented with bleeding p/v for last 10-15 days
- 4. • Most common cancer in developed countries • Disease of postmenopausal age (6th-7th decade) • 75% occur after 50yr of age • Types: -Type I, estrogen-related, endometrioid - Type II, non-estrogen-related nonendometrioid
- 5. Risk factors • Age>50,postmenopausal • Race: caucasian • Prolonged/unopposed oestrogen: obesity, nulliparity, PCOS early menarche, late menopause anovulatory infertility HRT(only oestrogen therapy) oestrogen secreting ovarian tumour • Tamoxifen therapy (2-3times more risk) • DM, HTN (corpus cancer syndrome) • HNPCC syndrome • Germ line mutation: p53, PTEN
- 6. Precursors • Simple hyperplasia– 1% • Simple hyperplasia with atypia-8% • Complex hyperplasia– 3% • Complex hyperplasia with atypia—28% 30-40% of endometrial cancers are found in a background of atypical hyperplasia. Overall, these tend to be lower grade tumors
- 7. • DECREASED RISK Oral contraceptive use Nonmedicated plastic or copper intrauterine device (IUD) use Consumption of some phytoestrogens, such as isoflavones and lignans Diet rich in fruits, vegetables, and fiber Physical activity Cigarette smoking
- 8. Screening • Routine screening not recommended & not cost effective • High risk women: TVS, Endometrial sampling
- 9. Patients in Whom a Diagnosis of Endometrial Cancer Should Be Excluded
- 10. Histological grading • Endometroid adenocarcinoma(80%) • Mucinous carcinoma • Serous carcinoma • Clear cell carcinoma • Squamous cell carcinoma • Mixed cell carcinoma • Undiffrentiated carcinoma
- 11. Clinical Features • 90% abnormal vaginal bleeding, most commonly postmenopausal bleeding, occurs early in the course of the disease. • Intermenstrual bleeding or heavy prolonged bleeding • The diagnosis may be delayed, usually ascribed to “hormonal imbalance.” • A high index of suspicion for early diagnosis in women < 40 years of age. • No vaginal bleeding: cervical stenosis, particularly in thin, elderly, estrogen-deficient patients. • Hematometra: In some patients with cervical stenosis • pyometra :a small percentage have a purulent vaginal discharge
- 12. • Physical exam: -obese, hypertensive, postmenopausal woman, 1/3rd not overweight. • Abdominal exam : -unremarkable except in advanced cases: ascites and palpable hepatic or omental metastases - hematometra: a large, smooth midline mass arising from the pelvis. • Pelvic exam: -inspect and palpate the vulva, vagina, and cervix. - uterus may be bulky, often not significantly enlarged. • Rectovaginal examination : - the fallopian tubes, ovaries, and cul-de-sac. - endometrial carcinoma may metastasize to these sites - Coexistent ovarian tumors such as a granulosa cell tumor, thecoma, epithelial ovarian carcinoma
- 13. • Pattern of spread: - direct extension -lymphatic spread -hematogenous - retrograde transtubal
- 14. Clinical evaluation • History • Physical examination • TVS: endometrial thickness>5mm • Sonosalpingography • Endometrial tissue for histology -office biopsy (pipelle), (false negative 10%) - FC • Hysteroscopy
- 16. • Fractional Curettage -under anesthesia, - bimanual rectovaginal examination - speculum is placed in the vagina - the cervix is grasped with a tenaculum. - endocervical canal is curetted before cervical dilatation, -The uterus then is sounded, the cervix dilated, and the endometrium systematically curetted. - The tissue is placed in a separate container so that the histopathologic status of the endocervix and endometrium can be determined separately.
- 17. Routine pre-op investigations • Full blood count • Serum creatinine and electrolytes • Liver function tests • Blood sugar • Urinalysis • Chest x-ray, ECG • CT scan of chest, pelvis, and abdomen, particularly for high-risk histologies
- 18. Pelvic and abdominal CT scan MRI may be helpful to determine the extent of metastatic disease in the following circumstances: • abnormal liver function test results • clinical hepatomegaly • palpable upper abdominal mass • palpable extrauterine pelvic disease • clinical ascites • grade 3 endometrioid or nonendometrioid carcinomas
- 19. Treatment • Staging laparotomy: adequate abdominal incision peritoneal washings for cytology exploration of pelvis & abdomen extrafascial hysterectomy b/l salpingo-oopherectomy Pelvic & paraaortic lymphadenectomy advanced stage- cytoreductive surgery
- 20. • Lymphadenectomy can be omitted: stage1A, grade 1, <2cm tumor size with non- clear cell or non-papillary serous type • Infracolic omentectomy: serous and clear cell histology
- 23. Prognostic factors Race FIGO stage Depth of myometrial invasiona Tumor gradea Histologic subtypea Cervical involvement Adnexal involvement Positive pelvic washings Metastases to the pelvic or paraaortic lymph nodes Lymph-vascular space invasion DNA aneuploidy
- 24. Post-operative Adjuvant therapy Radiotherapy: • vaginal brachytherapy • External radiation pelvic radiation extended-field radiation whole abdominal radiation Chemotharapy: stage III IV and recurrent cancer • cisplatin • paclitaxel • doxorubicin • cyclophosphamide
- 25. Hormone therapy • Progestin therapy: 1. young women- stage1A, grade1, child bearing desired 2. stage III, IV as adjuvant therapy • Tamoxifen & other SERM
- 29. THANK YOU