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Carcinoma Endometrium
By Sidra Javed
08-182
Batch J
Final yr MBBS
What is Carcinoma ?
A carcinoma is tumor tissue derived from
epithelial cells whose genome has become
altered to such an extent that it begin to
exhibit abnormal malignant properties.
What is Endometrial carcinoma ?
• Endometrial carcinoma arises from epithelial
tissues in the lining of glands and columnar
cells constituting the surface of the
endometrium.
Why it is important ?
• Commonest gynecological cancer
in USA and many other western
countries.
• Fourth most common cancer in
women in developed countries.
Who are at risk ?
1. AGE
1. Peak incidence
about 55-60 years
of life.
2. 25 % are
premenopausal.
2. Parity
50 % have born only one or two child.
25 % are nulliparous.
3. Late Menopause
4. Obesity
3- 10 times greater risk.
5. Estrogen over activity
Estrogen producing
tumors. (POD)
Continuous Estrogen only
replacement therapy
6. Endometrial hyperplasia
Atypical hyperplasia has highest risk.
( 40-60 %)
7 . Diabetes mellitus. 3x risk
8. Hypertension
9. Radiation
10. Family history
( hereditary non polyposis colon cancer)
Protective effect
• Smoking
• Oral contraceptive.
• Progesterone.
Tell me its Types
Endometrial Carcinoma
Type 1(80%)1. 50 -55 years.
2. Adenocarcinoma
3. Endometrial Hyperplasia
4. PTEN, KRAS, p53, B.catenin.
5. less aggressive, lymphatic spread.
6. Low grade, good prognosis
7. Unopposed estrogen action.
Type 2(20%)
1. 65-75 years.
2. Serous , clear, mixed mullarian
3. Endometrial intraepithelial
carcinoma.
4. P53, aneulploidy.
5. Aggressive intraperitoneal and
lymphatic spread.
6. High grade, poor prognosis
7. Not related to estrogen.
Taken from Robbins and Cotran.
Histopathology
Grade 1 : Well differentiated, less than 5% solid growth. (40%)
Grade 2 : Moderately differented, less than 50% solid growth. (20%)
Grade 3 : Poorly differented , greater than 50% solid growth.( 40%)
1-Adenocarcinomas 80-85%
2-Adenocarcinoma with squamous differentiation
5%
• Malignant glands with benign squamous metaplasia
• Also subdivided into 3 grades
3-Adenosquamous Ca 10-20%
• Malignant glands & malignant squamous epithelium
• Often grade 3
4-Papillary Serous CA 10%
5-Clear cell CA 4%
6-Mucinous CA 9%
7-Secretory CA 1-2%
8-Squamous cell CA extremely rare
How It will present ?
Symptoms.
1. Bleeding
• Post menopausal bleeding in 75% of cases.
• In premenopausal , irregular menstruation
and menorrghia.
• Small, rarely heavy
2. Vaginal discharge and spotting.
. Brownish or blood stained vaginal discharge.
3. Pain.
. During urination, intercourse
.In lower abdomen.
.Dull or colicky pain.
Signs
• No typical signs.
• Distant metastasis causes indurations in the parametrical tissues, and inguinal lymph node may become palpable.
How it spreads?
1. Direct Spread .
2. Through Lymphatic.
• Never occurs without myometrial invasion
• Pelvic lymph nodes common 35%
• Para-aortic lymph nodes 10-20%
Rarely involved without pelvic nodes
involvement
• Inguinal lymph nodes rare
Through blood
•Less common route
•Involved in late stage of disease
•Occurs with recurrent or disseminated disease
4. Implantation
• Malignant cells implantation in vagina during hysterectomy.
How I will diagnose it ?
1. History
2. Examination
• Physical examination of the patient with endometrial
carcinoma is frequently entirely normal, it should include
palpation of supraclavicular and inguinal lymph nodes .
• Inspection of vulva, vaginal skin in suburethral area
and cervix. ( Pyogenic discharge in case of pyometra)
• Bimanual vaginal examination assesses uterine size, and mobility
Investigations
• Ultrasonography
• In postmenopausal UGS shows irregular and
polypoidal endometrium
• If thickness of endometrium is more than
5mm it require further investigations.
• Endometrial sampling.
Histological investigation is
investigation of choice for diagnosis of endometrial
carcinoma.
Fractional Curettage HysteroscopyBiopsy
Fractional Curettage
• Uterine cavity and endocervix is thoroughly curetted.
• In the past the “gold standard” was Fractional
curettage.
• The current “gold standard” is hysteroscopy
with targeted endometrial biopsy
Others
• MRI depth of carcinoma invasion and Lymph
node involvement
• Chest X-Ray exclude pulmonary spread.
Differential Diagnosis
• Various causes of abnormal bleeding
• Endometrial hyperplasia
• Endometrial & Cervical polyps
• Fibroid
• Ovarian, Cervical or tubal neoplasm
• Postmenopausal Pt atrophic vaginitis, endometrial
atrophy, exogenous estrogens
• Trauma
How it is treated ?
• Depends upon the Stage of disease and health
of patient.
• Primary treatment is surgery.
• Radiotherapy, chemotherapy can be used in
patient with metastatic and recurrent disease.
Stage I
IA Tumor limited to endometrium
IB Invasion <50% of myometrium
IC Invasion > 50% of myometrium
Treatment of choice of Stage I
• Pelvic nodes removal and radiotherapy is
recommended if more than 1/3rd of
myometrium is invaded.
• Radiotherapy is not recommended for very
early tumor for IA and IB.
Stage II
IIA Endocervical glandular involvement only.
IIB Cervical stroma invasion.
Radial hysterectomy with pelvic lymphodectomy
followed by radiotherapy or radiotherapy alone.
Stage III
IIIA Tumor invade to serosa or adnexae or positive
peritoneal cytology.
IIIB Vaginal metastases
IIIC Metastasis to pelvic and para-aortic lymph node.
• If disease is restricted to pelvis than radiotherapy
alone is treatment of choice.
• Otherwise laparotomy recommended for accurate
staging and tumor debulking.
Stage IV
IVA Tumor invade bladder and bowl mucosa.
IVB Distant metastasis.
Aim is to relief the patient
• Radiotherapy.
• Debulking through palliative surgery.
• Cytotoxic drugs.
• Hormonal therapy.
• Progestogens
The role of chemotherapy is limited
• Anthracycline.
• Doxorubine.
• platinum drugs
Adjuvant hormonal therapy
Inj. Medoxyprogesterone.
Inj hydroxyprogesterone caproate.
Tab. Norethisterone.
Follow up
Prognosis
The 5 year survival rate for endometrial Ca :
• Stage I 75%
• Stage II 58%
• Stage III 30%
• Stage IV 10%
• Overall 5 year survival 70% most Patients
present early due to abnormal vaginal bleeding.
So we know
• Endometrial carcinoma
• Its etiology, signs and symptoms.
• Its diagnosis, treatment and prognosis.