ENDOMETRIAL CARCINOMA

AHMED FARRASYAH BIN MOHD KUTUBUDIN

071303511

BATCH 24

GROUP A2

1. What are types of endometrial hyperplasia?2. What are types of endometrial ca and the

commonest type? 3. What are the clinical features ?4. What are the investigations that should be done?5. In which lesion spontaneous regression is possible?6. What is mode of treatment?

1. Simple endometrial hyperplasia without atypiaComplex endometrial hyperplasia without atypiaSimple endometrial hyperplasia with atypiaComplex endometrial hyperplasia with atypia

2. adenocarcinoma,serous ca,clear cell adenocarcinoma,secondary metastasis

3. postmenopausal bleed,offensive vaginal discharge,pelvis discomfort

4. tvs,pelvic examination,endometrial biopsy(pipelle sampling),hysteroscopy,cxr,MRI

5. simple hyperplasia without atypia6. surgical/hormonal

Thorough intraperitoneal explorationPeritoneal washingExtrafascial hysterectomy and bilateral salphingoophorectomyPelvic with or without paraaortic lymphadenectomyOmentectomy- in advanced cases if omentum is involved

THANK YOU

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Diagnosis:

• Primary assessment in all cases is with transvaginal ultrasound and pelvic examination.

• All postmenopausal patients with an endometrial thickness >5mm or persistent bleeding despite a normal endometrial thickness should have an endometrial biopsy

• If the endometrium is difficult to identify then hysteroscopy should be considered.

• The value of endometrial thickness in perimenopausal bleeding is questionable as the thickness range is variable.

• Hysteroscopy should be used as a diagnostic tool only when ultrasound results are inconclusive

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Clinical features

• >90%: postmenopausal bleeding.– Usually 20% of those who come with post

menopausal bleed will have a carcinomatous origin. Out of those, 50% will be due to endometrial carcinoma.

• offensive vaginal discharge• Discomfort in the pelvis (not always)• Uterine enlargement in advanced disease• Vaginal metastases particularly in the

lower third.

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INTRODUCTION

• Endometrial carcinoma is the commonest gynaecological cancer in the developed world with a rising incidence in postmenopausal women.

• The crude incidence of endometrial carcinoma in the European Union is 16 cases/100 000 women/year

• Uterine cancer effects the lining of the uterus (endometrium). It is the fourth most common cancer in women in Peninsular Malaysia.

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Endometrial carcinoma

Type 1

- Related to hyperestrogenism associated with endometrial

hyperplasia

- Frequent expression of estrogen and progesterone

- Younger age

Type 2

- Unrelated to estrogen associated with atrophic endometrium

- Lack of estrogen and progesterone receptors

- Older age

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Risk factors:

• age: peak (65-75 years old)• Obesity[rcog]

• nulliparity• late menopause• polycystic ovary syndrome• Estrogen replacement therapy• Chronic diseases: DM, hypertension • family history of endometrial, ovarian or intestinal

malignancy• past history of breast, ovarian or intestinal malignancy.

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Endometrial hyperplasia

Classification of endometrial hyperplasia %

Simple endometrial hyperplasia without atypia 1

Complex endometrial hyperplasia without atypia 3

Simple endometrial hyperplasia with atypia 8

Complex endometrial hyperplasia with atypia 29

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Histopathology:

1. Endometriod adenocarcinoma– Most common type ~75-80%

2. Serous carcinoma– ~10% of all cases– Has papillary growths which resembles serous

carcinoma of ovary and Fallopian tubes3. Other cell types

– 4%-Clear cell adenocarcinoma– Secondary metastasize from breast, stomach, colon,

pancreas, kidney, ovary

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Investigations:

• After confirming the diagnosis the objectives of further investigations are todetermine the extent of diseasedetermine suitable treatment.

• Endometrial biopsy using pipelle sampling with sensitivity of 81-99% and specificity of 98%.

• A chest X-ray is essential. • An MRI scan: lymph node metastases and

the presence of occult cervical involvement.

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Treatment: (premalignant lesions)

• Spontaneous regression is possible in simple hyperplasia without atypia (72% cases)

• Most important determinant for the choice of treatment is presence of atypia.

• Treatment of others either hormonally/surgically

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Endometrial hyperplasia

Simple hyperplasia

Expectant/ progesterone Rx

Complex hyperplasia

premenopause

Progesterone Rx, USG, repeat

curettage

postmenopause

Progesterone Rx, USG, repeat

curettage/ hysterectomy

Atypical hyperplasia

prememopause

Progesterone Rx, USG, repeat

curettage/ hysterectomy

postmenopause

Simple hysterectomy

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Surgical

• The most important mode of treatment• Consists of:

– Maylard’s incision (if early) or midline (if advanced)– Thorough intraperitoneal exploration– Peritoneal washing– Extrafascial hysterectomy and bilateral

salphingoophorectomy– Peliv with or without paraaortic lymphadenectomy– Omentectomy- in advanced cases if omentum is

involved.

radiotherapy

• Only applied adjuvant or if patient is unstable for surgical treatment

• Indications include– Grade 3 tumours– Myometrial invasion >50%– Histology- clear cell ca of uterine papillary

serous carcinoma– Cervical involvment– Lymph node involvment– Lymphovascular space involvment

Chemotherapy

• Use of adjuvant chemotherapy has been used in recent years

• The combination of doxorubicin + cisplatin + paclitaxel significantly improve overall survival

• Because of toxicity considerations, an alternative option may be the combination of carboplatin and paclitaxel

• HRT: continuous combined therapy may be theoretically most appropriate for post operative patients with persistent climacteric symptoms (low dose progestin).

Prognosis:

STAGE 5 YEAR SURVIVAL (%)

I 75

II 58

III 30

IV 10

REFERENCE

1. Endometrial cancer incidence statistic, Srdjan Saso, published 6/7/11

http://www.bmj.com/content/343/bmj.d3954, last viewed on 26/6/13.

2. Incidence of endometrial cancer in Malaysia(2007): http://www.malaysiaoncology.org/article.php?aid=297

3. The New FIGO Staging for Carcinoma of the Vulva, Cervix, Endometrium, and Sarcomas (2009)

http://www.medscape.com/viewarticle/722721

4. Karlsson B, Granberg S, Wikland M et al. (1995) Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding – a Nordic multicentre study. Am J Obstet Gynecol, 172, 1488-94.

5. Clark TJ, Barton PM, Coomarasamy A et al. (2006) Investigating postmenopausal bleeding for endometrial cancer: cost-effectiveness of initial diagnostic strategies. Br J Obstet Gynaecol, 113, 502-10.

6. Creutzberg CL, van Putten WL, Koper PC et al. (2000) Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group . Lancet; 35, 1404-11.

7. North Wales Cancer Guidelines, Endometrial Cancer (April 2008)

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THANK YOU