Endometrial CancerEndometrial Cancer
Tseng Jen-Yu
02/05/2007Tseng Jen-Yu
02/05/2007
OverviewOverview Origin => Uterine endometrial lining Most common gynecologic malignancy 35,000 cases diagnosed each year Resulting in 4000 ~ 5000 deaths Normally occurs in postmenopausal Average age at diagnosis => 60 y/o < 5% under age of 40 Lifetime risk: 1.1% Lifetime risk of dying: 0.4%
Origin => Uterine endometrial lining Most common gynecologic malignancy 35,000 cases diagnosed each year Resulting in 4000 ~ 5000 deaths Normally occurs in postmenopausal Average age at diagnosis => 60 y/o < 5% under age of 40 Lifetime risk: 1.1% Lifetime risk of dying: 0.4%
Estrogen dependent disease Prolonged exposure without the balancing effects o
f progesterone Premalignant potential
Endometrial hyperplasia Simple => 1% Complex => 3% Simple with atypia => 8% Complex with atypia => 29%
Estrogen dependent disease Prolonged exposure without the balancing effects o
f progesterone Premalignant potential
Endometrial hyperplasia Simple => 1% Complex => 3% Simple with atypia => 8% Complex with atypia => 29%
Incidence and PrevalenceIncidence and Prevalence Most common gynecologic cancer 4th most common in women (US) 2nd most common in women (UK) 5th most common in women (worldwide) Western developed > Southeast asia 35,000 new cases annually 5,000 death annually Increase in the 1970’s
Increased use of menopausal estrogen therapy
Most common gynecologic cancer 4th most common in women (US) 2nd most common in women (UK) 5th most common in women (worldwide) Western developed > Southeast asia 35,000 new cases annually 5,000 death annually Increase in the 1970’s
Increased use of menopausal estrogen therapy
TypesTypes 90% endometrial adenocarcinoma Arise from the epithelium Tumor grading
Grade 1 Well differentiated
Grade 2 Moderately differentiated with solid component
Grade 3 Poorly differentiated with solid sheets of tumor
90% endometrial adenocarcinoma Arise from the epithelium Tumor grading
Grade 1 Well differentiated
Grade 2 Moderately differentiated with solid component
Grade 3 Poorly differentiated with solid sheets of tumor
10% rare cell types Papillary serous carcinoma Clear cell carcinoma Papillary endometrial carcinoma Mucinous carcinoma
Rarer cancers Onset at later age Greater risk for metastases Poorer prognosis 50% of treatment failure
10% rare cell types Papillary serous carcinoma Clear cell carcinoma Papillary endometrial carcinoma Mucinous carcinoma
Rarer cancers Onset at later age Greater risk for metastases Poorer prognosis 50% of treatment failure
Risk FactorsRisk Factors Obesity
Excess weight have 2 ~ 5 x greater risk Fat cells (adipocytes) produce estrogen
Diabetes Mellitus and Hypertension DM women have 2 x greater risk
Nulliparity Progesterone counterbalances estrogen Pregnancy lowers risk
Obesity Excess weight have 2 ~ 5 x greater risk Fat cells (adipocytes) produce estrogen
Diabetes Mellitus and Hypertension DM women have 2 x greater risk
Nulliparity Progesterone counterbalances estrogen Pregnancy lowers risk
Early Menarche and Late Menopause Associated with more estrogen exposure
Estrogen Replacement Therapy Place women at high risk Risk reduced when + progesterone
Tamoxifen Anti-estrogenic drug for breast cancer Side effect
Induces non-cancerous uterine tumors Some may develop into endometrial cancer Long term use => endometrial cancer Only 1 in 500 develop endometrial cancer
Early Menarche and Late Menopause Associated with more estrogen exposure
Estrogen Replacement Therapy Place women at high risk Risk reduced when + progesterone
Tamoxifen Anti-estrogenic drug for breast cancer Side effect
Induces non-cancerous uterine tumors Some may develop into endometrial cancer Long term use => endometrial cancer Only 1 in 500 develop endometrial cancer
Genetic Predisposition Risk may approach 50% in some families
Previous Cancer History of breast / colon / ovarian cancer are at
increased risk Time interval can be as long as 10 years
Diet Association is still unclear Diet rich in animal fat and protein => risk ^ Diet rich in vegetable, fruits, grain=> risk v
Genetic Predisposition Risk may approach 50% in some families
Previous Cancer History of breast / colon / ovarian cancer are at
increased risk Time interval can be as long as 10 years
Diet Association is still unclear Diet rich in animal fat and protein => risk ^ Diet rich in vegetable, fruits, grain=> risk v
Reduced RiskReduced Risk Oral Contraceptives
Combined OC => 50% reduced rate Actual reduction number small because
uncommon in women of child bearing age Long term offers protection Reduced risk presumably => progesterone
Tobacco Smoking Some evidence that it reduces the rate Smokers have lower levels of estrogen and lower
rate of obesity
Oral Contraceptives Combined OC => 50% reduced rate Actual reduction number small because
uncommon in women of child bearing age Long term offers protection Reduced risk presumably => progesterone
Tobacco Smoking Some evidence that it reduces the rate Smokers have lower levels of estrogen and lower
rate of obesity
Prevention and SurvivalPrevention and Survival Early detection is best prevention Treating precancerous hyperplasia
Hormones (progestin) D&C Hysterectomy 10 ~ 30% untreated develop into cancer
Average 5 year survival Stage I => 72 ~ 90% Stage II=> 56 ~ 60% Stage III => 32 ~ 40% Stage IV => 5 ~ 11%
Early detection is best prevention Treating precancerous hyperplasia
Hormones (progestin) D&C Hysterectomy 10 ~ 30% untreated develop into cancer
Average 5 year survival Stage I => 72 ~ 90% Stage II=> 56 ~ 60% Stage III => 32 ~ 40% Stage IV => 5 ~ 11%
SignsSigns Postmenopausal vaginal bleeding Abnormal uterine bleeding
Bleeding in between periods Heavier / longer lasting menstrual bleeding
Abnormal vaginal discharge / Pyometra Pelvic or back pain Pain on urination Pain on sexual intercourse Blood in stool or urine
Postmenopausal vaginal bleeding Abnormal uterine bleeding
Bleeding in between periods Heavier / longer lasting menstrual bleeding
Abnormal vaginal discharge / Pyometra Pelvic or back pain Pain on urination Pain on sexual intercourse Blood in stool or urine
DiagnosisDiagnosis Endometrial sampling
Dilation and curettage / Endometrial aspiration Image
TVS / CT scan / MRI Standard
Hysteroscopy + targeted biopsy Tumor marker
Ca 125 / 199 Cystoscope / Proctoscope
Endometrial sampling Dilation and curettage / Endometrial aspiration
Image TVS / CT scan / MRI
Standard Hysteroscopy + targeted biopsy
Tumor marker Ca 125 / 199
Cystoscope / Proctoscope
Staging Staging Stage I
Tumor confined to uterine body Stage Ia
Tumor limited to endometrium Stage Ib
Tumor invades less than ½ of myometrium Stage Ic
Tumor invades more than ½ of myometrium
Stage II Tumor extends to the cervix Stage IIa
Cervical extension limited to endocervical glands Stage IIb
Tumor invades cervical stroma
Stage I Tumor confined to uterine body Stage Ia
Tumor limited to endometrium Stage Ib
Tumor invades less than ½ of myometrium Stage Ic
Tumor invades more than ½ of myometrium
Stage II Tumor extends to the cervix Stage IIa
Cervical extension limited to endocervical glands Stage IIb
Tumor invades cervical stroma
Stage III Regional tumor spread Stage IIIa
Tumor invades serosa / adnexa / peritoneum / ascites (+)
Stage IIIb Vaginal involvement / metastases present
Stage IIIc Tumor spread to pelvic LN
Stage IV Bulky pelvic disease or distant spread Stage IVa
Tumor has spread to bladder or rectum
Stage IVb Distant metastases present / inguinal LN
Stage III Regional tumor spread Stage IIIa
Tumor invades serosa / adnexa / peritoneum / ascites (+)
Stage IIIb Vaginal involvement / metastases present
Stage IIIc Tumor spread to pelvic LN
Stage IV Bulky pelvic disease or distant spread Stage IVa
Tumor has spread to bladder or rectum
Stage IVb Distant metastases present / inguinal LN
SpreadSpread Direct spread
Through endometrial cavity to the cervix Through fallopian tubes to ovary / peritoneum Invade myometrium reaching serosa Rare: invasion to pubic bone
Lymphatic spread Pelvic and para-aortic LN Inguinal LN ( rare )
Hematogenous spread Rare but may spread to lungs
Direct spread Through endometrial cavity to the cervix Through fallopian tubes to ovary / peritoneum Invade myometrium reaching serosa Rare: invasion to pubic bone
Lymphatic spread Pelvic and para-aortic LN Inguinal LN ( rare )
Hematogenous spread Rare but may spread to lungs
TreatmentTreatment Surgery
Early stage ( I and II ) Typical surgery is ATH + BSO + BPLND VTH + BSO + laparoscopic BPLND LAVH + BPLND
Advanced stage Debulking surgery Radiotherapy +/- hormone / chemotherapy
Surgery Early stage ( I and II )
Typical surgery is ATH + BSO + BPLND VTH + BSO + laparoscopic BPLND LAVH + BPLND
Advanced stage Debulking surgery Radiotherapy +/- hormone / chemotherapy
Radiation External beam pelvic radiation
Reserve use of radiotherapy until post-ATH Adjuvant radiation therapy is controversial Regional pelvic radiation proven to decrease pelvic r
ecurrence Not necessarily improve survival rate Most beneficial for patients with tumor confined to th
e pelvis Patients with increased likelihood of recurrence
( Stage Ic to IIIc) Brachytherapy
Prevent vaginal cuff recurrence
Radiation External beam pelvic radiation
Reserve use of radiotherapy until post-ATH Adjuvant radiation therapy is controversial Regional pelvic radiation proven to decrease pelvic r
ecurrence Not necessarily improve survival rate Most beneficial for patients with tumor confined to th
e pelvis Patients with increased likelihood of recurrence
( Stage Ic to IIIc) Brachytherapy
Prevent vaginal cuff recurrence
Hormonal therapy Progesterone => for metastatic cancer Less than 20% response rate
Chemotherapy No clear results on effectiveness Potentially most useful in metastatic cancer Not as important as surgery and radiation Only used in advanced or recurrent tumor after
definitive treatment with surgery and radiation
Hormonal therapy Progesterone => for metastatic cancer Less than 20% response rate
Chemotherapy No clear results on effectiveness Potentially most useful in metastatic cancer Not as important as surgery and radiation Only used in advanced or recurrent tumor after
definitive treatment with surgery and radiation
RecurrenceRecurrence Likely in women with advanced disease Within 3 years of original diagnosis Hormone therapy can be considered Use of chemotherapy is being evaluated External beam pelvic radiation or brachyth
erapy
Likely in women with advanced disease Within 3 years of original diagnosis Hormone therapy can be considered Use of chemotherapy is being evaluated External beam pelvic radiation or brachyth
erapy
Thank you for your attentionThank you for your attention
Top Related