Background
Most common gynaecological carcinoma in
developed countries
Japan and Asia have 5 times lower incidence
Most cases are post-menopausal
< 5% under age of 40 ( hyperestrogenic )
At diagnosis 75% have Stage 1 disease
OBESITY strong link as peripheral conversion to Estrone
SHBG(sex hormone binding globulin) decrease with an increase in FREE estrogen for uptake in target tissues
Lifetime risk: 1.1%
Lifetime risk of dying: 0.4%
5-year survival rates are considered to be
good at around 75%
The prognosis is generally good because the majority
of patients are diagnosed in an early stage
Role of hormones (estrogen)
Estrogen dependent disease
Prolonged exposure without the balancing effects of progesterone
Conditions of Estrogen excess
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
Reduced 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
Physical exercise and fruit vegetables diet
Endometrial Carcinoma: aetiology
Hyperoestrogenic states
Age - mainly 60-70 years (late menopause)
Parity - nulliparity, relative infertility
Metabolic disorders [Cancer Triad]
Obesity, Diabetes, Hypertension
Ovarian tumours
granulosa cell tumour, PCOD
unopposed Exogenous oestrogens [HRT]
other conditions
leiomyomas; adenomyosis, endometriosis, breast Ca
Risk factors
- Usually in postmenopausal women
- Unapposed estrogen stimulation
- Preceded by endometrial hyperplasia
- Simple hyperplasia
Adenomatous hyperplasia
Cellular Atypia
Clinical Features
Abnormal bleeding
mainly postmenopausal
intermenstrual or pre-menstrual
menorrhagia
Lower abdominal pain
abnormal vaginal discharge / pyometra
Endometrial Carcinoma
Diagnosis
Endometrial sampling
Dilation and curettage / Endometrial aspiration
Image
TVS / CT scan / MRI
Standard
Hysteroscopy + targeted biopsy
Tumor marker
Ca 125 / 199
Cystoscope / Proctoscope
Prevention
Early detection is best prevention
Treating precancerous hyperplasia
Hormones (progestin)
Hysterectomy
10 ~ 30% untreated develop into cancer
Histology/ grade
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
Rare cell types
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
Spread
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
Adenocarcinoma uterus
Intraoperatively obtained gross specimen of the uterus, bivalved in a sagittal plane, shows deep invasion (50% of the myometrial thickness) of endometrial carcinoma
Stage 1 Tumour confined to corpus
Stage 1a <50% myometrial invasion
Stage 1b >50% myometrial invasion
Stage 2 Tumour invades Cx stroma
Stage 3 Local/regional tumour spread
3a Invades serosa/+- adnexa
3b Vaginal or parametrial spread
3c1 Positive pelvic nodes
3c2 Positive para-aortic nodes
Stage 4 Invades bladder/bowel/distant
Treatment of endometrial hyperplasia/ carcinoma
Endometrial hyperplasia
Excessive stimulation of the uterine endometrium results in endometrial hyperplasia
Imbalance of hormones or hormonal changes can happen around the time of menopause, and contribute to the development of hyperplasia in some women.
Endometrial hyperplasia of the uterus, by itself, is not cancerous, but requires treatment and monitoring to prevent the risk of cancer.
Managing endometrial hyperplasia
Uterine hyperplasia can get worse, leading to atypical and precancerous cellular changes.
This is why any woman with hyperplasia is considered to be at a higher risk for cancer than one without hyperplasias.
investigate thickened endometrium,
hyperplasia can lead to uterine cancer —
early identification and intervention for uterine abnormalities is highly successful.
The evaluation process begins with a
speculum and bimanual exam
(internal exam and external palpation of the pelvic organs)
An ultrasound and tissue sampling
with endometrial biopsy, hysteroscopy and/or D&C
Hormonal treatment of endometrial hyperplasia
hyperplasia without atypia
progesterone/progestin therapy for three months,
then to retest the endometrium.
Provera
micronized natural progesterone at high doses
Atypia present
option for women who want to wait or avoid surgery altogether is Megace (megestrol acetate), a very potent, orally administered hormonal agent.
Ca Endometrium Treatment Algorithms
Clinical Stage I
TAH BSO
( Grade? Depth? Cell type ?)
Low Risk ~ 75%
Observation
High Risk ~ 25%
EBRT to pelvis
(but~13% have PA nodes)
Treatment of endometrial cancer
Stage II
Consider radical hysterectomy
With macroscopic tumor on cervix:
Consider a cervical cancer
Intra-abdominal spread:
Remove all tumor if possible
Advanced stage
Debulking surgery
Radiotherapy
+/- hormone / chemotherapy
Recurrence
Likely in women with advanced disease
Within 3 years of original diagnosis
Hormone therapy can be considered
External beam pelvic radiation or brachytherapy.
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