Download the fourth most common

Endometrial Carcinoma
Fuat Demirkıran, MD
Istanbul University, Cerrahpaşa
School Of Medicine, OB&GYN
Department, Gyn Oncology
In developed countries, cancer of the uterine
corpus is the most common malignancy seen in
the female pelvis today
It is the fourth most common cancer in women.
GTN
2%
Vulva
3%
Endometrium
24%
Ovary
49%
Cervix
22%
49%
Ovary
24%
Endomet
N: 1730
22%
Cervix
Vulva
GTT
3%
2%
CTF Gynecol Oncol 2004
EPIDEMIOLOGY and Risk Factors
The median age for adenocarcinoma of the uterine
corpus is 61 years, with the largest number of
patients noted between the ages of 50 and 59 years.
Approximately 5% of women will have adenocarcinoma
before the age of 40, and 20% to 25% will be
diagnosed before the menopause.
EPIDEMIOLOGY and Risk Factors
The use of combination oral contraceptives (OC)
decreases the risk of developing endometrial
cancer.
Cigarette smoking apparently decreases the risk of
developing endometrial cancer. The RR decreased
by about 30% when one pack of cigarettes was
smoked per day
increased risk
obesity increases the risk.....related to depressed SHBG
in obese women
nulliparity and late menopause have increased risk
.....related to unoppesed estrogen ·
DDM and hypertansion are frequently associated with EC·
The use of continuous estrogen increases the risk of EC·
Tamoxifen.......related to its estrogenic effect on
endometrium ·
PCO·
Granulosa cell tumor
Risk factors for Endometrial cancer
Risk factors
Obesity
Nulliparity
Late menopause
Risk
Overweight
21-50 lb
3´
>50 lb
10´
Compared with
1 child
2´
5 or more children
3´
Age
>52 yr
2.4´
Endometrial cancer filling
endometrial cavity
Endometrial cancer
spreading cervix
Symptoms of Endometrial Cancer
1. abnormal uterine bleeding in premenopausal
period
(prolonged and heavy menstruel periods and
intermenstruel spoting may be related to EC.)
2. postmenopausal bleeding in postmenopausal
period
as the patient’s age increases after the menopause,
the probability of EC with uterine bleeding
increases progressively.
Distribution of endometrial carcinoma by stage
(surgical)
Stage
I
II
III
IV
Patients
73 %
12 %
12 %
3%
Classification of Endometrial Cancer
Endometrioid adenocarcinomas (Type I)
Usual
Secretory
Villoglandular or papillary
With squamous differantiation
Special(non-enometrioid) variant carcinomas(Type II)
Papillary serous (UPSC)
Clear cell(CCC)
Mucinous
Pure squamous cell
Mixed
Undifferentiated
Diagnosis of Endometrial Cancer
Cytology
Endometrial cytology to make the diagnosis of EC have been
less successful than sampling.
only 1/3 and ½ of the patients with EC have abnormal c-v
smear.
Hysterograhpy and hysteroscopy
methods in making the diagnosis of EC
are adjuvants
USG
is a diagnostic tool particularly in postmenopausal women
to diagnose endometrial pathology and to evaluate depth of MI
of EC
Tumor markers and MRI
Endometrial sampling(Biopsy)
Which technique for
endometrial biopsy ?
D&C
Pipelle-endorette
Hysteroscopy
D&C
the oldest technique
reasonable accuracy rate
need general anaesthesia
complications
Gold-standard technique !
False negative rates of D&C are
as high as 6 and 10%.
It is found that in
approximately 60% of the D&C
procedures, less than half of
the uterine cavity is curetted
Brooks et al, Grimes et al Am Obstet Gynecol 1988, 1982
Stock et al. Am J Obstet Gynecol 1975
Pipelle-Endorette
doesn’t need anaesthesia
inexpensive
easily used
the rate of adequate sampling!
histopathologic agreement with others techniques!
The Rates of Sufficient Endometrial Sample with
Pipelle (-endorette)
Stovall et al.,
1991......Cancer............... 98%
Fothergill et al.,
1992......All pathology..... 84%
Momerger et al.,
1998......All pathology.... 95%
Monganiello et al.,,
1998.....
Thanuja ve ark,
2000.....All pathology..... 89%
Epstein et al.,
2001....All pathology......... 71 %
All pathology.....
99%
The failure rate of endometrial sample .......1-30 %
The false negative rate........5-15 %
Hysteroscopy
end-point diagnostic work-up for endometrial pathology
False negative rate
3%
PROGNOSTIC FACTORS IN
ENDOMETRIAL ADENOCARCINOMA
Histologic type (pathology)
Stage of disease
Histologic differentiation
Myometrial invasion
Peritoneal cytology
Lymph node metastasis
Adnexal metastasis
Stage and five-year survival in
endometrial cancer
Stage
Survival
I
II
III
IV
86 %
66 %
44 %
16 %
Tumor differentiation and 5-year
survival rate stage I (surgical)
Grade
1
2
3
Survival
94%
88%
79%
Relationship between depth of myometrial invasion
and 5-year survival rate
MI
<1/3
1/3-1/2
>1/2
Survival rate
82.4 %
78.0 %
66.8 %
FIGO 2009
IA
IB
II
IIIC1
IIIC2
Treatment
Total abdominal hysterectomy (TAH) + Bilateral
salpingo-oophorectomy + pelvic and paraaortic
lympadenectomy should be done
After getting pathologic results , adjuvant
treatment is being decided according to risk factors
Adjuvant Therapy Following Surgery
IA
IB
Grade I
Grade
II
Grade
III
Br-RT ?
Br-RT Br-RT
Ex-RT: External radiotherapy
Br-RT: Brachytherapy
IC
II
ve
>
Br-RT
Ex-RT
Br-RT
Ex-RT
Ex-RT
Ex-RT
With vertical incision
Treatment
Low-risk =
stage Ia / Ib + grade I-II
( myometrial involvement < 1/2
peritoneal cytology negative
lymph node negative )
No more therapy
High- risk = Other conditions greater than low-risk
papiller / clear cell
Adjuvant Radiotherapy (Pelvic / paraaortic )
Treatment of Advanced Stage
Endometrial Carcinoma
Surgery
TAH +BSO
Cytoreduction
Pelvic & para-aortic Lymphadenectomy
Adjuvant Therapy..RT, CT & hormone
Treatment
Treatment of patients with stage III-IV
disease must be individualized; however, in
most instances hormonal treatment or
chemotherapy, or both, must be used in
addition to surgery and radiation therapy.