Download CARCINOMA OF THE ENDOMETRIUM

CARCINOMA OF THE
ENDOMETRIUM
presented by:
Dr. Rozhan Yassin khalil
FICOG,CABOG,HDOG,FICS,MBChB
2014
CARCINOMA OF ENDOMETRIUM:
•
One of the commonest gynecological
cancers，especially in white Americans.
•
It is a disease of postmenopausal
women with a peak incidence in the
6th & 7th decade of life
it occurs most often in postmenopausal
women（up to 80％of cases）with less
than 5％ diagnosed under 40 years of
age．
A UTERUS WITH ADENOCARCINOMA OF THE
ENDOMETRIUM.
SCREENING:
 There
is no effective screening
programme，
 but
occasionally cervical smears
contain endometrial cancer cells
or double thickness endometrial
 ultrasonic
thickness of 4mm or more
indicates a need for endometrial
sampling．
RISK FACTORS OF ENDOMETRIAL CA.
1. The actual cause
3. Estrogen secreting
tumors of the ovary are
associated with an
increased incidence of
endometrial
carcinoma．
of this cancer is
unknown
(idiopathic).
. -Early menarche
< 12 Y
- Late menopause >
52 Y
given estrogen alone as
postmenopausal hormone
replacement therapy .
2.
Estrogen
RISK FACTORS:
4.Nulliparity and PCO
syndrome（with defective
progesterone synthesis）carry
an increased risk．
5. obese，diabetic and
hypertensive women
develop endometrial
cancer．
6.  risk in women
with breast, ovarian
(endometrial type) &
colorectal Ca.
8.Family Hx of
endometrial Ca
7.Previous pelvic
radiation therapy
RISK FACTORS:
 9.
The endometrial hyperplasia induced
by Tamoxifen produces endometrial
polyp suggested a four-fold increase in
endometrial carcinoma．
RISK FACTORS FOR ENDOMETRIAL
CANCER:
• Obesity
 • Impaired carbohydrate tolerance
 • Nulliparity
 • Late menopause
 • Unopposed oestrogen therapy
 • Functioning ovarian tumours
 • Previous pelvic irradiation
 • Family history of carcinoma of breast,
ovary or colon

PROTECTION FOR ENDOMETRIAL CA.
 1-
Oral contraception，especially after
long term use.reduces incidence of both
endometrial and ovarian carcinomas).
 2-
Cigarette smoking has also been
associated with the reduced risk of
endometrial cancer.
SYMPTOMATOLOGY:
The usual presenting symptom of endometrial
carcinoma is :
1.postmenopausal bleeding which carries a
10％ risk of associated malignancy in the
absence of hormone replacement therapy.
Curettage，or endometrial sampling is
mandatory.
2.Postmenopausal discharge from
pyometra carries a 50％ risk of associated
malignancy.
3.Pain may occur with pyometra or
metastatic spread．
DIAGNOSIS:
1-Hysteroscopy with endometrial curettage
2-endometrial sampling.
3- curettage alone，
4- outpatient endometrial sampling alone，are
essential．
Curettage is not infallible．On the other hand，
if a Pipelle has been correctly introduced
and the pathology is benign, or no tissue is
obtained ， it is most unlikely that
malignancy exists．
DIAGNOSIS:
Hysteroscopy，cervical
smear
（>1％risk of concurrent cervical
malignancy）and
 vaginal or abdominal
ultrasound for ovarian
pathology are advised，when
endometrial malignancy is found．
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HISTOPATHOLOGY:
 1-Adenocarcinomas
 60 – 70 %.
 2- Adenosquamous Ca  10-20%
 3- Papillary Serous Ca  10%.
 4- Clear cell Ca  4%.
 5- Mucinous Ca  9%.
 6- Secretory Ca  1-2%.
 7- Squamous cell Ca  extremely
rare
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Staging
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SPREAD :
In general this cancer is slow to
spread from the uterine cavity,
probably because the endometrium
lacks lymphatics.
 A chest X-ray helps detect lung
metastases.
 Magnetic resonance imaging is
preferable to ultrasound for
detection of myometrial invasion and
pelvic spread.

LOCAL SPREAD:
Local Spread
spread may
involve the
vaginal vault.
Slow invasion of
the myometrium is
the commonest
spread.
It may produce
considerable uterine
enlargement;
VENOUS SPREAD:
Venous
Spread
This pathway might account for
the occasional appearance of a
low vaginal metastasis;
 but venous spread is not a
common feature of uterine
cancer.
LYMPHATIC SPREAD:
Lymphatic Spread

The incidence of this seems to be
between 10 and 30%.
 All pelvic nodes, including the internal
iliacs, the parametrium, the ovaries, and
the vagina may be involved, probably with
equal frequency.
 Lymphatic spread is more likely to
occur when the tumour is anaplastic and
the uterine wall is deeply invaded.
TUBAL SPREAD:
 Tubal
Spread
 Malignant cells can pass along the
tube in the same way that peritoneal
spill may occur during menstruation.
 This
may account
ovarian metastases.
for
isolated
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PROGNOSIS OF
ENDOMETRIAL CARCINOMA

With the exception of stage 1 tumors of
histological grades I and II, the prognosis
is less favourable than many gyaecologists
believe，
an overall 5 year survival of 70
％ approximately．
 with
 Fortunately
over 80％of cases are
diagnosed at stage 1．
PROGNOSTIC FACTORS:
 1.Staging
diagnosis,
 2. extent of myometrial invasion .
 3. histological grading(differentiation).
are the most important prognostic
factors apart from competence of
treatment.
Stage
 I
 II
 III
 IV

5 year survival
85%
68%
42%
22%
TREATMENT OF ENDOMETRIAL
CARCINOMA
This is essentialy surgical，with
postoperative radiotherapy added
when :
 1.unfavourable prognostic features are
found at surgery ,
 2.Pre-operative clinical Staging is
inaccurate．

 Progestogen
therapy is probably only of
value in recurrent disease．
WOMEN UN FIT FOR OP.:
 Few
women are unfit for surgery，
and caesium insertion
radioactive therapy may be
employed for these,
 but radiation alone is less
effective than combined surgical
and radiation treatment．
STAGE I:(TREATMENT)
Total abdominal hysterectomy
and bilateral salpingooophorectomy without partial
removal of vagina.
 Peritoneal saline washings are taken
for cytology on opening the
abdomen and the Abdominal
contents carefully examined．

STAGE II:
 Stage
IIa carries a similar prognosis
to Stage I and may be treated as stage
I．
 Stage
IIb，with clinical invasion of the
cervix，has a poorer prognosis than
Stage I and radical hysterectomy，
pelvic lymphadenectomy and para-aortic
lymph node sampling are indicated，
 with
a combination of local and external
radio therapy as an alternative
treatment．
STAGE III:
Following the Staging laparotomy，
 radical hysterectomy，
lymphadenectomy，para-aortic
node sampling and removal of as
much malignant tissue as possible，
omentectorny is carried out．
 Stage III diseases limited to the
pelvis may be treated by
radiotherapy．

STAGE IV:
 Treatment
of this Stage is designed
to control tumour growth and
alleviate symptoms．
Surgery，radiation
therapy，
cytotoxic therapy and
adjuvant progestogen therapy
all have a place．
CARCINOMA OF THE ENDOMETRIUM
COMPARED WITH CA CERVIX:
 The
overall results are better than
for carcinoma of the cervix，not
because it is less malignant tumour，
but because treatment is usually
given earlier．
 Post－menopausal bleeding is
much more difficult to ignore than
the irregular bleeding of the younger
woman．
RECURRENCE OF ENDOMETRIAL
CARCINOMA

The incidence of recurrence within 5years is
in the region of 30％and is accepted along
with the 5-year survival rate as a measure of
the effectiveness of the various systems of
treatment．
 The
majority recurrences appear
within 3 years of treatment. Early
recurrence has a poor Prognosis.
PROGESTOGENS:


Many endometrial carcinomata are
hormone dependent and progestogens
have been used as part of a combined
primary treatment , recurrent or
metastatic growths．
Between 15％and 50％of recurrences will
respond．Medroxyprogesterone acetate，
400 mg to 600 mg daily
CHEMOTHERAPY:
 Chemotherapy
Cytotoxic
chemotherapy has a limited place
in advanced recurrence．
 Single
agent therapy with adriamycin,
cisplatinum ,cyclophosphamide gives
response rates between 20％and 40％．
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THANKS