Carcinoma Endometrium

By Sidra Javed

08-182

Batch J

Final yr MBBS

What is Carcinoma ?

A carcinoma is tumor tissue derived from

epithelial cells whose genome has become

altered to such an extent that it begin to

exhibit abnormal malignant properties.

What is Endometrial carcinoma ?

• Endometrial carcinoma arises from epithelial

tissues in the lining of glands and columnar

cells constituting the surface of the

endometrium.

Why it is important ?

• Commonest gynecological cancer

in USA and many other western

countries.

• Fourth most common cancer in

women in developed countries.

Who are at risk ?

1. AGE

1. Peak incidence

about 55-60 years

of life.

2. 25 % are

premenopausal.

2. Parity

50 % have born only one or two child.

25 % are nulliparous.

3. Late Menopause

4. Obesity

3- 10 times greater risk.

5. Estrogen over activity

Estrogen producing

tumors. (POD)

Continuous Estrogen only

replacement therapy

6. Endometrial hyperplasia

Atypical hyperplasia has highest risk.

( 40-60 %)

7 . Diabetes mellitus. 3x risk

8. Hypertension

9. Radiation

10. Family history

( hereditary non polyposis colon cancer)

Protective effect

• Smoking

• Oral contraceptive.

• Progesterone.

Tell me its Types

Endometrial Carcinoma

Type 1(80%)1. 50 -55 years.

2. Adenocarcinoma

3. Endometrial Hyperplasia

4. PTEN, KRAS, p53, B.catenin.

5. less aggressive, lymphatic spread.

6. Low grade, good prognosis

7. Unopposed estrogen action.

Type 2(20%)

1. 65-75 years.

2. Serous , clear, mixed mullarian

3. Endometrial intraepithelial

carcinoma.

4. P53, aneulploidy.

5. Aggressive intraperitoneal and

lymphatic spread.

6. High grade, poor prognosis

7. Not related to estrogen.

Taken from Robbins and Cotran.

Histopathology

Grade 1 : Well differentiated, less than 5% solid growth. (40%)

Grade 2 : Moderately differented, less than 50% solid growth. (20%)

Grade 3 : Poorly differented , greater than 50% solid growth.( 40%)

1-Adenocarcinomas 80-85%

2-Adenocarcinoma with squamous differentiation

5%

• Malignant glands with benign squamous metaplasia

• Also subdivided into 3 grades

3-Adenosquamous Ca 10-20%

• Malignant glands & malignant squamous epithelium

• Often grade 3

4-Papillary Serous CA 10%

5-Clear cell CA 4%

6-Mucinous CA 9%

7-Secretory CA 1-2%

8-Squamous cell CA extremely rare

How It will present ?

Symptoms.

1. Bleeding

• Post menopausal bleeding in 75% of cases.

• In premenopausal , irregular menstruation

and menorrghia.

• Small, rarely heavy

2. Vaginal discharge and spotting.

. Brownish or blood stained vaginal discharge.

3. Pain.

. During urination, intercourse

.In lower abdomen.

.Dull or colicky pain.

Signs

• No typical signs.

• Distant metastasis causes indurations in the parametrical tissues, and inguinal lymph node may become palpable.

How it spreads?

1. Direct Spread .

2. Through Lymphatic.

• Never occurs without myometrial invasion

• Pelvic lymph nodes common 35%

• Para-aortic lymph nodes 10-20%

Rarely involved without pelvic nodes

involvement

• Inguinal lymph nodes rare

Through blood

•Less common route

•Involved in late stage of disease

•Occurs with recurrent or disseminated disease

4. Implantation

• Malignant cells implantation in vagina during hysterectomy.

How I will diagnose it ?

1. History

2. Examination

• Physical examination of the patient with endometrial

carcinoma is frequently entirely normal, it should include

palpation of supraclavicular and inguinal lymph nodes .

• Inspection of vulva, vaginal skin in suburethral area

and cervix. ( Pyogenic discharge in case of pyometra)

• Bimanual vaginal examination assesses uterine size, and mobility

Investigations

• Ultrasonography

• In postmenopausal UGS shows irregular and

polypoidal endometrium

• If thickness of endometrium is more than

5mm it require further investigations.

• Endometrial sampling.

Histological investigation is

investigation of choice for diagnosis of endometrial

carcinoma.

Fractional Curettage HysteroscopyBiopsy

Fractional Curettage

• Uterine cavity and endocervix is thoroughly curetted.

• In the past the “gold standard” was Fractional

curettage.

• The current “gold standard” is hysteroscopy

with targeted endometrial biopsy

Others

• MRI depth of carcinoma invasion and Lymph

node involvement

• Chest X-Ray exclude pulmonary spread.

Differential Diagnosis

• Various causes of abnormal bleeding

• Endometrial hyperplasia

• Endometrial & Cervical polyps

• Fibroid

• Ovarian, Cervical or tubal neoplasm

• Postmenopausal Pt atrophic vaginitis, endometrial

atrophy, exogenous estrogens

• Trauma

How it is treated ?

• Depends upon the Stage of disease and health

of patient.

• Primary treatment is surgery.

• Radiotherapy, chemotherapy can be used in

patient with metastatic and recurrent disease.

Stage I

IA Tumor limited to endometrium

IB Invasion <50% of myometrium

IC Invasion > 50% of myometrium

Treatment of choice of Stage I

• Pelvic nodes removal and radiotherapy is

recommended if more than 1/3rd of

myometrium is invaded.

• Radiotherapy is not recommended for very

early tumor for IA and IB.

Stage II

IIA Endocervical glandular involvement only.

IIB Cervical stroma invasion.

Radial hysterectomy with pelvic lymphodectomy

followed by radiotherapy or radiotherapy alone.

Stage III

IIIA Tumor invade to serosa or adnexae or positive

peritoneal cytology.

IIIB Vaginal metastases

IIIC Metastasis to pelvic and para-aortic lymph node.

• If disease is restricted to pelvis than radiotherapy

alone is treatment of choice.

• Otherwise laparotomy recommended for accurate

staging and tumor debulking.

Stage IV

IVA Tumor invade bladder and bowl mucosa.

IVB Distant metastasis.

Aim is to relief the patient

• Radiotherapy.

• Debulking through palliative surgery.

• Cytotoxic drugs.

• Hormonal therapy.

• Progestogens

The role of chemotherapy is limited

• Anthracycline.

• Doxorubine.

• platinum drugs

Adjuvant hormonal therapy

Inj. Medoxyprogesterone.

Inj hydroxyprogesterone caproate.

Tab. Norethisterone.

Follow up

Prognosis

The 5 year survival rate for endometrial Ca :

• Stage I 75%

• Stage II 58%

• Stage III 30%

• Stage IV 10%

• Overall 5 year survival 70% most Patients

present early due to abnormal vaginal bleeding.

So we know

• Endometrial carcinoma

• Its etiology, signs and symptoms.

• Its diagnosis, treatment and prognosis.