CARCINOMA ENDOMETRIUM

Prof. M.C.Bansal

MBBS,MS,MICOG,FICOG

Professor OBGY

Ex-Principal & Controller

Jhalawar Medical College & Hospital

Mahatma Gandhi Medical College, Jaipur.

INTRODUCTION

Most frequently encountered gynaecologic

cancer in west because of decline in Ca Cx

Account for 7.0%of all cancer in women

Peak incidence is in the age group of 55 to

69 years.

Over three-fourth of these women are

diagnosed when the disease is still localized and

surgery offers satisfactory results.

PREDISPOSING FACTORS

1. Unsupervised administration of ERT in menopausal women.

2. Women suffering from Hyperestrogenic states i.e. Endometrial hyperplasia as cases of DUB.

3. Familial predisposition to it and may be due to genetic factors or dietary habits.

4. Tamoxifen prescribed to women with breast cancer.

CONTN..

5. OCPs containing only estrogen while OCPs

with E & P have protective effect.

6. Obesity, HT, Diabetes, Infertility, nulliparity

are associated with endometrial cancer in

30% cases.

7. PCOD patients are more prone to this

disease.

PATHOLOGY

Uterus is enlarged and Endometrial cancer may be localized or diffuse.

Localized form may appear as a nodule or polyp or localized carcinomatous patch.

Diffuse form may be involving the entire uterine cavity stopping short of internal os.

It may infiltrate uterine myometrium and remain restricted to its boundaries for a long time.

In advanced stages growth may directly spread beyond uterine body to cervix, vagina, adnexa and may metastesize into nodes and distant sites.

THIS ADENOCARCINOMA OF THE ENDOMETRIUM IS MORE OBVIOUS. IRREGULAR

MASSES OF WHITE TUMOR ARE SEEN OVER THE SURFACE OF THIS UTERUS THAT

HAS BEEN OPENED ANTERIORLY. THE CERVIX IS AT THE BOTTOM OF THE PICTURE.

THIS ENLARGED UTERUS WAS NO DOUBT PALPABLE ON PHYSICAL EXAMINATION.

SUCH A NEOPLASM OFTEN PRESENT WITH ABNORMAL BLEEDING.

THE ENDOMETRIAL ADENOCARCINOMA IS PRESENT ON THE LUMENAL

SURFACE OF THIS CROSS SECTION OF UTERUS. NOTE THAT THE

NEOPLASM IS SUPERFICIALLY INVASIVE. THE CERVIX IS AT THE RIGHT.

This uterus is not enlarged, but there is an irregular mass in the upper

fundus that proved to be endometrial adenocarcinoma on biopsy.

Such carcinomas are more likely to occur in postmenopausal women.

Thus, any postmenopausal bleeding should make you suspect that

this lesion may be present.

HISTOPATHOLOGY

It is adeno carcinoma

Grading of these tumors is based on

differentiation and ability to maintain gland

formation, morphology and anaplasia of the

tumour lining cells and presence of infiltration

in stroma

Tumor grading affects the prognosis of the

disease in any individual case

THE ENDOMETRIAL ADENOCARCINOMA IN THE POLYP AT THE LEFT

IS MODERATELY DIFFERENTIATED, AS A GLANDULAR STRUCTURE

CAN STILL BE DISCERNED. NOTE THE HYPERCHROMATISM AND

PLEOMORPHISM OF THE CELLS, COMPARED TO THE UNDERLYING

ENDOMETRIUM WITH CYSTIC ATROPHY AT THE RIGHT.

THIS IS ENDOMETRIAL ADENOCARCINOMA WHICH CAN BE SEEN INVADING

INTO THE SMOOTH MUSCLE BUNDLES OF THE MYOMETRIAL WALL OF THE

UTERUS. THIS NEOPLASM HAS A HIGHER STAGE THAN A NEOPLASM THAT

IS JUST CONFINED TO THE ENDOMETRIUM OR IS SUPERFICIALLY INVASIVE.

SYMPTOMS

1. May be asymptomatic to begin with.

2. Menometrorrhagia in perimenopausal

women

3. Post menopausal bleeding.

SIGNS

1. Per vaginal examination: may or may not reveal a bulky uterus.

2. Enlarged uterus may be associated with Ca endometrium along with fibroid or pyometra

3. Sub-urethral Vaginal metastatic growth may be noted in advanced cases.

4. When adnexa is involved in late stages enlarged uterus with unilateral or bilateral adnexal enlargement and fixed nodules in Pouch of Douglas may be present.

INVESTIGATIONS

1. Routine Haematogram and blood chemistry, urine examination, X-ray chest and ECG should be done.

2. USG- often reveals thickened and hyperplastic, polyp in uterine cavity.

Post menopausal endometrial thickness >4mm is abnormal

3. Endometrial cell sampling by aspiration cytology.

4. Diagnostic hysteroscopy followed by selective biopsy of suspected area.

5. Fractional curettage and histopathological examination- this will help in differentiating whether Ca endometrium is involving cervical canal or not.

6. CT/MRI help in defining the extent of disease into the myometrium , nodes and distant organs.

DIFFERENTIAL DIAGNOSIS

1. Senile endometritis

2. Genital tuberculosis

3. Atypical endometrial hyperplasia

4. Any other cause of post menopausal

bleeding like senile vaginitis, foreign body,

ERT abuse, cervical polyp, urethral

caruncle, Ca cervix and ovarian carcinoma

etc

SCREENING OF ENDOMETRIAL CARCINOMA

1. Routine screening of all asymptomatic women on HRT and tamoxifen therapy

2. Perimenopausal women with menometrorrhagia should be investigated and screened to exclude endometrial carcinoma.

3. All women with postmenopausal bleeding should be screened by pv examination, TVS, Pipelle aspiration cytology.

4. Fractional curettage along with diagnostic hysteroscopy.

• Local and/or regional spread

• 3A-Tumor involves serosa, spreads to adnexae, positive peritoneal cytology.

• 3B- Presence of vaginal metastasis

• 3C- Node metastasis to pelvis and para aortic nodes.

3

• Tumour Widespread

• 4A Tumor involves bladder and /or bowel mucosa

• 4B Tumor shows distant metastasis ( intra-abdominal and inguinal nodes)

4

• DESCRIPTIONSTAGE

• Cancer confined to corpus uteri

• 1A- Tumor limited to endometrium

• 1B- Tumor involving half or less than half themyometrial thickness

• 1C – Tumor involves more than half the myometrial thickness

1

• Tumor involves cervix but does not extend beyond uterus

• 2A- Endocervical gland involvement only.

• 2B- Cervical stromal invasion

2

TREATMENT

cases of simple hyperplasia develop in malignancy in 10-20%

60-70% cases of atypical hyperplasia develop into malignancy.

Stage 0-(Endometrial hyperplasia)-Abdominal Pan Hysterectomy is the ideal treatment.

Young women may be kept under observation and 30-40 mg medroxyprogesterone daily therapy may be offered for 6-12 months.

Mirena IUCD is also suitable for such

RX CONTN..

Stage IA: (low risk Grade 1 and 2of

endometrium HPR) TAH and BSO is

sufficient because involvement of nodes is

seen in only 2% cases while myometrial

invasion is only 4%.

Stage IB- High risk > 50% myometrium

involved and HPR shows grade 3 tumor or

there is presence of lymphatic involvement

then chances of lymph node metastasis is

10-40% therefore TAH and BSO followed by

post op pelvic radiation 4000- 5000cgy.

RX: CONTN..

Stage II- Pre operative radiotherapy followed by TAH and BSO, or Wertheims Hysterectomy as done for Ca cervix.

Post operative radiotherapy is needed if lymph nodes are Ca positive.

Stage III- Advanced disease not suitable for surgery. Chemotherapy plus Radiotherapy plus weekly injection of Medroxy progesterone.

Stage IV- Palliative Radiotherapy, chemotherapy and hormonal therapy using large dose of progesterone. Progesterone helps in regression of lung metastasis in 30% cases.

SURVIVAL RATE

Stage I 75 %

Stage II 55 %

Stage III 30%

Stage IV 10%

SARCOMA OF UTERUS

SARCOMA OF THE UTERUS

Introduction:

These are rare tumors comprising 4.5% of all

malignant growths of the uterus.

About 0.5% of myomas undergo sarcomatous

changes at menopausal age.

Common in the age of 40-60 yrs.

Rare before 30 yrs.

8% of sarcomas occur in women who have

received radiation for Ca cervix 8-10 yrs ago.

VARIETIES OF UTERINE SARCOMAS

1. Intramural- arise in the myometrium

2. Mucosal- Develops from endometrium.

3. Sarcomatous changes in pre-existing myoma.

4. Grape like sarcoma of the cervix.

Intramural is most common . Histologically tumour may be round cell, spindle-celled, mixed cell or giant cell type.

Spindle- cell type is most common and called leiomyosarcoma.

GROSS APPEARANCE

Cut surface: is hemorrhagic and irregular

without whorled appearance like myoma. It is

friable and soft. Margins are not clear and

invasion into surrounding myometrium is

common. There is no definite capsule.

Mucosal form- projects in cavity like polyp or

spreads around the cavity of the uterus to

produce uniform enlargement.

THIS IS A LEIOMYOSARCOMA PROTRUDING FROM MYOMETRIUM INTO

THE ENDOMETRIAL CAVITY OF THIS UTERUS THAT HAS BEEN OPENED

LATERALLY SO THAT THE HALVES OF THE CERVIX APPEAR AT RIGHT

AND LEFT. FALLOPIAN TUBES AND OVARIES PROJECT FROM TOP AND

BOTTOM. THE IRREGULAR NATURE OF THIS MASS SUGGESTS THAT IS

NOT JUST AN ORDINARY LEIOMYOMA.

HERE IS THE MICROSCOPIC APPEARANCE OF A LEIOMYOSARCOMA. IT IS

MUCH MORE CELLULAR AND THE CELLS HAVE MUCH MORE

PLEOMORPHISM AND HYPERCHROMATISM THAN THE BENIGN

LEIOMYOMA. AN IRREGULAR MITOSIS IS SEEN IN THE CENTER.

SARCOMAS, INCLUDING LEIOMYOSARCOMAS, OFTEN HAVE VERY

LARGE BIZARRE GIANT CELLS ALONG WITH THE SPINDLE CELLS.

A COUPLE OF MITOTIC FIGURES APPEAR AT THE LEFT AND

LOWER LEFT.

METASTASES

Relatively earlier, occurs via blood stream,

lymphatics, direct spread and by

implantation.

Lymphatic nodes-35% cases in stage I and II

and Para-aortic lymph nodes in 15% cases.

Direct spread in the peritoneum leads to

multiple metastasis leading to ascites and

omental cake.

SYMPTOMS AND SIGNS

Profuse and irregular vaginal bleeding which

is often painful.

60% patients have fever due to degeneration

and infection of the tumour.

Rapid enlargement of the tumour usually

occurs due to sarcoma.

TREATMENT

Pan Hysterectomy, omentectomy and

debulking of metastasis foci is done.

Followed by radiation therapy.

Chemotherapy of VAC combination reduces

the recurrence rate.

5 yr cure rate is <30% and largely depends

on the type of growth, being worst in

endometrial sarcoma i.e. round cell type.

BOTRYOID AND GRAPE-LIKE SARCOMA

Pathologically the tumour is mesodermal mixed tumour as the often contain cartilage, striated muscle fibres, glands and fat.

Stroma is embryonic in type.

Grape sarcoma of cervix arises typically in adult women somewhat similar tumor are known to develop in cervix and vagina in children in very early age. In these cases prognosis is very poor and rapid recurrence follows their removal.