Endometrial

Cancer
Presented by
Dr/ Ahmed Walid Anwar
Assistant professor of Obs & Gyn
Benha Faculty of Medicine
 Endometrial cancer
– The most common ♀ pelvic genital cancer .
– The life time risk of developing endometrial Ca is
2.4% in white women & 1.3% in black (In USA).
– Age:
 Peak incidence in the 6th & 7th decade of life (disease of
postmenopausal women).
 Only 2-5% occur before 40 years.
– Higher survival rate due to early diagnosis ( 75%
diagnosed in Stage I).
– Estrogen has been implicated as a causative factor.
These risk factors are only helpful in identifying
women at risk for type I disease.
Risk factors for endometrial cancer
OLD AUNT
O=Obesity
L=Late menopause
D=Diabetes mellitus
A=cAncer: ovarian, breast, colon
U=Unopposed estrogen: PCOS, anovulation, HRT
N=Nulliparity
T=Tamoxifen, chronic use
Causes of high unopposed estrogen
 Exogenous Estrogen: Estrogen Replacement
Therapy in postmenopausal women.
 Endogenous Estrogen:
– Increased secretion : e.g. feminizing ovarian tumors
(granulose cell tumor).
– Increased androgen precursors: e.g. androgen secreting
tumors, liver diseases, chronic an-ovulation (PCOS), or
stress.
– Increased aromatization: e.g. obesity, liver diseases, or
hyperthyroidism.
– Increased free estrogen due to decreased level of
SHBG.
 Protective Factors
1. Oral contraceptives: Protective effect probably due to progesterone

Decreases both the risk of ovarian and endometrial cancer (RR = 0.6 if

used for one year…effect lasts for 15 years!)

1. Physical activity

2. Pregnancy and breast-feeding :The risk may be lower in women with a

higher number of pregnancies and who breast-feed for more than 18 months.

3. Diet: low in saturated fats and high in fruits and vegetables and soy -based foods as

a regular part of the diet may lower the risk of endometrial cancer.

4. Smoking
 Other Types of Uterine Cancer
 Leiomyosarcoma
– Rapidly growing fibroid should be evaluated
 Stromal sarcoma
 Carcinosarcoma (MMMT)

MMMT

leiomyosarcom
a
 Spread Patterns
 Direct extension
– most common
 Transtubal
 Lymphatic
– Pelvic usually first, then para-aortic
 Hematogenous
– Lung most common
– Liver, brain, bone
Endometrial hyperplasia
 Endometrial Intraepithelial
Neoplasia (EIN) system
 Def: EIN is a histopathological presentation of premalignant
endometrial disease which elevated the risk of {endometrioid
(Type I) endometrial adenocarcinoma}.
 Significance:
– Women with endometrial hyperplasia subdivided into EIN
versus non-EIN categories.
– Progression to cancer more than one year following
EIN diagnosis is 45 times more likely compared to
women without EIN.
 Representation
 Asymptomatic : Endometrial cells on Pap
 B: The “classic symptom” is abnormal uterine Bleeding
20-30% of women with post-menopausal bleeding will
have uterine cancer.
( the risk is higher the farther they are away from
menopause)
 C
 D
 E
 P (Pain, Pressure)
 Metastasis
 Diagnostic evaluation
 Outpatient endometrial biopsy with the Pipelle catheter is
reliable and accurate for the detection of disease in most cases of
endometrial cancer (level of evidence: A).
 Detection rates by pipelle was :
– 91 and 99% for endometrial ca.
– 81% for hyperplasia was
 Hysteroscopic-guided endometrial biopsy remains the gold
standard for endometrial cancer diagnosis (level of evidence:
A ).
 Diagnostic evaluation
 Transvaginal ultrasonography is highly sensitive
and specific in predicting the presence of endometrial
cancer and can be used to select patients for
endometrial biopsy (level of evidence: B).
 If symptomatology persists despite negative findings
from the previously cited tests, further evaluation is
justified because none of these tests have 100%
sensitivity (level of evidence: B).
 Metastatic evaluation
 Routine preoperative assessment of endometrial cancer
patients with imaging tests evaluating for metastasis is not
necessary as it is surgically staged disease (level of evidence:
A).

 Serum CA125 measurement may be useful in management

planning of selected endometrial cancer patients but cannot
currently be recommended for routine clinical use (level of
evidence: C).
 Treatment

 Treatment of endometrial hyperplasia .

 Treatment of endometrial cancer.

Treatment of endometrial cancer
 Approach to endometrial cancer:
best practices
 The initial management of endometrial cancer should include
total hysterectomy, bilateral salpingo-oophorectomy, and
pelvic and para-aortic lymphadenectomy. Exceptions to this
approach should be made only after consultation with a
gynecologic oncologist (level of evidence: A).

 Laparoscopy should be embraced as the standard surgical

approach for comprehensive surgical staging in women with
endometrial cancer (level of evidence: A).
 Approach to endometrial cancer:
best practices
 Vaginal hysterectomy may be an appropriate
treatment in select patients who are at high risk
for surgical morbidity (level of evidence: C).

 Robotic-assisted laparoscopic staging is feasible

and safe in women with endometrial cancer (level
of evidence: B).
 Role of lymphadenectomy
 Patients with grade 1–2 endometrioid tumors, less than
50%myometrium invasion, and tumor of 2 cm or less seem to
be at low risk for recurrence and may not require a surgical
lymphadenectomy (level of evidence: B).
 Lymphadenectomy may alter or eliminate the need for
adjuvant therapy and its associated morbidity (level of
evidence: B).
 Sentinel lymph node dissection may reduce the morbidity
associated with standard lymphadenectomy and may enhance
the therapeutic benefit of surgical staging in early endometrial
cancer (level of evidence: I).
 Surgical approach for
advanced endometrial cancer
 Aggressive surgical cytoreduction improves
progression-free and overall survival in
patients with advanced or recurrent
endometrial cancer (level of evidence: C).
 Exenteration offers the only curative option in
patients with recurrent endometrial cancer who
have received previous irradiation (level of
evidence: C).
Adjuvant Therapy in
Endometrial Cancer
 Stage I Intermediate-Risk
Endometrial Cancers
 External beam pelvic radiotherapy
– 1. Pelvic radiation has been shown to reduce local
recurrence in low to intermediate-risk endometrial
carcinoma. (II-1)

– 2. Pelvic radiation has been shown to reduce local

pelvic and vaginal recurrences in intermediate- to
high-risk endometrial carcinoma. (II-1)
 Stage I Intermediate-Risk
Endometrial Cancers
 Vaginal brachytherapy
– 3. Vaginal brachytherapy alone in the treatment of women with
intermediate- to high-risk endometrial cancer has been shown to have
outcomes in local control and overall survival that are similar to those
of pelvic radiotherapy in a well-defined intermediate- to high-risk
group. (I)
– 4. Vaginal brachytherapy has the same outcome as external beam
radiotherapy with respect to overall survival in the defined
intermediate- to high-risk group. (I)
 Stage I Intermediate-Risk
Endometrial Cancers
 Chemotherapy
– 5. Chemotherapy has not been well studied in
stage I intermediateto high-risk endometrial
cancers. There is no strong evidence for or against
chemotherapy in this population at present. The
benefits of chemotherapy in addition to adjuvant
radiotherapy specifically in surgically stage I
patients with high-risk features are not clearly
defined. (III)
 Stage I Intermediate-Risk
Endometrial Cancers
 Expectant Management
– 6. Patients in the intermediate-risk category who
are managed expectantly have a higher recurrence
rate than those who are treated, although there has
not been a lack of survival benefit demonstrated.
Patients who are managed expectantly report
higher scores in quality of life studies because of
less gastrointestinal toxicity. (II-3)
 Advanced Stage (II to IV)
Endometrial Cancer

– 7. Chemotherapy with cisplatin and doxorubicin

or carboplatin and paclitaxel has demonstrated

efficacy in advanced uterine cancer in published

phase III studies. (II-2)

 Five Year Survival

72% diagnosed at this stage I, 3% Diagnosed at stage IV

 Conclusions
 Endometrial carcinoma is the commonest female
genital tract cancer.
 Routine screening for EC is not recommended.
However annual screening is recommended in
women at risk for hereditary nonpolyposis colorectal
cancer.
 Endometrial carcinoma is a surgically staged disease.
 Conclusions
 The initial management of endometrial cancer should
include total hysterectomy, bilateral salpingo-
oophorectomy, and pelvic and para-aortic
lymphadenectomy.
 Primary radiotherapy or hormonal treatment may be
recommmended in special situations.
 Adjuvant radiotherapy and /or chemotherapy are
recommended in patients with high risk for
recurrence.
 Conclusions
 Endometrial carcinoma has the best prognosis
due to early presentation (PMB).
 Disease stage is the most predictive factor for
survival.
 Lymph node metastasis is the most predictive
factor for survival in early stage endometrial
carcinoma.