Endometrial Carcinoma

Almina, Rabika, Rabia

Endometrial cancer

 Uterine cancer refers to tumours that arise from the body of the uterus
 The most common are endometrial cancers that originate from the
endometrium (lining of the uterine cavity), specifically from the
glandular component of the endometrium
 Tumours arsing from the myometrium (sarcomas) are rare
Incidence and Prevalance
 Most common gynaecologic cancer
 4th most common in women (US)
 2nd most common in women (UK)
 5th most common in women
(worldwide)
 Western; developed countries >
Southeast Asia
 The mean age of diagnosis is 62 years, but it
can be diagnosed in women throughout their
reporductive life
 Approximately 25% of endometrial cancers
occur before menopause
 The incidence has increased over the past 20
years due to women shying away from
hysterectomy for benign conditions as well
as the increasing obesity in the population.
Types

 Endometroid carcinoma (most common)

 Squamous cell carcinoma
 Adenosquamous carcinoma
 Clear cell carcinoma
 Papillary serous carcinoma
 Histological Classification
 Type 1 endometrial cancers (75%) –
endometroid carcinoma
 Estrogen dependent
 Arise from endometrial hyperplasia
 Occur in younger women
 Low grade (histologically) and favorable
prognosis
 Assoicated with inactivation of PTEN gene
 Type 2 endometrial cancers (25%)– serous
and clear cell carcinomas
 Estrogen independent
 Arise from endometrial atrophy
 Occur in older women
 High grade (histologically) and poor prognosis
 Associated with P-53 gene mutation
 Psammoma body formation
Psammoma Body
 Type 1 Risk/Protective Factors
 Risk factors
 Obesity – more likely to have anovulatory cycle  Protective factors
and less
likely to get pregnant; increased androgen to estrogen conversion by
 Hysterectomy – prophylactic in
adipose tissue
women with Lynch Syndrome
 Diabetes – insulin stimulates endometrial proliferation
 Combined OCP
 Nullliparity/infertility
 Progestin based contraceptives
 Late menopause >52 years/ early menarche
 IUD – Cu-IUD; LNG-IUS
 Unopposed estrogen therapy
 Pregnancy
 Tamoxifen therapy – antiestrogenic in the breast but stimulatory in the
 Smoking
endometrium
 Family history of CRC and Ca endometrium– Lynch syndrome
Clinical Features
 Usually presents at an early stage with onset of postmenopausal bleeding
 Postmenopausal bleeding is a RED FLAG symptom.
 5-10% women with PMB have an underlying gyencological malignancy
 Abnormal bleeding in premenopausal women is also a common complaint
 They complain of heavy, irregular or intermenstrual bleeding
 Symptoms of advanced stages are
 Abdominal pain/distention
 Abnormal bowel movements
 Urinary disturbances
 Respiratory symptoms
Investigations and Diagnosis

 A careful insepction of external genitalia should be done

 A speculum examination to exclude vulval, vaginal and cervical cancer as the cause
 Physical examination may be normal
 Mainstays of diagnosis are transvaginal ultrasound scan (TVUSS); hysteroscopy and
endometrial biopsy
 Transvaginal Ultrasound Scan

 TVUSS allows a quick and accurate assessment of

endometrial thickness
 If the endometrium measures less than 4 mm, cancer
is very unlikely and further investigation is not
needed
 A measurement of more than 4 mm requires further
investigation with hysteroscopy and biopsy
 Hysteroscopy and Biopsy

 Hysteroscopy is performed in the outpatient setting under local anesthesia

 General anesthesia is indicated in patients with cervical stenosis or where
hysteroscopy is poorly tolerated
 The histological report from the biospy will describe the type of cancer (type 1 or 2),
and the grade of tumour.
 Complex hyperplasia with atypia is a premalignant condtion that coexists with low grade
endometroid tumours
 Risk of progression to endometrial cancer in 25 – 50%
Staging

 The extent of the disease is determined by a MRI scan and then staged in
accordance to FIGO staging
 Patients with high grade tumours are also required to undergo a CT scan of the
chest, abdomen, and pelvis to exclude ditant metastasis
Tumour Tumour
confined to confined to
uterus;<50% uterus;>50%
Cervical Serosal
involvement invasion
Vaginal/parametrium
Mets to para-aortic-pelvic
involvement
nodes
Bowel/bladder invasion
Distant metastasis
 Management – Surgical
 Surgery is the mainstay of treatment of endometrial cancers
 The extent of the surgery depends on the grade and stage of the cancer, as well as the patient’s co-
morbidities
 Standard surgery is a total hysterectomy and bilateral salpingo-oopherectomy
 Removal of the uterus and both falopian tubes and ovaries
 It can be performed abdominally as well as laparoscopically
 If a MRI suggests cervical involvement then a modified radical hysterctomy is performed
 Consists of removal of the uterus, both fallopian tubes and ovaries, excision of vaginal cuff, and excision of
paracervical and parametrial tissue
 If the tumour is high grade (grade 3) or of type 2 histology then there is also removal of pelvic and
para-aortic nodes
Management – Adjuvant/Hormone Therapy

 Adjuvant therapy
 Postoperative radiotherapy reduces lical recurrence but it does not imporve survival
 Chemotherapy is given for advanced or metastatic disease
 Hormone therapy
 Indicated in women not fit for surgery or those who wish avoid it to spare fertility
 High dose oral or intrauterine progestins is effective for women with premalignant complex
atypical hyperplaisa and low grade stage 1A endometrial tumors
 Relapse rates are high
 Prognosis

 5 year survival rates are based on  Adverse prognostic features are

tumour type, stage, and grade of tumour  Advanced age

 Low grade stage 1A – 93%  Grade 3 tumours

 High grade stage 1B – 66%  Type 2 histological tumours

 Stage 2 – 75%  Deep myometrial invasion

 Stage 3 – 55%  Lymphovascular inviolvement

 Stage 4 – 16%  Distant metastasis

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