Endomertial cancer & other uterine

malignancies

Prof. Dr. Noorhan Shakir

 ENDOMETRIAL CANCER
• Cancer of uterine endometrial lining.
• Most common female reproductive cancer.
• 6% of all cancers in women.
• Generally high rate of survival due to early
diagnosis.
 Types of endometrial cancer

Type 1:
• Premenopausal & perimenopausal women.
• History of unopposed oestrogen exposure.
• Endometrial hyperplasia
• Minimal invisions, low-grade endometrioid type
• Good prognosis

Type 2:
• Postmenopausal women
• Non-estrogen dependent (worse prognosis)
• High-grade tumours
• Poorer prognosis.
Histological subtypes in endometrial cancer

• EndometrioId adenocarcinoma
• Adenosquamous
• Serous papillary
• Sarcomas/liomyosarcomas
• Carcinosarcomas
• Clear cell carcinoma
 Incidence and Prevalence
• Most common gynecologic cancer
• 4th most common in women (US)
• 2nd most common in women (UK)

Increased use of menopausal estrogen therapy

Endometrial Cancer and Lifestyle
 How endometrial hyperplasia is associated with
endometrial cancer
Endometrial hyperplasia is a continuum…(Simple hyperplasia complex
hyperplasia without atypiacomplex hyperplasia with atypia endometrial
cancer (well differentiated adenocarcinhoma,).

• Endometrial hyperplasia is precursor to endometrial cancer

– usually presents with abnormal bleeding.
 Endometrial Hyperplasia (EIN)
• Simple endometrial Hyperplasia
– Benign irregular dilated glands, with atypia: 8% progress to
endometrial cancer.
– Often regress spontaneously.
– Progestin treatment used for treating bleeding may help in treating
hyperplasia as well.
• Complex endometrial Hyperplasia
– Proliferation of glands with irregular outlines, back to back crowding of
glands,
– Atypia: 29% progress to endometrial cancer
Complex hyperplasia with atypia
treated by hysterectomy or high dose progestin tx
Or Marina(IUCD).
 RISK FACTORS FOR ENDOMETRIAL CANCER
• Early menarche & late menopause
(< 12 & >52)
• Infertility or nulliparous
• Obesity
• Tamoxifen for breast cancer
• Estrogen replacement therapy (ERT)
after menopause
• Diet high in animal fat
• Diabetes
• Age greater than 40
• Caucasian women
• Family history of endometrial
cancer or hereditary Non
polyposis colon cancer (HNPCC)
• Personal history of breast or
ovarian cancer
• Prior radiation therapy for pelvic
cancer
 RISK FACTORS FOR ENDOMETRIAL CANCER

The cause of endometrial cancer is unknown, but there are

number of factors are related to an increase in level of
oestrogen unapposed to progesterone .
Postmenopausal lady the type of oestrogen is derived by
aromatized peripheral androgens( (androstenedione)
conversion is adipose tissue.
In addition PM women with DM have increase oestrogen
level
 Reduced Risk
• Oral Contraceptives
– Combined OC => 50% reduced rate
• Tobacco Smoking
– Smokers have lower levels of estrogen and lower
rate of obesity
• -Physical activity
SYMPTOMS OF ENDOMETRIAL CANCER

• Symptoms & signs

– Non-menstrual bleeding or discharge
• Especially post-menopausal bleeding
– Heavy bleeding & discharge
– Dysuria
– Pain during intercourse
– Pain and/or mass in pelvic area
– Weight loss
– Back pain
– Enlarged uterus which may associated with pyometra
 Preoperative Work-up
• Diagnosis:
 Pelvic examination
 Pap smear (detect cancer spread to cervix)
 TVS; - By ultrasound endometrial Thickness ˂5mm in normal menopausal
woman
 -Endometrial sampling done by 3 ways
1- biopsy by pipelle (91 - 99%) as initial test ,easy to do in office
2– Outpatient hysteroscopy
3- hysteroscopy & currretage under a general anesthesia (gold standard) if EMB
inconclusive or high suspicion
(hyperplasia with atypia, pyometria, presence of necrosis, or persistant bleeding)

For suspected advanced stage may need:

 Cystoscopy, Sigmoidoscopy
 Pelvic and Abdominal MRI/CT find depth of tumour invasion.

• Labs
– CBC
– Liver function tests
– RFT, CXR
 Differential Diagnosis for endomaterial cancer

• Atrophic endometritis/vaginitis
• Endometrial/cervical polyps
• Endometrial hyperplasia
• Other gynecological cancers
 Prognosis
This is related to:
-Stage , grade of diseases, myomaterial
invasion, L.N involvment, age, obesity, type of
endomatrial cancer also,
Behaviors of hormone receptor:
1- O.R abandoned good.
2- P .R if present is also is good.
 Staging of Endometrial Cancer
• Stage I: Confined to uterine corpus
– IA: limited to endometrium
– IB: invades less than ½ of myometrium
– IC: invades more than ½ of myometrium
 Staging of Endometrial Cancer

Stage II : Cx involved
IIa: Endocervical gland involvement only.
IIb: Cx stromal invasion does not extend beyond
the body of the uterus.
 Staging of Endometrial Cancer
• III: local and/or regional spread
– IIIA: invades serosa/adnexa, or positive cytology
– IIIB: vaginal metastasis
– IIIC: metastasis to pelvic or para-aortic lymph nodes
 Staging of Endometrial Cancer

• IVA: Invades bladder/bowel mucosa.

• IVB: Distant metastasis.
Spread Patterns

• Direct extension ;most common

• Tran tubal
• Lymphatic;
Pelvic usually first, then para-aortic
• Hematogenous
– Lung most common(Canon-ball appearance)
– Liver, brain, bone
– Surgery is the primary intervintion fot
• Hysterectomy+bilateral Salpingo-oophorectomy
+/- Pelvic lymph node dissection
• Laparoscopic lymph node sampling
_Adjuveint therapy:
– Radiation therapy
– Chemotherapy
– Hormone therapy
• Progesterone
• Tamoxifen
 Treatment
• Stage IB or less: Total hyst/BSO/PLND, cytology
• Stage IC to IIB: total hyst/BSO/PLND, cytology,
adjuvant pelvic XRT
• Stage III: total hyst/BSO/PLND, cytology, adjuvant
chemotherapy
• Stage IV: Palliative XRT and chemotherapy

• PLND: pelvic lymph node dissection

 Five Year Survival

• Stage I  75%
• Stage II  58%
• Stage III 30%
• Stage IV 10%
• Overall 5 Y survival  70%  most Pt present
early due to abnormal vaginal bleeding
 RADICAL RADIOTHERAPY

A combination of external-beam pelvic irradiation covering the uterus, parametria

and the lymphnodes and intracavitary irradiation for the central disease is used
 Prevention and Survival
• Early detection is best prevention
• Treating precancerous hyperplasia
– Hormones (progestin )
– D&C
– Hysterectomy
– 10 ~ 30% untreated develop into cancer
 Other Types of Uterine Cancer
• Leiomyosarcoma
– Rapidly growing fibroid should be evaluated
• Stromal sarcoma
• Carcinosarcoma (MMMT)
(>age 52)

MMMT

leiomyosarcoma