gynecology
oj
kk
Total Lectures :20
Dr. Maad
Endometrial cancer
Lec . 5
Done by :
Ali Faleh
2016-2017
مكتب اشور لالستنساخ
ENDOMETRIAL CARCENNOMA Dr. Maad
[Year]
1
By : Ali Faleh
ENDOMETRIAL CARCENNOMA
It is the most common malignancy of the females genital tract in the western world and
the most common cancer in women after breast ,lung and colorectum .
Black women have a 40% lower risk of the disease but a 54% greater risk of dying from
it, mainly because of late diagnosis . Two different clinicopathological subtype of
endometrial cancer are recognized :
Esterogen related (type 1 , endometroid )
Non estrogen related (type 2 non endometroid )
Approximately 80% of newly diagnosed CA is type 1
Still there is no ideal mass screening for E CA
Patient who is in need for assessment to exclude endometrial CA include :
1- post menopausal women on exogenous estrogen without progestin
2-Women with family history of nonpolyposis colorectal cancer syndrome .
3- premenopausal women with anovulatory cycles, such as those with poly cystic
ovarian syndrome
• Only approximately 50% of women with endometrial cancer have malignant cells
on a Pap smear and are more likely to have deeper myometrial invasion, higher
tumor grade , positive peritoneal cytological findings , and more stage of disease
When there is no cervical cells in Pap smear the prevalence of (pre)malignant
disease is 0.2% When normal endometrial cells were found in the cervical smear ,
the prevalence is about (6.5%) In case of abnormal endometrial cells are present,
then approximately 25% of women have endometrial CA .
• Several available devices have been developed to allow direct sampling like
Pipelle ,Gyno Sampler ,Vabra aspirator ,Novak or Kevorkian curette, .A
metaanalysis reported that the Pipelle was the best device , with detection rates
ENDOMETRIAL CARCENNOMA Dr. Maad
[Year]
2
By : Ali Faleh
for endometrial cancer in postmenopausal and premenopausal women of 99.6%
and 91% respectively .
• In 1990s, transvaginal u/s ,with or without color-flow imaging, was investigated as
a screening technique , Mean thickness of the endometrial strip was measured
as 3.4± 1.2mm in women with atrophic endometrial , 9.7±2.5mm in women with
hyperplasia, and 18.2±6.2mm in women with endometrial cancer.
• A meta-analysis reported that 4% of endometrial cancer would be missed using
transvaginal u/s for the investigation of postmenopausal bleeding , with false
positive rate as high as 50% .
• Tamoxifen increase the risk of Endo Ca 2- 3 folds and produce a songraphically
unique picture of an irregularly echogenic endometrium that is attributed to
cystic glandular dilatation , edema, and hyperplasia of the adjacent myometrium.
• Patient taking tamoxifen should be informed of the increased risk of endometrial
cancer and told to report any abnormal bleeding or spotting immediately. And
must be investigated by biopsy .
Clinical features :
SYMPTOMS
: 90% of patient with endo ca will have abnormal uterine bleeding ,
intermenstrual bleeding , heavy prolonged bleeding in premenopausal or an ovulatory
premenopausal women , post menopausal pyometra .
Signs :
Patient commonly obese ,hypertensive ,post menopausal, one third are not
over weight.
Abdominal examination is unremarkable except in advanced cases when ascites may be
present and hepatic or omental mass arising from the pelvis ON examination , it is
important to inspect and palpate the vulva , vagina, and cervix to exclude metastatic
spread or other causes of abnormal vaginal bleeding , the uterus may be bulky , but
often it is not significantly enlarged .
ENDOMETRIAL CARCENNOMA Dr. Maad
[Year]
3
By : Ali Faleh
• Rectovaginal examination should be preformed to evaluate the fallopian tubes ,
ovaries and cul-de- sac , to exclude metastesis,or ovarian mass (granulosa cell
tumors, thecoma or epithelial carcinoma .
DIAGNOSIS
1- All patients suspected of having endometrial Ca should have
an endocervical
curettage
and an office endometrial biopsy and there is false negative rate 10%, a
negative endometrial biopsy in a symptomatic patient must be followed by a fractional
curettage under anesthesia. Hysteroscopy is good but there is a speculation that fluid
hysteroscopy may facilitate the abdominal dissemination of malignant cells .
2- Fractional curettage: under GA careful bimanual rectovaginal examination is
performed, the endocervical canal is curetted before cervical dilatation , and the tissue
placed in a specially labeled container. The uterus then is sounded , the cervix dilated,
and the endometrium systematically curetted. The tissues is placed in a separated
container so that the histologic status of the endocervix and endometrium can be
determined separately .
Pre operative investigations :
1- Full blood count 2- Serum creatinine and electrolytes
3- Liver function test 4- Blood sugar
5- Urinalysis
6- CT scan of the chest , pelvis ,and abdomen ,particularly for high risk histological ,but
it has limited usefulness in determining the depth of myometrial invasion or the
presence of nodal disease .
7- MRI is good for differentiation between low and high risk patient i.e. for evaluation of
the depth of myometrial invasion , lymph node involvement .
ENDOMETRIAL CARCENNOMA Dr. Maad
[Year]
4
By : Ali Faleh
8- Positron emission tomography ,PET , it has higher sensitivity for the detection of extra
uterine lesion but has limited utility due to its inability to identify lymph nodes less than
1 cm in diameter .
9- Elevated CA125 levels have been demonstrated to correlate with advanced
stages of disease and positive L N status .
Staging :
•
Histopathology
: 1- Endomertroid ( adeno ca, adenoacanthoma:
adenocarcenoma with squamous carcinoma )
2- Non endometroid : Mucinous adenocarcinoma, serous adenocarcinoma .
• clear cell adenocarcinoma , undifferentiated carcinoma,Mixed carcinomas that
contain more than one type with at least 10% of each component .
Histological grades
:
• GX: grade can not be assessed
• G1: well differentiated , <5% of a nonsequamous or nonmorular solid growth
pattern .
• G2: Moderately differentiated, 6%- 50% of a non squmous or nonmorular solid
growth pattern .
• G3: POORLY DIFERENTIATED , >50% .
FIGO staging
• Stage 1: tumor confined to the corpus uteri
• 1A, No or less than ½ myometrial invasion
• 1B , Invasion equal to or more than ½ of the M
Stages
ENDOMETRIAL CARCENNOMA Dr. Maad
[Year]
5
By : Ali Faleh
• I a Tumor confined to the corpus uteri
• IA a No or less than half myometrial invasion
• IB a Invasion equal to or more than half of the myometrium
• II a Tumor invades cervical stroma, but does not extend beyond the uterus b
• III a Local and/or regional spread of the tumor
• IIIA a Tumor invades the serosa of the corpus uteri and/or adnexae c
• IIIB a Vaginal involvement and/or parametrial involvement
• IIIC a Metastases to pelvic and/or para-aortic lymph nodesc
• IIIC1 a: Positive pelvic nodes
• IIIC2 a: Positive para-aortic nodes with or without positive pelvic lymph nodes
• IV a Tumor invades bladder and/or bowel mucosa, and/or distant metastases
• IVAa Tumor invasion of bladder and/or bowel mucosa
• IVBa Distant metastasis, including intra-abdominal metastases and/or inguinal
nodes
Prognostic tumor characteristics for high-risk disease
• The recommended histopathologic criteria for determining high risk disease are
as follows:
1- Tumor grade 3 (poorly differentiated).
2- More than 50% of myometrial invasion.
ENDOMETRIAL CARCENNOMA Dr. Maad
[Year]
6
By : Ali Faleh
3- Lymphovascular space invasion.
4- Non-endometrioid histology (serous, clear cell, undifferentiated,
5- small cell anaplastic•
6- Cervical stromal involvement.,.
• In 1988, the FIGO Cancer Committee changed the official FIGO
• staging from clinical to surgical for endometrial cancer. Since that
recommendation, considerable debate has ensued as to what constitutes an
internationally acceptable approach.
A generally recommended protocol would be that the abdomen should be opened with
a vertical midline abdominal incision and peritoneal washings taken immediately from
the pelvis and abdomen, followed by careful exploration of the intra-abdominal
contents.
• The omentum, liver, peritoneal cul-de-sac, and adnexal surfaces should be
examined and palpated for any possible metastases, followed by careful palpation
for suspicious or enlarged nodes in the aortic and pelvic areas.
The standard surgical procedure :
• should be an extrafascial total hysterectomy with bilateral salpingoophorectomy
• Adnexal removal is recommended even if the tubes and ovaries appear normal, as
they may contain micro metastases .
• Vaginal cuff removal is not necessary, nor is there any benefit from excising
parametrial tissue in the usual case.
• If cervical stromal involvement is demonstrated preoperatively, or if unsuspected
involvement is noted and can be encompassed by a modified radical
hysterectomy,
ENDOMETRIAL CARCENNOMA Dr. Maad
[Year]
7
By : Ali Faleh
• whether or not lymphadenectomy has been performed, adjuvant radiotherapy is
not indicated for patients with grade 1-2 tumors and no more than 50%
myometrial invasion, or for those with only a single risk factor .
• For patients with high– intermediate risk factor (at least 2 of the factors: age >60
years, deep myometrial invasion, grade 3, serous or clear cell LVSI) ,
vaginal brachytherapy alone is preferable to EBRT, providing excellent vaginal control
without impacting on quality of life in patient with higher –risk disease (3 or more risk
factors, Stages II and III), the roles of EBRT and/or chemotherapy are currently being
investigated .
Progestogen therapy
• This has been widely prescribed in the past, but a meta-analysis of 6 randomized
trials involving a total of 3339 women has shown nosurvival benefit for adjuvant
progestogen therapy in endometrial cancer . A subsequently published
randomized trial of 1012 women also failed to demonstrate any survival benefit .
Stage II
• Patients with clinically occult Stage II disease are generally managed in a similar
fashion to patients with Stage I disease.
• Radical hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic
lymphadenectomy, and selective aortic node dissection can be used as primary
treatment for clinically overt cervical involvement.
• Preoperative MRI scanning is advisable to exclude bladder involvement and
ensure local resectability.
• Studies indicate excellent results for this approach, with no benefit from the
addition of radiation for patients with negative nodes .
ENDOMETRIAL CARCENNOMA Dr. Maad
[Year]
8
By : Ali Faleh
• Adjuvant radiotherapy is usually reserved for patients with involved nodes and/or
close or involved surgical margins ,If surgery is not considered feasible because of
tumor extension, full pelvic radiotherapy and intracavitary brachytherapy, as in
cervical cancer, may be employed.
• Patients with presumed Stage III disease because of adnexal involvement should
have full surgical staging and expert pathologic examination of the specimen, as
primary tumors of both the ovary and the endometrium may be present.
• Management should be individualized, and based on the stage of each tumor
• Patients with clinical Stage III endometrial carcinoma that is not felt to be
resectable by virtue of vaginal or parametrial extension are best treated primarily
by pelvic irradiation. Once therapy has been completed, exploratory laparotomy
should be considered for those patients whose disease now appears to be
resectable .
Stage IV
• Patients with Stage IV disease based on intraperitoneal spread can benefit from
cytoreductive surgery only if there is no residual tumor.
• Neoadjuvant chemotherapy is an option, particularly if ascites is present, and
postoperative morbidity is considered likely in Patients with evidence of extra-
abdominal metastase usually managed with systemic platinum-based
chemotherapy, or hormonal therapy if grade 1 and/or receptor positive.
• Combination chemotherapy is the treatment of choice in advanced-stage disease
as well as in relapsed disease.
• Pelvic radiotherapy in Stage IV disease may be used to provide local tumor control
and/or to treat symptoms such as vaginal bleeding or pain from a local tumor
mass, or leg edema due to lymph node involvement.
• Palliation of brain or bone metastases can be effectively obtained with short
courses (1–5 fractions )