carcinoma endometrium
TRANSCRIPT
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Carcinoma Endometrium
By Sidra Javed
08-182
Batch J
Final yr MBBS
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What is Carcinoma ?
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A carcinoma is tumor tissue derived from
epithelial cells whose genome has become
altered to such an extent that it begin to
exhibit abnormal malignant properties.
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What is Endometrial carcinoma ?
• Endometrial carcinoma arises from epithelial
tissues in the lining of glands and columnar
cells constituting the surface of the
endometrium.
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Why it is important ?
• Commonest gynecological cancer
in USA and many other western
countries.
• Fourth most common cancer in
women in developed countries.
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Who are at risk ?
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1. AGE
1. Peak incidence
about 55-60 years
of life.
2. 25 % are
premenopausal.
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2. Parity
50 % have born only one or two child.
25 % are nulliparous.
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3. Late Menopause
4. Obesity
3- 10 times greater risk.
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5. Estrogen over activity
Estrogen producing
tumors. (POD)
Continuous Estrogen only
replacement therapy
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6. Endometrial hyperplasia
Atypical hyperplasia has highest risk.
( 40-60 %)
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7 . Diabetes mellitus. 3x risk
8. Hypertension
9. Radiation
10. Family history
( hereditary non polyposis colon cancer)
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Protective effect
• Smoking
• Oral contraceptive.
• Progesterone.
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Tell me its Types
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Endometrial Carcinoma
Type 1(80%)1. 50 -55 years.
2. Adenocarcinoma
3. Endometrial Hyperplasia
4. PTEN, KRAS, p53, B.catenin.
5. less aggressive, lymphatic spread.
6. Low grade, good prognosis
7. Unopposed estrogen action.
Type 2(20%)
1. 65-75 years.
2. Serous , clear, mixed mullarian
3. Endometrial intraepithelial
carcinoma.
4. P53, aneulploidy.
5. Aggressive intraperitoneal and
lymphatic spread.
6. High grade, poor prognosis
7. Not related to estrogen.
Taken from Robbins and Cotran.
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Histopathology
Grade 1 : Well differentiated, less than 5% solid growth. (40%)
Grade 2 : Moderately differented, less than 50% solid growth. (20%)
Grade 3 : Poorly differented , greater than 50% solid growth.( 40%)
1-Adenocarcinomas 80-85%
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2-Adenocarcinoma with squamous differentiation
5%
• Malignant glands with benign squamous metaplasia
• Also subdivided into 3 grades
3-Adenosquamous Ca 10-20%
• Malignant glands & malignant squamous epithelium
• Often grade 3
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4-Papillary Serous CA 10%
5-Clear cell CA 4%
6-Mucinous CA 9%
7-Secretory CA 1-2%
8-Squamous cell CA extremely rare
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How It will present ?
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Symptoms.
1. Bleeding
• Post menopausal bleeding in 75% of cases.
• In premenopausal , irregular menstruation
and menorrghia.
• Small, rarely heavy
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2. Vaginal discharge and spotting.
. Brownish or blood stained vaginal discharge.
3. Pain.
. During urination, intercourse
.In lower abdomen.
.Dull or colicky pain.
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Signs
• No typical signs.
• Distant metastasis causes indurations in the parametrical tissues, and inguinal lymph node may become palpable.
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How it spreads?
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1. Direct Spread .
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2. Through Lymphatic.
• Never occurs without myometrial invasion
• Pelvic lymph nodes common 35%
• Para-aortic lymph nodes 10-20%
Rarely involved without pelvic nodes
involvement
• Inguinal lymph nodes rare
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Through blood
•Less common route
•Involved in late stage of disease
•Occurs with recurrent or disseminated disease
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4. Implantation
• Malignant cells implantation in vagina during hysterectomy.
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How I will diagnose it ?
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1. History
2. Examination
• Physical examination of the patient with endometrial
carcinoma is frequently entirely normal, it should include
palpation of supraclavicular and inguinal lymph nodes .
• Inspection of vulva, vaginal skin in suburethral area
and cervix. ( Pyogenic discharge in case of pyometra)
• Bimanual vaginal examination assesses uterine size, and mobility
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Investigations
• Ultrasonography
• In postmenopausal UGS shows irregular and
polypoidal endometrium
• If thickness of endometrium is more than
5mm it require further investigations.
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• Endometrial sampling.
Histological investigation is
investigation of choice for diagnosis of endometrial
carcinoma.
Fractional Curettage HysteroscopyBiopsy
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Fractional Curettage
• Uterine cavity and endocervix is thoroughly curetted.
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• In the past the “gold standard” was Fractional
curettage.
• The current “gold standard” is hysteroscopy
with targeted endometrial biopsy
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Others
• MRI depth of carcinoma invasion and Lymph
node involvement
• Chest X-Ray exclude pulmonary spread.
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Differential Diagnosis
• Various causes of abnormal bleeding
• Endometrial hyperplasia
• Endometrial & Cervical polyps
• Fibroid
• Ovarian, Cervical or tubal neoplasm
• Postmenopausal Pt atrophic vaginitis, endometrial
atrophy, exogenous estrogens
• Trauma
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How it is treated ?
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• Depends upon the Stage of disease and health
of patient.
• Primary treatment is surgery.
• Radiotherapy, chemotherapy can be used in
patient with metastatic and recurrent disease.
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Stage I
IA Tumor limited to endometrium
IB Invasion <50% of myometrium
IC Invasion > 50% of myometrium
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Treatment of choice of Stage I
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• Pelvic nodes removal and radiotherapy is
recommended if more than 1/3rd of
myometrium is invaded.
• Radiotherapy is not recommended for very
early tumor for IA and IB.
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Stage II
IIA Endocervical glandular involvement only.
IIB Cervical stroma invasion.
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Radial hysterectomy with pelvic lymphodectomy
followed by radiotherapy or radiotherapy alone.
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Stage III
IIIA Tumor invade to serosa or adnexae or positive
peritoneal cytology.
IIIB Vaginal metastases
IIIC Metastasis to pelvic and para-aortic lymph node.
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• If disease is restricted to pelvis than radiotherapy
alone is treatment of choice.
• Otherwise laparotomy recommended for accurate
staging and tumor debulking.
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Stage IV
IVA Tumor invade bladder and bowl mucosa.
IVB Distant metastasis.
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Aim is to relief the patient
• Radiotherapy.
• Debulking through palliative surgery.
• Cytotoxic drugs.
• Hormonal therapy.
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• Progestogens
The role of chemotherapy is limited
• Anthracycline.
• Doxorubine.
• platinum drugs
Adjuvant hormonal therapy
Inj. Medoxyprogesterone.
Inj hydroxyprogesterone caproate.
Tab. Norethisterone.
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Follow up
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Prognosis
The 5 year survival rate for endometrial Ca :
• Stage I 75%
• Stage II 58%
• Stage III 30%
• Stage IV 10%
• Overall 5 year survival 70% most Patients
present early due to abnormal vaginal bleeding.
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So we know
• Endometrial carcinoma
• Its etiology, signs and symptoms.
• Its diagnosis, treatment and prognosis.