Endometrial Carcinoma

Fuat Demirkıran, MDIstanbul University, CerrahpaşaSchool Of Medicine, OB&GYNDepartment, Gyn Oncology

In developed countries, cancer of the uterine corpus is the most common malignancy seen in the female pelvis today

It is the fourth most common cancer in women.

2%

3%

22%

24%

49%

GTT

Vulva

Cervix

Endomet

Ovary

N: 1730

CTF Gynecol Oncol 2004

GTN2%

Vulva3%

Endometrium24%

Cervix22%

Ovary49%

Gyneco

logic m

alignancy

EPIDEMIOLOGY and Risk Factors

The median age for adenocarcinoma of the uterine corpus is 61 years, with the largest number of patients noted between the ages of 50 and 59

years.

Approximately 5% of women will have adenocarcinoma before the age of 40, and 20% to

25% will be diagnosed before the menopause.

EPIDEMIOLOGY and Risk Factors

The use of combination oral contraceptives (OC) decreases the risk of developing endometrial

cancer.

Cigarette smoking apparently decreases the risk of developing endometrial cancer. The RR

decreased by about 30% when one pack of cigarettes was smoked per day

increased risk   obesity increases the risk.....related to depressed SHBG in obese women

  nulliparity and late menopause have increased risk .....related to unoppesed estrogen ·      

DDM and hypertansion are frequently associated with EC·      

The use of continuous estrogen increases the risk of EC·     

  Tamoxifen.......related to its estrogenic effect on endometrium ·     

  PCO·      

Granulosa cell tumor

Risk factors for Endometrial cancer

Risk factors Risk

Obesity Overweight 21-50 lb 3´ >50 lb 10´

Nulliparity Compared with 1 child 2´ 5 or more children 3´

Late menopause Age >52 yr 2.4´

Endometrial cancer filling endometrial cavity

Endometrial cancer spreading cervix

1. abnormal uterine bleeding in premenopausal period(prolonged and heavy menstruel periods and intermenstruel spoting may be related to EC.) 2. postmenopausal bleeding in postmenopausal periodas the patient’s age increases after the menopause,the probability of EC with uterine bleeding increases progressively.

Symptoms of Endometrial Cancer

Distribution of endometrial carcinoma by stage(surgical)

Stage Patients

I 73 % II 12 % III 12 % IV 3 %

Classification of Endometrial Cancer

Endometrioid adenocarcinomas (Type I)

Usual SecretoryVilloglandular or papillaryWith squamous differantiation

Special(non-enometrioid) variant carcinomas(Type II)

Papillary serous (UPSC)Clear cell(CCC)Mucinous Pure squamous cellMixedUndifferentiated

Endometrial sampling(Biopsy)

CytologyEndometrial cytology to make the diagnosis of EC have been less successful than sampling.only 1/3 and ½ of the patients with EC have abnormal c-v smear. 

Hysterograhpy and hysteroscopy are adjuvants methods in making the diagnosis of EC 

USG is a diagnostic tool particularly in postmenopausal women to diagnose endometrial pathology and to evaluate depth of MI of EC Tumor markers and MRI

Diagnosis of Endometrial Cancer

Which technique forendometrial biopsy ?

D&C

Pipelle-endorette

Hysteroscopy

D&C

the oldest technique

reasonable accuracy rate

need general anaesthesia

complications

Gold-standard technique !

False negative rates of D&C are as high as 6 and 10%.

It is found that in approximately 60% of the D&C procedures, less than half of the uterine cavity is

curetted

Brooks et al, Grimes et al Am Obstet Gynecol 1988, 1982

Stock et al. Am J Obstet Gynecol 1975

Pipelle-Endorettedoesn’t need anaesthesia

inexpensive

easily used

the rate of adequate sampling!

histopathologic agreement with others techniques!

The Rates of Sufficient Endometrial Sample with

Pipelle (-endorette)

Stovall et al., 1991......Cancer............... 98%

Fothergill et al., 1992......All pathology..... 84%

Momerger et al., 1998......All pathology.... 95%

Monganiello et al.,, 1998..... All pathology..... 99%

Thanuja ve ark, 2000.....All pathology..... 89%

Epstein et al., 2001....All pathology......... 71 %

The failure rate of endometrial sample .......1-30 %

The false negative rate........5-15 %

Hysteroscopy

False negative rate 3%

end-point diagnostic work-up for endometrial pathology

PROGNOSTIC FACTORS IN ENDOMETRIAL ADENOCARCINOMA

Histologic type (pathology)

Stage of disease

Histologic differentiation

Myometrial invasion

Peritoneal cytology

Lymph node metastasis

Adnexal metastasis

Stage and five-year survival in endometrial cancer

Stage Survival I 86 % II 66 % III 44 % IV 16 %

Tumor differentiation and 5-year survival rate stage I (surgical)

Grade Survival 1 94% 2 88% 3 79%

Relationship between depth of myometrial invasion and 5-year survival rate

MI Survival rate

<1/3 82.4 %

1/3-1/2 78.0 %

>1/2 66.8 %

FIGO 2009 IA

IB

II

IIIC1IIIC2

Treatment

Total abdominal hysterectomy (TAH) +

Bilateral salpingo-oophorectomy + pelvic

and paraaortic

lympadenectomy should be done

After getting pathologic results , adjuvant

treatment is being decided according to risk

factors

IA IB IC II ve >

Grade I Br-RT

Grade II

Br-RT

Grade III

Br-RT Br-RT

Ex-RT

Ex-RT

Ex-RT Ex-RT

Adjuvant Therapy Following Surgery

Ex-RT: External radiotherapyBr-RT: Brachytherapy

Br-RT ?

With vertical incision

TreatmentLow-risk = stage Ia / Ib + grade I-II

( myometrial involvement < 1/2

peritoneal cytology negative No more therapy

lymph node negative )

High- risk = Other conditions greater than low-risk

papiller / clear cell

Adjuvant Radiotherapy (Pelvic / paraaortic )

Treatment of Advanced Stage Endometrial Carcinoma

SurgeryTAH +BSO

Cytoreduction Pelvic & para-aortic Lymphadenectomy

Adjuvant Therapy..RT, CT & hormone

Treatment

Treatment of patients with stage III-IV

disease must be individualized;

however, in most instances hormonal

treatment or chemotherapy, or both,

must be used in addition to surgery and

radiation therapy.