ENDOMETRIAL CARCINOMA Dr. Madhavi Karki

INCIDENCE : Most common gynecological malignancy . Third most common cause of gynecologic cancer death . It usually is a disease of peri-menopausal age women, the peak incidence is 55-60 years .

RISK FACTORS: High levels of estrogen Nulliparity (never having carried a pregnancy) Infertility (inability to become pregnant) Early menarche Late menopause Obesity Hypertension Diabetes

Feminizing ovarian tumors Contd.... Feminizing ovarian tumors Fibroids Polycystic ovarian disease Dysfunctional uterine bleeding Tamoxifen

PATHOPHYSIOLOGY The mediating factor for endometrial carcinoma appears to be unopposed oestrogen.There will be excessive hyper stimulation of the endometrium without the stabilizing effect of the progesterone.

Pathology Naked eye: The uterus may be smaller, normal or even enlarged due to myomyetrial involvement.

It may be either localized or diffuse. localised diffuse The usual site is the Fundus. It is either sessile or pedunculated. Myometrial involvement is late. The spread is through the endometrium. The myometrium is commonly invaded.

Microscopic appearance Adenocarcinoma 80%

Spread Direct Lymphatic Lymphatic spread includes pelvic,paraaortic and rarely involves inguinal and femoral lymph nodes. The tubes and ovaries may be involved either directly or lymph node metastasis. It is confined to the endometrium for a longer period of time. Then it spread to involve the myometrium and spread to the parametrium or into the peritoneal cavity. It may spread downward to involve the cervix in 15%.

SIGNS SYMPTOMS Pallor is present Postmenopausal bleeding which may be slight, irregular or continuous. Watery and offensive vaginal discharge may be present. Pain is present. SIGNS Pallor is present

Bimanual examination Speculum examination Healthy looking cervix and blood and purulent offensive discharge escapes out external os. Uterine size may be either normal or enlarged. Regional lymph nodes may be enlarged if it has metastasize.

Diagnosis 1.Endometrial biopsy 2.Hysteroscopy-Direct visualization of the endometrium. 3.USG-Thickness of the lining of the endometrium .Findings are endometrial thickness >8mm,hyoerechoeic areas with irregular outline (in postmenopausal women endometrial thickness must be less than 5mm)

Differential Diagnosis : 1. Endometrial Carcinoma 2. Vaginal or Endometrial Atrophy 3. Postmenopausal Hormonal Replacement Therapy

STAGING Stage II: Extension to the cervix Stage I: Spread limited to the uterus. Ia: Limited to the endometrium Ib: Invasion of less than half of myometrium Ic: Invasion of more than half of myometrium Stage II: Extension to the cervix IIa: Involves only endocervical glands IIb: Invasion of cervical stroma

Stage III: Spread adjacent to the uterus Stage IV: Spread further from the uterus IVa: Involves the bladder or rectum IVb: Distant metastasis Stage III: Spread adjacent to the uterus IIIa: Invades serosa or adnexa or positive cytology IIIb: Invasion of vagina IIIc: Invasion of para-aortic nodes

MANAGEMENT: Negative Histology: Endometrial sampling –negative Treatment: Hormone Replacement Therapy Positive Histology: Endometrial sampling -positive Treatment: Adenocarcinoma Treatment Surgery

Good / Poor Prognosis( postoperative pathology report) SURGICAL THERAPY Total Abdominal Hysterectomy(TAH) and Bilateral Salpingo - oophorectomy(BSO), pelvic and para-aortic lymphadectomy, and peritoneal washings. RADIATION THERAPY: Good / Poor Prognosis( postoperative pathology report) Poor prognostic Factors: - metastasis to lymph node >50% myometrial invasion positive surgical margins - Poorly differentiated histology. CHEMOTHERAPY : For metastatic disease and involves progestins and cytotoxic agents.

TAH-BSO : BASIC TREATMENT FOR ALL STAGES STAGE I TAH-BSO only STAGE II + RADIATION STAGE III +RADIADION & CHEMOTHERAPY STAGE IV +RADIATION & CHEMOTHERAPY

Prevention Postmenopausal women taking estrogen replacement therapy must be given progestin's to unoppose the action of estrogen. PCO women must be given progestin's to unoppose the action of estrogen.