District 1 ACOG Medical Student Teaching Module 2009 Endometrial Cancer District 1 ACOG Medical Student Teaching Module 2009

Symptoms Post menopausal bleeding Endometrial cells on Pap Perimenopausal with irregular heavy menses, increasingly heavy menses Premenopausal with abnormal uterine bleeding with history of anovulation

Differential Diagnosis for PMB Exogenous estrogen use- ie tamoxifen Atrophic endometritis/vaginitis Endometrial/cervical polyps Endometrial hyperplasia Endometrial Cancer Other gynecologic cancers

Risk factors for Endometrial Cancer Increased estrogen Hormone therapy Obesity Anovulation/PCOS Estrogen secreting tumors Older age Infertility Early menarche Late menopause Genetics HNPCC Caucasian

Preoperative Work-up Endometrial biopsy Ultrasound For suspected advanced stage may need: Cystoscopy Sigmoidoscopy Pelvic and Abdominal CT Labs CBC Chem 7 Liver function tests EKG, CXR

Endometrial Hyperplasia (EIN) Precursor to endometrial cancer Risk of progression related to cytologic atypia Presents with abnormal bleeding Simple Benign irregular dilated glands No atypia: 1% progress Atypia: 8% progress Complex Proliferation of glands with irregular outlines, back to back crowding of glands, but no atypia No atypia: 3% progress Atypia: 29% progress

Staging of Endometrial Cancer 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 II: invades cervix but not beyond uterus IIA: endocervical gland involvement only IIB: cervical stroma involvement

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

Five Year Survival Stage I: 81-91% Stage II: 71-78% Stage III: 52-60% 72% diagnosed at this stage Stage II: 71-78% Stage III: 52-60% Stage IV: 14-17% 3% diagnosed at this stage

Spread Patterns Direct extension Transtubal Lymphatic Hematogenous most common Transtubal Lymphatic Pelvic usually first, then para-aortic Hematogenous Lung most common Liver, brain, bone

Treatment Stage IB or less: total hyst/BSO/PPALND, cytology Stage IC to IIB: total hyst/BSO/PPALND, cytology, adjuvant pelvic XRT Stage III: total hyst/BSO/PPALND, cytology, adjuvant chemotherapy Stage IV: palliative XRT and chemotherapy

Histologic Types Estrogen dependent Endometrioid- most common Non estrogen dependent- worse prognosis Papillary Serous Clear cell Adenosquamous Undifferentiated

Other Types of Uterine Cancer Leiomyosarcoma Rapidly growing fibroid should be evaluated Stromal sarcoma Carcinosarcoma (MMMT) MMMT leiomyosarcoma