1. ENDOMETRIAL CARCINOMA
Dr. Madhavi Karki

2. 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 years .

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

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

5. 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.

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

7. 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.

8. Microscopic appearance
Adenocarcinoma 80%

9. 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%.

10. 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

11. 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.

12. 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)

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

14. 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

15. 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

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

17. 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.

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

19. 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.