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

2. 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

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

4. 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

5. 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

6. 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

7. 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

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

9. 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

10. Staging of Endometrial Cancer
IVA: invades bladder/bowel mucosa
IVB: distant metastasis

11. 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

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

13. 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

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

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