endo ca
DESCRIPTION
endometrial cancerTRANSCRIPT
Moderator : Dr. V.V. Padhmalatha
Most common malignancy of female genital tract.
4th most common cancer.
Overall incidence – 2%- 3%
80% - age of 60-70 years ; <5% under 40 years.
Exaggerated physiological state
Carcinoma in situ
Due to protracted estrogen
stimulation in the absence of
progestin.
Non Atypical hyperplasia ( without atypia)
Simple hyperplasia - 1%
Complex hyperplasia – 3%
(adenomatous hyperplasia)
Atypical hyperplasia
Simple atypical hyperplasia – 8%
Complex atypical – 29%
(atypical adenomatous hyperplasia)
SIMPLE HYPERPLASIA
(WITHOUT ATYPIA)
ATYPICAL
HYPERPLASIA
Sporadic:
Type 1 ( 75-85%)
estrogen dependant
Type 2 ( 5%)
non- estrogen dependant
more in African – American , Asian women
Hereditory:
HNPCC or Lynch II Syndrome
Autosomal Dominant
32- 60% risk
TYPE I TYPE II
MENOPAUSALSTATUS
PERI-MENOPAUSAL
POSTMENOPAUSAL
ESTROGENRELATED
YES NO
ESTROGEN OR PROGESTRONE
RECEPTOR
POSITIVE NEGATIVE
HISTOLOGY PROLIFERATIVE ATROPHIC
TYPE I TYPE II
BUILT OBESE THIN
GRADE LOW HIGH
HISTOLOGYSUBTYPE
ENDOMTERIOD SEROUS/ CLEAR CELL
CLINICALBEHAVIOUR
INDOLENT AGGRESSIVE
RISK FACTORS REALATIVE RISK
NULLIPARITY 2-3
LATE MENOPAUSE 2.4
OBESITY 3-10
DIABETES MELLITUS 2.8
UNOPPOSED ESTROGEN THERAPY
4-8
TAMOXIFEN THERAPY 2-3
ATYPICAL ENDOMETRIALHYPERPLASIA
8-29
LYNCH-II SYNDROME 20
Tamoxifen:
- competitive inhibitor of estrogen binding to ER.
- ACOG recommends:
• Benefits outweigh the risk
• Annual gynecologic examination
• Report any abnormal vaginal symptoms and investigated
• Hysterectomy if atypical endometrial hyperplasia
• Classify as high and low risk grps prior to starting therapy
• Tamoxifen not found to be benifical beyond 5 years
Unopposed Estrogen:
• Endogenous
functional ovarian tumor
Obesity – androstenedione estrone
- SHBG
• Exogenous - HRT
Protective Factors:
OCPs
Physical activity
Smoking – stimulation of hepatic
metabolism of estrogens
No role of routine screening.
Routine Papanicolaou testing
- 30-50% have abnormal test
Screening of high risk individuals
1. Lynch II syndrome – annual pevic
examination, TVS, EB beginning from
30-35 years of age.
2. risk with positive history in first degree
relative ( CASH study) – 3 fold
Post menopausal bleeding with
exogenous estrogen
Premenopausal with anovulatory cycles.
75% pt older than 50 years.
90% - vaginal bleeding or discharge.
10% of PMB will have endometrial ca.
Pelvic pressure or discomfort
Presence of hematomtera or pyometra, causing purulent vaginal discharge.
5% are asymptomatic
Premenopausal woman –
abnormal uterine bleeding
menometrorrhagia
oligomenorhea
cyclical bleeding beyond usual age
CAUSE PERCENTAGE
Endomterial
atrophy
60-80
estrogen
replacement therapy
15-25
Endometrial polyp 2-12
Endometrial hyperplasia 5-10
Endometrial cancer 10
Local
- endometritis
- cervical polyp
- cervicitis
- senile atrophic vaginitis
- vulval dystrophy
-submucous fibroid
- ca cervix
Systemic – bleeding disorders,
endogenous estrogen
Associated constitutional factors- obesity,
hypertension, diabetes – corpus cancer
syndrome.
Physical examination:
site of metastasis – peripheral lymph node,
breast
abdominal examination- ascites, hepatic or
omental metastasis
Pelvic Examination:
vaginal and cervical examination
suburetheral area
Bimanual rectovaginal examination
-uterine size and mobility
-adnexa for masses
- parametrium
- POD for nodularity
DIRECT :
cavity to cervix
fallopian tube ovaries, peritoneal cavity.
invading endometrium serosal surface, parametrium and pelvic wall
rarely to pubic bone
HEMATOGENOUS :
to lung, live
occurs with recurrent ca.
CLINICAL STAGING:
- for patient not fit for surgery
- due to gross cervical invovement,
parametrial spread,invasion to bladder
and rectum
- distant metastsis- liver, lung,
virchow’s node.
PATHOLOGICAL
CLASSSIFICATION
A. Endometrioidadenocarcinoma
(80%)
- villoglandular or papillary(2%)
- secretory
-with squamousdifferentiation(15-25%)
SQUAMOUS
DIFFERENTIATIONVILLOGLANDULAR
B. Mucinous carcinoma: (5%)
-cells with intracytoplasmic mucin
- should be differentiated from
endocervical carcinoma.
-positive immunohistochemical
staining with vimentin.
C.Papillary serous
carcinoma
-3-4%
-similar to ca
of ovary and
fallopian tube
-psammoma
bodies
- high- risk
lesion
D. Clear Cell
Carcinoma
-< 5%
-Cells arrange in
hobnail
configuration
- Poor prognosis
E. Squamous carcinoma of endometrium
- rare
-associated with cervical stenosis, chronic inflammation, pyometra.
- poor prognosis
F. Synchronous tumor of the endometrium and ovary
- 1.4 – 3.8%
- well diff. adenocarcinoma – good prognosis
FACTORS PROGNOSIS
AGE Increase recurrence by 7%
for every 1 year inc. in age
HISTOLOGIC TYPE Non- endometrioid
HISTOLOGIC GRADE Tumor with grade 3
TUMOR SIZE Size > 2cm
HORMONE RECEPTOR
STATUS
Estrogen and
progesterone + ve tumors
( better prognosis)
DNA Ploidy and
Proliferative index
Inc. aneuploid cells – bad
prognosis
Myometrial invasion Inc. depth of invasion – inc.
spread and recurrence
Lymph-Vascular
invasion
Present – poor prognosis
Isthmus and cervix
extension
Increased recurrence
Peritoneal cytology Recurrence when present
other poor prognostic factors
Adnexal or uterine
serosal involvement
Poor prognosis
Lymph node metastasis 90% - without l.n
54%- with l.n
Intraperitoneal
metastasis
Poor prgnosis
Rare tumor of meodermal origin.
2-6% of uterine malignancies
Increased incidence after radiation therapy for ca cervix or bening condition.
Most common histologic variants:
- leiomyosarcoma and cacinosarcoma(40%)
-endometrial stromal sarcoma(15%)
Endometrial Stromal Tumor
- perimenopausal women
- symptoms – abnormal uterine bleeding, pain
and pressure
-3 types
I. Endometrial stromal nodule
II. Endometrial stromal sarcoma
III. Undifferentiated sarcoma
Leiomyosarcoma43- 53 years
short duration of symptoms
variants-
I. Myxoid lieomyosarcoma
II. Leiomyoblastoma
III. Intravenous leiomyomatosis
IV. Benign metastasizing leiomyomatosis
V. Disseminated peritoneal leiomyomatosis
Carcinosarcoma / malignant mixed
mullerian tumor :
- mixture of glandular and sarcomatous
elements
- median age of 62 years
- post menopausal bleeding(80-90%)
- highly malignant extension beyond
uterus in 40-60%
Berek’s and Novak’s gynecology -15 th ed.
Clinical gynecology, Berek’s and Novak’s
Histopathology of endometrial ca, Lars-
Chrisitan Horn et al
ACOG – Tamoifen and uterine ca, June 2006