endometrial carcinoma fuat demirkıran, md istanbul university, cerrahpaşa school of medicine,...
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Endometrial Carcinoma
Fuat Demirkıran, MDIstanbul University, CerrahpaşaSchool Of Medicine, OB&GYNDepartment, Gyn Oncology
In developed countries, cancer of the uterine corpus is the most common malignancy seen in the female pelvis today
It is the fourth most common cancer in women.
2%
3%
22%
24%
49%
GTT
Vulva
Cervix
Endomet
Ovary
N: 1730
CTF Gynecol Oncol 2004
GTN2%
Vulva3%
Endometrium24%
Cervix22%
Ovary49%
Gyneco
logic m
alignancy
EPIDEMIOLOGY and Risk Factors
The median age for adenocarcinoma of the uterine corpus is 61 years, with the largest number of patients noted between the ages of 50 and 59
years.
Approximately 5% of women will have adenocarcinoma before the age of 40, and 20% to
25% will be diagnosed before the menopause.
EPIDEMIOLOGY and Risk Factors
The use of combination oral contraceptives (OC) decreases the risk of developing endometrial
cancer.
Cigarette smoking apparently decreases the risk of developing endometrial cancer. The RR
decreased by about 30% when one pack of cigarettes was smoked per day
increased risk obesity increases the risk.....related to depressed SHBG in obese women
nulliparity and late menopause have increased risk .....related to unoppesed estrogen ·
DDM and hypertansion are frequently associated with EC·
The use of continuous estrogen increases the risk of EC·
Tamoxifen.......related to its estrogenic effect on endometrium ·
PCO·
Granulosa cell tumor
Risk factors for Endometrial cancer
Risk factors Risk
Obesity Overweight 21-50 lb 3´ >50 lb 10´
Nulliparity Compared with 1 child 2´ 5 or more children 3´
Late menopause Age >52 yr 2.4´
Endometrial cancer filling endometrial cavity
Endometrial cancer spreading cervix
1. abnormal uterine bleeding in premenopausal period(prolonged and heavy menstruel periods and intermenstruel spoting may be related to EC.) 2. postmenopausal bleeding in postmenopausal periodas the patient’s age increases after the menopause,the probability of EC with uterine bleeding increases progressively.
Symptoms of Endometrial Cancer
Distribution of endometrial carcinoma by stage(surgical)
Stage Patients
I 73 % II 12 % III 12 % IV 3 %
Classification of Endometrial Cancer
Endometrioid adenocarcinomas (Type I)
Usual SecretoryVilloglandular or papillaryWith squamous differantiation
Special(non-enometrioid) variant carcinomas(Type II)
Papillary serous (UPSC)Clear cell(CCC)Mucinous Pure squamous cellMixedUndifferentiated
Endometrial sampling(Biopsy)
CytologyEndometrial cytology to make the diagnosis of EC have been less successful than sampling.only 1/3 and ½ of the patients with EC have abnormal c-v smear.
Hysterograhpy and hysteroscopy are adjuvants methods in making the diagnosis of EC
USG is a diagnostic tool particularly in postmenopausal women to diagnose endometrial pathology and to evaluate depth of MI of EC Tumor markers and MRI
Diagnosis of Endometrial Cancer
Which technique forendometrial biopsy ?
D&C
Pipelle-endorette
Hysteroscopy
D&C
the oldest technique
reasonable accuracy rate
need general anaesthesia
complications
Gold-standard technique !
False negative rates of D&C are as high as 6 and 10%.
It is found that in approximately 60% of the D&C procedures, less than half of the uterine cavity is
curetted
Brooks et al, Grimes et al Am Obstet Gynecol 1988, 1982
Stock et al. Am J Obstet Gynecol 1975
Pipelle-Endorettedoesn’t need anaesthesia
inexpensive
easily used
the rate of adequate sampling!
histopathologic agreement with others techniques!
The Rates of Sufficient Endometrial Sample with
Pipelle (-endorette)
Stovall et al., 1991......Cancer............... 98%
Fothergill et al., 1992......All pathology..... 84%
Momerger et al., 1998......All pathology.... 95%
Monganiello et al.,, 1998..... All pathology..... 99%
Thanuja ve ark, 2000.....All pathology..... 89%
Epstein et al., 2001....All pathology......... 71 %
The failure rate of endometrial sample .......1-30 %
The false negative rate........5-15 %
Hysteroscopy
False negative rate 3%
end-point diagnostic work-up for endometrial pathology
PROGNOSTIC FACTORS IN ENDOMETRIAL ADENOCARCINOMA
Histologic type (pathology)
Stage of disease
Histologic differentiation
Myometrial invasion
Peritoneal cytology
Lymph node metastasis
Adnexal metastasis
Stage and five-year survival in endometrial cancer
Stage Survival I 86 % II 66 % III 44 % IV 16 %
Tumor differentiation and 5-year survival rate stage I (surgical)
Grade Survival 1 94% 2 88% 3 79%
Relationship between depth of myometrial invasion and 5-year survival rate
MI Survival rate
<1/3 82.4 %
1/3-1/2 78.0 %
>1/2 66.8 %
FIGO 2009 IA
IB
II
IIIC1IIIC2
Treatment
Total abdominal hysterectomy (TAH) +
Bilateral salpingo-oophorectomy + pelvic
and paraaortic
lympadenectomy should be done
After getting pathologic results , adjuvant
treatment is being decided according to risk
factors
IA IB IC II ve >
Grade I Br-RT
Grade II
Br-RT
Grade III
Br-RT Br-RT
Ex-RT
Ex-RT
Ex-RT Ex-RT
Adjuvant Therapy Following Surgery
Ex-RT: External radiotherapyBr-RT: Brachytherapy
Br-RT ?
With vertical incision
TreatmentLow-risk = stage Ia / Ib + grade I-II
( myometrial involvement < 1/2
peritoneal cytology negative No more therapy
lymph node negative )
High- risk = Other conditions greater than low-risk
papiller / clear cell
Adjuvant Radiotherapy (Pelvic / paraaortic )
Treatment of Advanced Stage Endometrial Carcinoma
SurgeryTAH +BSO
Cytoreduction Pelvic & para-aortic Lymphadenectomy
Adjuvant Therapy..RT, CT & hormone
Treatment
Treatment of patients with stage III-IV
disease must be individualized;
however, in most instances hormonal
treatment or chemotherapy, or both,
must be used in addition to surgery and
radiation therapy.