Endometrial cancer is the most common gynecologic cancer. It has a lifetime risk of 2.4% in white women. Risk factors include obesity, late menopause, diabetes, and unopposed estrogen exposure. Diagnosis is usually made with endometrial biopsy. Treatment involves hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection. Adjuvant radiation and/or chemotherapy may be used in high risk cases. With early stage diagnosis, endometrial cancer has a good prognosis.
2. Endometrial cancer
– The most common ♀ pelvic genital cancer .
– The life time risk of developing endometrial Ca is
2.4% in white women & 1.3% in black (In USA).
– Age:
Peak incidence in the 6th
& 7th
decade of life (disease of
postmenopausal women).
Only 2-5% occur before 40 years.
– Higher survival rate due to early diagnosis ( 75%
diagnosed in Stage I).
– Estrogen has been implicated as a causative factor.
3. These risk factors are only helpful in identifying
women at risk for type I disease.
4. Risk factors for endometrial cancer
OLD AUNT
O=Obesity
L=Late menopause
D=Diabetes mellitus
A=cAncer: ovarian, breast, colon
U=Unopposed estrogen: PCOS, anovulation, HRT
N=Nulliparity
T=Tamoxifen, chronic use
5. Causes of high unopposed estrogen
Exogenous Estrogen: Estrogen Replacement
Therapy in postmenopausal women.
Endogenous Estrogen:
– Increased secretion : e.g. feminizing ovarian tumors
(granulose cell tumor).
– Increased androgen precursors: e.g. androgen secreting
tumors, liver diseases, chronic an-ovulation (PCOS), or
stress.
– Increased aromatization: e.g. obesity, liver diseases, or
hyperthyroidism.
– Increased free estrogen due to decreased level of
SHBG.
6. Protective Factors
1. Oral contraceptives: Protective effect probably due to progesterone
Decreases both the risk of ovarian and endometrial cancer (RR = 0.6 if
used for one year…effect lasts for 15 years!)
1. Physical activity
2. Pregnancy and breast-feeding :The risk may be lower in women with a
higher number of pregnancies and who breast-feed for more than 18 months.
3. Diet: low in saturated fats and high in fruits and vegetables and soy -based foods as
a regular part of the diet may lower the risk of endometrial cancer.
4. Smoking
7.
8. Other Types of Uterine CancerOther Types of Uterine Cancer
LeiomyosarcomaLeiomyosarcoma
– Rapidly growing fibroid should be evaluatedRapidly growing fibroid should be evaluated
Stromal sarcomaStromal sarcoma
Carcinosarcoma (MMMT)Carcinosarcoma (MMMT)
leiomyosarcom
a
MMMT
9. Spread PatternsSpread Patterns
Direct extensionDirect extension
– most commonmost common
TranstubalTranstubal
LymphaticLymphatic
– Pelvic usually first, then para-aorticPelvic usually first, then para-aortic
HematogenousHematogenous
– Lung most commonLung most common
– Liver, brain, boneLiver, brain, bone
12. Endometrial Intraepithelial
Neoplasia (EIN) system
Def: EIN is a histopathological presentation of premalignant
endometrial disease which elevated the risk of {endometrioid
(Type I) endometrial adenocarcinoma}.
Significance:
– Women with endometrial hyperplasia subdivided into EIN
versus non-EIN categories.
– Progression to cancer more than one year following
EIN diagnosis is 45 times more likely compared to
women without EIN.
13.
14. RepresentationRepresentation
Asymptomatic : Endometrial cells on PapAsymptomatic : Endometrial cells on Pap
BB:: The “classic symptom” is abnormal uterine Bleeding
20-30% of women with post-menopausal bleeding will
have uterine cancer.
( the risk is higher the farther they are away from
menopause)
CC
DD
EE
P (Pain, Pressure)P (Pain, Pressure)
MetastasisMetastasis
15.
16.
17.
18. Diagnostic evaluation
Outpatient endometrial biopsy with the Pipelle catheter is
reliable and accurate for the detection of disease in most cases of
endometrial cancer (level of evidence: A).
Detection rates by pipelle was :Detection rates by pipelle was :
– 91 and 99% for endometrial ca.91 and 99% for endometrial ca.
– 81% for hyperplasia was81% for hyperplasia was
Hysteroscopic-guided endometrial biopsy remains the gold
standard for endometrial cancer diagnosis (level of evidence:
A ).
19. Diagnostic evaluation
Transvaginal ultrasonography is highly sensitive
and specific in predicting the presence of endometrial
cancer and can be used to select patients for
endometrial biopsy (level of evidence: B).
If symptomatology persists despite negative findings
from the previously cited tests, further evaluation is
justified because none of these tests have 100%
sensitivity (level of evidence: B).
20. Metastatic evaluation
Routine preoperative assessment of endometrial cancer
patients with imaging tests evaluating for metastasis is not
necessary as it is surgically staged disease (level of evidence:
A).
Serum CA125 measurement may be useful in management
planning of selected endometrial cancer patients but cannot
currently be recommended for routine clinical use (level of
evidence: C).
27. Approach to endometrial cancer:
best practices
The initial management of endometrial cancer should include
total hysterectomy, bilateral salpingo-oophorectomy, and
pelvic and para-aortic lymphadenectomy. Exceptions to this
approach should be made only after consultation with a
gynecologic oncologist (level of evidence: A).
Laparoscopy should be embraced as the standard surgical
approach for comprehensive surgical staging in women with
endometrial cancer (level of evidence: A).
28. Approach to endometrial cancer:
best practices
Vaginal hysterectomy may be an appropriate
treatment in select patients who are at high risk
for surgical morbidity (level of evidence: C).
Robotic-assisted laparoscopic staging is feasible
and safe in women with endometrial cancer (level
of evidence: B).
29. Role of lymphadenectomy
Patients with grade 1–2 endometrioid tumors, less than
50%myometrium invasion, and tumor of 2 cm or less seem to
be at low risk for recurrence and may not require a surgical
lymphadenectomy (level of evidence: B).
Lymphadenectomy may alter or eliminate the need for
adjuvant therapy and its associated morbidity (level of
evidence: B).
Sentinel lymph node dissection may reduce the morbidity
associated with standard lymphadenectomy and may enhance
the therapeutic benefit of surgical staging in early endometrial
cancer (level of evidence: I).
30. Surgical approach for
advanced endometrial cancer
Aggressive surgical cytoreduction improves
progression-free and overall survival in
patients with advanced or recurrent
endometrial cancer (level of evidence: C).
Exenteration offers the only curative option in
patients with recurrent endometrial cancer who
have received previous irradiation (level of
evidence: C).
35. Stage I Intermediate-Risk
Endometrial Cancers
External beam pelvic radiotherapy
– 1. Pelvic radiation has been shown to reduce local
recurrence in low to intermediate-risk endometrial
carcinoma. (II-1)
– 2. Pelvic radiation has been shown to reduce local
pelvic and vaginal recurrences in intermediate- to
high-risk endometrial carcinoma. (II-1)
36. Stage I Intermediate-Risk
Endometrial Cancers
Vaginal brachytherapy
– 3. Vaginal brachytherapy alone in the treatment of women with
intermediate- to high-risk endometrial cancer has been shown to have
outcomes in local control and overall survival that are similar to those
of pelvic radiotherapy in a well-defined intermediate- to high-risk
group. (I)
– 4. Vaginal brachytherapy has the same outcome as external beam
radiotherapy with respect to overall survival in the defined
intermediate- to high-risk group. (I)
37. Stage I Intermediate-Risk
Endometrial Cancers
Chemotherapy
– 5. Chemotherapy has not been well studied in
stage I intermediateto high-risk endometrial
cancers. There is no strong evidence for or against
chemotherapy in this population at present. The
benefits of chemotherapy in addition to adjuvant
radiotherapy specifically in surgically stage I
patients with high-risk features are not clearly
defined. (III)
38. Stage I Intermediate-Risk
Endometrial Cancers
Expectant Management
– 6. Patients in the intermediate-risk category who
are managed expectantly have a higher recurrence
rate than those who are treated, although there has
not been a lack of survival benefit demonstrated.
Patients who are managed expectantly report
higher scores in quality of life studies because of
less gastrointestinal toxicity. (II-3)
39. Advanced Stage (II to IV)
Endometrial Cancer
– 7. Chemotherapy with cisplatin and doxorubicin
or carboplatin and paclitaxel has demonstrated
efficacy in advanced uterine cancer in published
phase III studies. (II-2)
40. Five Year SurvivalFive Year Survival
72%72% diagnosed at this stage I,diagnosed at this stage I, 3%3% Diagnosed at stage IVDiagnosed at stage IV
41.
42. Conclusions
Endometrial carcinoma is the commonest female
genital tract cancer.
Routine screening for EC is not recommended.
However annual screening is recommended in
women at risk for hereditary nonpolyposis colorectal
cancer.
Endometrial carcinoma is a surgically staged disease.
43. Conclusions
The initial management of endometrial cancer should
include total hysterectomy, bilateral salpingo-
oophorectomy, and pelvic and para-aortic
lymphadenectomy.
Primary radiotherapy or hormonal treatment may be
recommmended in special situations.
Adjuvant radiotherapy and /or chemotherapy are
recommended in patients with high risk for
recurrence.
44. Conclusions
Endometrial carcinoma has the best prognosis
due to early presentation (PMB).
Disease stage is the most predictive factor for
survival.
Lymph node metastasis is the most predictive
factor for survival in early stage endometrial
carcinoma.