CARCINOMA ENDOMETRIUM Prof. M.C.Bansal MBBS,MS,MICOG,FICOG Professor OBGY Ex-Principal & Controller Jhalawar Medical College & Hospital Mahatma Gandhi Medical College, Jaipur.
INTRODUCTIONMost frequently encountered gynaecologiccancer in western countaries because ofdecline in Ca Cx Account for 7.0%of all cancers in womenPeak incidence is in the age group of 55 to69 years.Over three-fourth of these women arediagnosed when the disease is still localized andsurgery offers satisfactory results.
PREDISPOSING FACTORS1. Unsupervised administration of ERT in menopausal women.2. Women suffering from Hyperestrogenic states i.e. Endometrial hyperplasia as cases of DUB.3. Familial predisposition to it and may be due to genetic factors or dietary habits.4. Tamoxifen prescribed to women with breast cancer.
CONTN..5. OCPs containing only estrogen while OCPs with E & P have protective effect.6. Obesity, HT, Diabetes, Infertility, nulliparity are associated with endometrial cancer in 30% cases.7. PCOD patients are more prone to this disease.
PATHOLOGY Uterus is enlarged and Endometrial cancer may be localized or diffuse. Localized form may appear as a nodule or polyp or localized carcinomatous patch. Diffuse form may be involving the entire uterine cavity stopping short of internal os. It may infiltrate uterine myometrium and remain restricted to its boundaries for a long time. In advanced stages growth may directly spread beyond uterine body to cervix, vagina, adnexa and may metastesize into nodes and distant sites.
THIS ADENOCARCINOMA OF THE ENDOMETRIUM IS MORE OBVIOUS. IRREGULARMASSES OF WHITE TUMOR ARE SEEN OVER THE SURFACE OF THIS UTERUS THATHAS BEEN OPENED ANTERIORLY. THE CERVIX IS AT THE BOTTOM OF THE PICTURE.THIS ENLARGED UTERUS WAS NO DOUBT PALPABLE ON PHYSICAL EXAMINATION.SUCH A NEOPLASM OFTEN PRESENT WITH ABNORMAL BLEEDING.
THE ENDOMETRIAL ADENOCARCINOMA IS PRESENT ON THE LUMENALSURFACE OF THIS CROSS SECTION OF UTERUS. NOTE THAT THENEOPLASM IS SUPERFICIALLY INVASIVE. THE CERVIX IS AT THE RIGHT.
This uterus is not enlarged, but there is an irregular mass in the upperfundus that proved to be endometrial adenocarcinoma on biopsy.Such carcinomas are more likely to occur in postmenopausal women.Thus, any postmenopausal bleeding should make you suspect thatthis lesion may be present.
THE ENDOMETRIAL ADENOCARCINOMA IN THE POLYP AT THE LEFTIS MODERATELY DIFFERENTIATED, AS A GLANDULAR STRUCTURECAN STILL BE DISCERNED. NOTE THE HYPERCHROMATISM ANDPLEOMORPHISM OF THE CELLS, COMPARED TO THE UNDERLYINGENDOMETRIUM WITH CYSTIC ATROPHY AT THE RIGHT.
HISTOPATHOLOGY It is adeno carcinoma Grading of these tumors is based on differentiation and ability to maintain gland formation, morphology and anaplasia of the tumour lining cells and presence of infiltration in stroma Tumor grading affects the prognosis of the disease in any individual case
THIS IS ENDOMETRIAL ADENOCARCINOMA WHICH CAN BE SEEN INVADINGINTO THE SMOOTH MUSCLE BUNDLES OF THE MYOMETRIAL WALL OF THEUTERUS. THIS NEOPLASM HAS A HIGHER STAGE THAN A NEOPLASM THATIS JUST CONFINED TO THE ENDOMETRIUM OR IS SUPERFICIALLY INVASIVE.
SYMPTOMS1. May be asymptomatic to begin with.2. Menometrorrhagia in perimenopausal women3. Post menopausal bleeding.
SIGNS1. Per vaginal examination: may or may not reveal a bulky uterus.2. Enlarged uterus may be associated with Ca endometrium along with fibroid or pyometra3. Sub-urethral Vaginal metastatic growth may be noted in advanced cases.4. When adnexa is involved in late stages enlarged uterus with unilateral or bilateral adnexal enlargement and fixed nodules in Pouch of Douglas may be present.
INVESTIGATIONS1. Routine Haematogram and blood chemistry, urine examination, X-ray chest and ECG should be done.2. USG- often reveals thickened and hyperplastic, polyp in uterine cavity. Post menopausal endometrial thickness >4mm is abnormal3. Endometrial cell sampling by aspiration cytology.4. Diagnostic hysteroscopy followed by selective biopsy of suspected area.5. Fractional curettage and histopathological examination- this will help in differentiating whether Ca endometrium is involving cervical canal or not.6. CT/MRI help in defining the extent of disease into the myometrium , nodes and distant organs.
DIFFERENTIAL DIAGNOSIS1. Senile endometritis2. Genital tuberculosis3. Atypical endometrial hyperplasia4. Any other cause of post menopausal bleeding like senile vaginitis, foreign body, ERT abuse, cervical polyp, urethral caruncle, Ca cervix and ovarian carcinoma etc
SCREENING OF ENDOMETRIAL CARCINOMA1. Routine screening of all asymptomatic women on HRT and tamoxifen therapy2. Perimenopausal women with menometrorrhagia should be investigated and screened to exclude endometrial carcinoma.3. All women with postmenopausal bleeding should be screened by pv examination, TVS, Pipelle aspiration cytology.4. Fractional curettage along with diagnostic hysteroscopy.
STAGE • DESCRIPTION • Cancer confined to corpus uteri • 1A- Tumor limited to endometrium 1 • 1B- Tumor involving half or less than half the myometrial thickness • 1C – Tumor involves more than half the myometrial thickness • Tumor involves cervix but does not extend beyond uterus 2 • 2A- Endocervical gland involvement only. • 2B- Cervical stromal invasion
• Local and/or regional spread • 3A-Tumor involves serosa, spreads to adnexae, positive peritoneal cytology.3 • 3B- Presence of vaginal metastasis • 3C- Node metastasis to pelvis and para aortic nodes. • Tumour Widespread • 4A Tumor involves bladder and /or4 bowel mucosa • 4B Tumor shows distant metastasis ( intra-abdominal and inguinal nodes)
TREATMENT cases of simple hyperplasia develop in malignancy in 10-20% 60-70% cases of atypical hyperplasia develop into malignancy. Stage 0-(Endometrial hyperplasia)- Abdominal Pan Hysterectomy is the ideal treatment. Young women may be kept under observation and 30-40 mg medroxyprogesterone daily therapy may be offered for 6-12 months.
RX CONTN.. Stage IA: (low risk Grade 1 and 2of endometrium HPR) TAH and BSO is sufficient because involvement of nodes is seen in only 2% cases while myometrial invasion is only 4%. Stage IB- High risk > 50% myometrium involved and HPR shows grade 3 tumor or there is presence of lymphatic involvement then chances of lymph node metastasis is 10-40% therefore TAH and BSO followed by
RX: CONTN.. Stage II- Pre operative radiotherapy followed by TAH and BSO, or Wertheims Hysterectomy as done for Ca cervix. Post operative radiotherapy is needed if lymph nodes are Ca positive. Stage III- Advanced disease not suitable for surgery. Chemotherapy plus Radiotherapy plus weekly injection of Medroxy progesterone. Stage IV- Palliative Radiotherapy, chemotherapy and hormonal therapy using large dose of progesterone. Progesterone helps in regression of lung metastasis in 30% cases.
SURVIVAL RATE Stage I 75 % Stage II 55 % Stage III 30% Stage IV 10%
SARCOMA OF THE UTERUS Introduction: These are rare tumors comprising 4.5% of all malignant growths of the uterus. About 0.5% of myomas undergo sarcomatous changes at menopausal age. Common in the age of 40-60 yrs. Rare before 30 yrs. 8% of sarcomas occur in women who have received radiation for Ca cervix 8-10 yrs ago.
VARIETIES OF UTERINE SARCOMAS1. Intramural- arise in the myometrium2. Mucosal- Develops from endometrium.3. Sarcomatous changes in pre-existing myoma.4. Grape like sarcoma of the cervix. Intramural is most common . Histologically tumour may be round cell, spindle-celled, mixed cell or giant cell type.Spindle- cell type is most common and called leiomyosarcoma.
GROSS APPEARANCE Cut surface: is hemorrhagic and irregular without whorled appearance like myoma. It is friable and soft. Margins are not clear and invasion into surrounding myometrium is common. There is no definite capsule. Mucosal form- projects in cavity like polyp or spreads around the cavity of the uterus to produce uniform enlargement.
THIS IS A LEIOMYOSARCOMA PROTRUDING FROM MYOMETRIUM INTOTHE ENDOMETRIAL CAVITY OF THIS UTERUS THAT HAS BEEN OPENEDLATERALLY SO THAT THE HALVES OF THE CERVIX APPEAR AT RIGHTAND LEFT. FALLOPIAN TUBES AND OVARIES PROJECT FROM TOP ANDBOTTOM. THE IRREGULAR NATURE OF THIS MASS SUGGESTS THAT ISNOT JUST AN ORDINARY LEIOMYOMA.
HERE IS THE MICROSCOPIC APPEARANCE OF A LEIOMYOSARCOMA. IT ISMUCH MORE CELLULAR AND THE CELLS HAVE MUCH MOREPLEOMORPHISM AND HYPERCHROMATISM THAN THE BENIGNLEIOMYOMA. AN IRREGULAR MITOSIS IS SEEN IN THE CENTER.
SARCOMAS, INCLUDING LEIOMYOSARCOMAS, OFTEN HAVE VERYLARGE BIZARRE GIANT CELLS ALONG WITH THE SPINDLE CELLS.A COUPLE OF MITOTIC FIGURES APPEAR AT THE LEFT ANDLOWER LEFT.
METASTASES Relatively earlier, occurs via blood stream, lymphatics, direct spread and by implantation. Lymphatic nodes-35% cases in stage I and II and Para-aortic lymph nodes in 15% cases. Direct spread in the peritoneum leads to multiple metastasis leading to ascites and omental cake.
SYMPTOMS AND SIGNS Profuse and irregular vaginal bleeding which is often painful. 60% patients have fever due to degeneration and infection of the tumour. Rapid enlargement of the tumour usually occurs due to sarcoma.
TREATMENT Pan Hysterectomy, omentectomy and debulking of metastasis foci is done. Followed by radiation therapy. Chemotherapy of VAC combination reduces the recurrence rate. 5 yr cure rate is <30% and largely depends on the type of growth, being worst in endometrial sarcoma i.e. round cell type.
BOTRYOID AND GRAPE-LIKE SARCOMA Pathologically the tumour is mesodermal mixed tumour as the often contain cartilage, striated muscle fibres, glands and fat. Stroma is embryonic in type. Grape sarcoma of cervix arises typically in adult women somewhat similar tumor are known to develop in cervix and vagina in children in very early age. In these cases prognosis is very poor and rapid recurrence follows their removal.