This document discusses endometrial carcinoma. It defines endometrial carcinoma as cancer of the uterine lining and notes it is the third most common gynecologic malignancy. Risk factors include increasing age, obesity, prolonged estrogen exposure without progesterone, late menarche and early menopause. The document outlines the pathology, staging, clinical evaluation, treatment including surgery and adjuvant therapies, and prognosis of endometrial carcinoma. Prevention focuses on weight control and restricting unnecessary estrogen use.

1. ENDOMETRIAL CARCINOMA
Dr.Abu Shuraih Sakhri

2. CONTENTS
 Definition
 Incidence
 Risk factors
 Basic pathology & pathogenesis
 Staging
 Clinical evaluation and Dx
 Treatment and prognosis

3. Endometrial carcinoma
 Uterine lining- (adenocarcinoma)
 3rd -MC
 postmenopausal women (60,70)
 75% …..> 50y
 Lower mortality rate………..early presentation.

4. INCIDENCE
 >>white population and lowest in India (4.5)
 Increasing incidence…… life expectancy, HRT,
Obesity
 Mean age Dx- 63 years (majority - 55 and 75 years)

5. RISK FACTORS
 Age,race
 Prolonged/ unopposed estrogen
Parity
early menarche,Late menopause
Obesity, pcos
Anovlatory infertility
Estrogen replacement
Estrogen secreting tumors- ovary
 Tamoxifen therapy
 DM , HTN
 Hereditary - HNPCC
 Germline mutations –PTEN,BRCA 1, p53
 Atypical endometrial hyperplasia

6. PATHOLOGY
 ENDOMETRIOID (type 1)
 estrogen excess &
endometrial hyperplasia
….perimenopausal women
 80%
 Estrogen dependent ..ER
,PR +
 Favourable prognosis
 SEROUS (type2 )
 Older women -endometrial
atrophy
 20%
 Estrogen independent
 Tp53
 Poor prognosis

8. Pathogenesis- type 1

9. Type 2

10. Morphology – gross

11. HISTOLOGICAL GRADING
 FIGO
 Grade 1- well differentiated (<5%- solid growth)
 Grade 2- moderate (6-50%-solid )
 Grade 3 –poor (>50%)
 Cellular differentiation !

12. Histomorphology TYPE 1
Grade 1 Grade 2
Grade 3

13. TYPE 2
p53
Serous carcinoma - papillary growth
cells -marked cytologic atypia (high NC ratio, atypical mitotic figures, and
hyperchromasia)

14. SPREAD
 Direct
 Lymphatic
 Hemato
 Retrograde

15. Staging – surgical -- FIGO

20. Clinical features
Symptoms
 AUB (postmenopausal, intermenstrual, frequent
menstruation etc)
 Abnormal discharge
 Advanced stage … ovarian mets , ascites,
hepatomegaly etc

21. APPROACH TO DIAGNOSIS

22. HISTORY
 Age
 Parity
 Symptoms
 Past history (anovulatory cycle , early menarche ,
late menopause)
 Family history ( hnpcc, ca breast )
 Medical conditions (obesity , DM, HTN)
 Medications (estrogen, tamoxifen)

23. Physical examination
 BMI
 BP
 Breast
 LN –inguinal, supraclavicular
 Abdomen –uterus enlarg, ascites , hepatomegaly
 Per speculum ( bleeding)
 Pelvic (tenderness, adnexal mass , uterus
enlargment)

24. D/D……….Post menopausal bleeding
 C A cervix
 Atrophic endometrium , vaginitis
 Endometrial polyp
 Endometrial hyperplasia
 Oestrogen producing tumors
 Sarcoma uterus

25. Diagnosis
 Histopathology – gold standard
1-Transvaginal USG
 ENDOMETRIAL THICKNESS >5mm IN
POSTMENOPAUSAL WOMAN (sensitivity-90% ,
specificity-50%)
SIZE & SHAPE OF UTERUS
ENDOMETRIAL POLYP
PYOMETRA
OVARIAN MASS

27. 2 – Sonosalpingography
Polyp or growth
Not used routinely
3- Endometrial sampling (Sensitivity -99% ,
specificity-98%)……pipelle
indicated in
 Postmenopausal bleeding
 Postmenopausal women on estrogen
 HNPCC
 AUB with risk facors

29. 4- D&C…. Fractional curettage….
indications
 Reccurrent bleeding with sampling neg
 Reccurrent bleeding & Thickness <5mm
 Complex atypical hyperplasia
5-Hysteroscopy
 D&C –ve
 High suspicion

30. MANAGEMENT
 PREVENTIVE
 CURATIVE

31. PREVENTIVE
PRIMARY PREVENTION
Weight control
restrict estrogen use / use cyclical progestins
education regarding AUB –peri &
postmenopausal
Secondary prevention
screening of high risk patients

32. High risk

33. Methods of screening
 Cytologic specimen – aspiration /lavage
 If suspicion – curettage and histopathology
 Premalignant lesions- judicial hysterectomy

34. CURATIVE TREATMENT
 SURGERY
 RADIATION
 CHEMOTHERAPY
 COMBO

35. PRETREATMENT EVALUATION
 HB
 BLOOD SUGAR
 RFT, LFT
 LIPID PROFILE
 CHEST XRAY… METS
 ABDOMEN AND PELVIC ULTRASONOGRAPHY
 CT AND MRI
 CA 125
 HORMONE RECEPTOR STATUS

37. TREATMENT - SURGERY
Surgical staging – laparoscopy or laparotomy
Steps
- Adequate abdominal incision (vertical )
- Peritoneal washing for cytology
- Exploration of abdomen and pelvis
- Extrafascial hysterectomy/TOTAL HYSTERECTOMY
- BL salpingo oopherectomy
- Open the uterus ( size , site of tumor, depth of invasion,
cervical extension)
- Lymphadenectomy (pelvic , para aortic)
- Advanced stage …… cytoreductive surgery

38. Laparoscopic and vaginal surgeries
less post operative morbidity
early ambulation
better wound healing
- Prefered in obese , stage1A , grade 1 where
lymphadenectomy is not required

39. Stage 1 disease
 surgery is the mainstay
 LN sampling
 Frozen section -myometrial invasion

40. Stage 2 disease
 Options are
A- radical hysterectomy BSO with pelvic node
dissection
B- surgery + radiation (after 6wks)
C- MR hysterectomy followed by external and
intravaginal radiation

41. Stage 3 & 4
 pelvic radiation + Adjuvant chemo
 Chemo- combination (adriamycin , cysplatin,,
cyclophosp)

42. POST OPERATIVE ADJUVANT
THERAPY
 RADIOTHERAPY
-Vaginal brachytherapy
-External radiation
1)pelvic radiation
2)extended-field radiation
3)whole abdominal radiation
 CHEMOTHERAPY

43. Choice of adjuvant therapy
 B/o Stage of disease, histology, recurrence risk etc
Low risk
 1A – G12,
 No lymphovascular involvement
 Type1 histology
Intermediate risk
 1A –G3,1B
 Stage 11

44. High risk
 Stage 3 or 4
 Clear or serous of any grade

46. RADIOTHERAPY
 Primary radio indicated in

47. Chemotherapy
 In advanced / recurrent / mets
Progestogens
-17 HPC (1g/week) or
-MPA (1g/week or 150mg od) or
- Megestrol (160mg od)
- If responsive continue in low dose
Atleast 3 months

48. Cytotoxic drugs
-singly /combination with hormone therapy
- adriamycin,cisplatin, cyclophosphamide,
carboplatin

49. Recurrent disease
 Within 2yrs of initial Rx
 Common – vagina and pelvis
 Extrapelvic – lung , bone ,LN
How to treat recurrence ?
 radiation
 Chemo + hormonal ?

50. Followup
 first 2yrs -Every 4months,
 next 2yrs – 6 months , thereafter annually
 Clinical + radiological
 CA 125 (in certain cases)

51. Place of HRT
 DEBATABLE ISSUE
 SEVERE postmenopausal symptoms –
MPA (5-10mg od)
clonidine
Urogenital symptoms – topical estrogen

52. Prognosis

54. Summary

55. REFERENCES
 ROBINS & COTRAN PATHOLOGIC BASIS OF
DISEASE
 ESSENTIALS OF GYNECOLOGY , Sheshadri, 2E
 DC DUTTA’S TEXTBOOK OF GYNAECOLOGY, 6E

56. THANK YOU