Endometrial cancer is the most common female pelvic genital cancer. It has a higher incidence in postmenopausal women and obesity is a major risk factor. Treatment involves total hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy for early stage disease. Adjuvant radiation or vaginal brachytherapy may be used for intermediate risk disease. Advanced stage disease is treated with chemotherapy using cisplatin and doxorubicin or carboplatin and paclitaxel. Five year survival is 72% for stage I disease but only 3% for stage IV disease.

1. Endometrial CancerEndometrial Cancer
Presented byPresented by
Dr/ Ahmed Walid AnwarDr/ Ahmed Walid Anwar
Professor of Obs & GynProfessor of Obs & Gyn
Benha Faculty of MedicineBenha Faculty of Medicine
20182018

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.

7. 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

8. 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

9. Endometrial hyperplasia

11. 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. RepresentationRepresentation
 Asymptomatic : Endometrial cells on PapAsymptomatic : Endometrial cells on Pap
 BB
 CC
 DD
 EE
 P (Pain, Pressure)P (Pain, Pressure)
 MetastasisMetastasis

17. 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).
 Hysteroscopic-guided endometrial biopsy
remains the gold standard for endometrial
cancer diagnosis (level of evidence: A).

18. 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).

19. 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).

22. Treatment

25. Treatment ofTreatment of endometrial cancer

26. Treatment ofTreatment of endometrial cancer
 Stage IB or lessStage IB or less:: total hyst/BSO/PPALND, cytologytotal hyst/BSO/PPALND, cytology
 Stage IC to IIB:Stage IC to IIB: total hyst/BSO/PPALND, cytology,total hyst/BSO/PPALND, cytology,
adjuvant pelvic XRTadjuvant pelvic XRT
 Stage III:Stage III: total hyst/BSO/PPALND, cytology,total hyst/BSO/PPALND, cytology,
adjuvant chemotherapyadjuvant chemotherapy
 Stage IV:Stage IV: palliative XRT and chemotherapypalliative XRT and chemotherapy

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).

33. Adjuvant Therapy in
Endometrial Cancer

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