This presentation describes about the risk factors, diagnosis, and management of endometrial cancer

1. Endometrial cancer

2. INTRODUCTION
• In India, ranks IIIrd among gynaecological malignancies next to
cervix and ovary
• Incidence: 2 per 1 lakh
• Unlike cancer cervix, cost effective screening program is not
available
• Common in postmenopausal women
• Increasing incidence due to
 Increased screening
 Improved hysteroscopic diagnosis
 Increase in geriatric population
 Estrogen use
• SURGICO PATHOLOGICAL STAGING, as opposed to clinical staging

3. Epidemiology
• Most frequent genital cancer in rich countries
• MEAN AGE: 60 years
• PEAK INCIDENCE: 55-70 years
• 20-25% - perimenopausal
• 5% - <40 years
• 5 year survival for stage I disease more than
90%
• Overall 5 year survival for all stages: 60-70%

5. ENDOGENOUS ESTROGEN
DEPENDENT
EXOGENOUS ESTROGEN HEREDITARY
Nulliparity, low parity Unopposed estrogen
therapy
LYNCH II / HEREDITARY
NON POLYPOSIS
COLORECTAL CANCER –
HNPCC SYNDROME
PCOD tamoxifen
Early menarche, late
menopause
Functioning ovarian tumours
Obesity
Hypertension
Diabetes
hyperlipidaemia

6. Protective factors / Prevention
• Oral contraceptive pills (combined pills with addition of
progesterone to HRT)
• Smoking (as it decreases level of estrogen, decreases
weight and associated with earlier age of menopause)
• Multiparity
• Phytoestrogens
• Green tea
• Coffee
• Physical exercise
• Treatment of PCOS
• MIRENA IUCD- effective in simple hyperplasia
• Early screening , while pt is on TAMOXIFEN

7. PATHOLOGY
• Localized/ diffuse
• App – nodule/ polyp/ diffuse lesion
• Involving entire uterine cavity

8. HISTOPATHOLOGY
• Adenocarcinoma / endometrioid 80%
• Adeno acanthoma
• Adenosqamous carcinoma 15%
• Papillary serous adenocarcinoma
• Mucinous adeno carcinoma
• Clear cell carcinoma
• Undifferentiated
• Mixed

9. SPREAD
• DIRECT EXTENSION – Most common
• Lymphatic spread - occurs to pelvic and para-
aortic nodes, fundus – para aortic nodes,
round ligament – supl inguinal nodes
• Hematogenous spread (usually to lungs, liver,
brain, bone) is rare
• Trans tubal – ovaries, pelvis, peritoneal cavity

10. GRADE 1 : The glandular pattern is maintained, but cells
show atypia
GRADE 222 : some glands show a papillary
pattern and are solid
GRADE 3
3
: glands are solid with cellular proliferation, and
glandular architecture is lost, endometrium is packed
with glands and little stroma
GRADING (FIGO)
Depends on differentiation , glandular architecture and anaplasia of cells

11. GRADE 1 GRADE 2
GRADE 3

12. Histological differences in endometrial cancer
FEATURES TYPE I ENDOMETRIOID
80%
TYPE II (NON
ENDOMETRIOID) 20%
Unopposed oestrogen present Absent
Menopausal status Pre and perimenopausal Postmenopausal
Hyperplasia present Absent
Race white Black
Grade low High
Myometrial invasion Minimal Deep
Specific subtypes Endometrioid
Adeno CA grade 1,2
Serous, clear cell, adeno CA
grade 3
Behavior stable Aggressive
Associated gene Pten/Kras p53
Good
prognosis
Poor
prognosis

13. Type I Type II

14. Clinical features
• Asymptomatic – 7 to 10%
• POST MENOPAUSAL BLEEDING
• irregular vaginal bleeding
• Discharge per vagina:
 brown , watery offensive discharge
 watery discharge free from blood-hydrorrhoea
• Past H/O PCOS, HRT
• Obesity/ HTN / DM – CORPUS CANCER
SYNDROME

15. pelvic pressure/ discomfort
Referred pain in hypogastrium / both iliac
fossa - simpson’s pain
Pain – not severe, tends to occur at the same
time each day, lasting for 1-2 hours
LUMP - Hematometra / pyometra in cervical
stenosis

16. • P/V : uterus bulky/normal
• Bulky uterus – growth / fibroid/
pyometra
• Adnexal mass – feminizing/ metastatic
ovarian tumours
• Advanced stage: cervix bulky, mass
protruding through the os, suburethral
vaginal nodule

17. INVESTIGATIONS
• PAP SMEAR
• Endometrial aspiration
• Fractional curretage
• Hysteroscopy and biopsy – GOLD STANDARD
• TVS – ET – irregular line / polyp / ovarian tumour
/ ovarian metastasis / extension to endocervix
• Doppler ultrasound- low RI 0.37 to 0.7 or below –
EC
• SALINE INFUSUION SONOGRAPHY
• CA 125

18. INVESTIGATIONS
• Contrast enhanced computerized tomography CECT – hypodensity in
myometrium – myometrial infiltration
• Pelvic and para aortic nodes >1cm
• CT IS SUPERIOR THAN MRI in detecting ascitis , bowel , and
omental metastasis
• MRI – superior to CT in detecting myometrial invasion, nodal
enlargement (90%)
• Endometrial and myometrial junction – low intensity zone exists – intact –
myometrial invasion ruled out
• MRI useful in endocervical stromal invasion
• XRAY CHEST – lung metastasis
• Bone and liver metastasis – RADIO ISOTOPE SCANNING – PET CT – reveal
metabolic activity in tissue and lymph node- helpful for staging

19. DIFFERENTIAL DIAGNOSIS
• Senile endometritis
• Tubercular endometritis
• Atypical hyperplasia
• Endometrial polyp

20. • Hyperplasia without atypia
• Atypical hyperplasia/ EIN (Endometrial intraepithelial
neoplasia)
• TREATMENT:
• endometrial hyperplasia without atypia –
progesterone oral / LNG IUS / MPA 10-20mg/day /
norethisterone 10-15mg/ day for 6 months
• ATYPICAL HYPERPLASIA – risk of EC = 8-29% - total
hysterectomy
• Young – high dose of progesterone with frequent
evaluation of endometrium - biopsy
New WHO classification of
endometrial hyperplasia - 2014

22. TREATMENT
• SURGICO – PATHOLOGICAL STAGING
• ABDOMINAL HYSTERECTOMY
• BILATERAL SALPHINGO – OOPHRECTOMY
• OMENTECTOMY
• PELVIC AND PARA AORTIC NODE SAMPLING
Remain the CORNER STONE for
management of early endometrial carcinoma

23. STAGE WISE MANAGEMENT OF ENDOMETRIAL CANCER
Stagewise Management
Stage I A grade 1 Surgery only
Stage I A grade 2, 3
Stage I B grade 1, 2
Sugery + vaginal brachytherapy
Stage IB grade 3 Surgery + vaginal brachytherapy +external beam
radiotherapy to pelvis
Stage II Surgery + external RT + Vaginal brachytherapy
Stage III Surgery + external RT + Vaginal brachytherapy +
Chemotheraoy
Stage IV Palliative RT + Chemotherapy + high dose
progesterone

24. SURGERY
• TAH with BSO +omentectomy (non endometriod type)
• Vaginal hysterectomy- obese, DM, prolapse
 morbidity is less + LAP lymphadenectomy / post
operative radiotherapy
• Modified Wertheims hysterectomy- stage II
• Debulking surgery – stage III
• Laparoscopic surgery
 Definite role in incompletely staged patients to decide
for adjuvant therapy
• Robotic surgery gaining importance

25. RADIOTHERAPY
• Vaginal vault irradiation – vaginal ovoids – dose = high
dose rate Iridium / Low dose rate Cesium via
COLPOSTAT to deliver 6000 cGy/6 weeks
• EXTERNAL PELVIC IRRADIATION:
Stage IB G3, Stage II, III
Dose: 4500 – 5040 cGy – 5-6 weeks
• EXTERNAL FIELD RADIATION:
4500 – 5000 cGy- positive para aortic nodes
• WHOLE ABDOMEN IRRADIATION:
Papillary serous, clear cell, adnexal upper abdominal
disease excised
• PRIMARY RADIOTHERAPY: inoperable stage III,IV-
brachytherapy + External RT + uterine cavity packed
with Heyman capsules

26. CHEMOTHERAPY
• High risk tumours to reduce and prevent extra pelvic
failure
• CYCLOPHOSPHAMIDE +ADRIAMYCIN + CISPLATIN – 6
cycles – 2 year progression free survival
HORMONE THERAPY
• MDPA 1g weekly or 200mg orally daily
• 17 α progesterone 1g weekly or northiesterone
• Tamoxifen 10mg twice daily
• Doxorubicin, platinum, taxane, carboplastin – under
trial

27. STAGE III
• Surgico pathological staging – TAH BSO / Radical
hysterectomy / debulking – SURGICAL
IRRADICATION, followed by RT / Chemo
• Stage III B, C – inoperable – pelvic radiation
followed by surgery or
• external beam RT or extended field RT followed
by intra uterine and intra vaginal brachytherapy
• STAGE IV – debulking surgery /
radiotherapy(whole abdomen irradiation)

28. FOLLOW UP
• First 3 years = every 3-4 months
• Next 3-5 years = every 6 months
• Annually thereafter
• Each visit
physical , pelvic examination
pap smear
USG
CA 125
CT, MRI – when indicated
Chest Xray
FNAC/ LAP/ Laparotomy – pelvic/ distant recurrences

29. Post operative management based on histopathological type , peritoneal cytology, grade, LVSI,
Cervix/isthmus invasion, node, adnexal metastases, intra abdominal and distinct metastases
Low risk:
 G1 without myoinvasion
 No cervix/isthmus
invasion, LVSI, METASTASIS
 Negative peritoneal
cytology
 Tumour < 2 cm
No further management
Intermediate risk:
 G1, G2 with <50%
myometrial invasion
 No cervix/isthmus
invasion, LVSI, METASTASIS
 Negative peritoneal
cytology
POST operative intra vaginal
ovoid brachytherapy
High risk:
 G3 tumours
 Myoinvasion >50%
Adnexal spread
cervical invasion
 Lymph node metastasis
 LVSI
 Clear cell , PSC histology
 Intra abdominal / distant
metastasis
 Whole pelvic RT
Extended field RT if aortic /
common iliac nodes have
metastases/ CT

30. PROGNOSTIC VARIABLES IN
ENDOMETRIAL CARCINOMA
• Age
• Histological type
• Histological grade
• Myometrial invasion
• LVSI
• Isthmus/ cervix extension
• Adnexal involvement
• Lymph node metastasis
• Intra peritoneal tumour
• Tumour size
• Peritoneal cytology
• Hormone receptor status
• DNA/ ploidy / proliferative index
• Genetic / molecular tumour markers

31. Pre operative evaluation:
• HISTORY, examination
• Fractional curretage/ hysteroscopy
• Imaging – USG, CT ,MRI , CHEST XRAY
• Serum CA 125
SURGICAL = vertical incision/ LAP
Peritoneal cytology/ exploration
Type I hysterectomy with BSO
Cut section: tumour sixe, grade, MI
ENDOMETRIOID, no adverse risk factors:
G1, MI <50%, Tumour <2cm
NO FURTHER SURGERY 
SURVEILLANCE
High risk / NON ENDOMETROID

32. ENDOMETRIAL CANCER DIAGNOSED
POST HYSTERECTOMY
• High risk factors identified: COMPLETE
SURGICAL STAGING
• ALTERNATE = external beam radiation to the
pelvis

33. Recurrent endometrial cancer
MC time of recurrence Within first two years
MC symptom of local recurrence Vaginal bleeding
MC symptom of pelvic recurrence Pelvic pain
MC site of recurrence Vagina and pelvis
MC site of extrapelvic recurrence Lung
LN (Aortic)
Liver
Brain
Bones

34. Management
• For patients with recurrent endometrioid
tumours with hormone receptors positive, initial
treatment is progestin
• Contraindication to progestin  TAMOXIFEN
• Hormone negative  local management
• If Operable – surgery to be done
• If inoperable – RT is given
• If local treatment cannot be given – palliative
chemotherapy is given

35. THANK YOU