This document discusses endometrial carcinoma, a common cancer in postmenopausal women. It presents the risk factors as being older age after 50, obesity, prolonged estrogen exposure without progesterone, and tamoxifen use. Symptoms include abnormal vaginal bleeding. Diagnosis involves ultrasound, biopsy, and fractional curettage. Treatment is staging surgery including hysterectomy, lymph node dissection, and possible radiation or chemotherapy depending on stage. Prognosis depends on stage, grade, histology, and presence of lymph node or organ metastasis.

1. ENDOMETRIAL
CARCINOMA
Dr Sunita Samal
Professor
Dept of Obs & Gyn

2. A 60yr old postmenopausal obese women presented
with bleeding p/v for last 10-15 days

3. Causes of PMB

4. • Most common cancer in developed countries
• Disease of postmenopausal age (6th-7th decade)
• 75% occur after 50yr of age
• Types: -Type I, estrogen-related, endometrioid
- Type II, non-estrogen-related
nonendometrioid

5. Risk factors
• Age>50,postmenopausal
• Race: caucasian
• Prolonged/unopposed oestrogen:
obesity, nulliparity, PCOS
early menarche, late menopause
anovulatory infertility
HRT(only oestrogen therapy)
oestrogen secreting ovarian tumour
• Tamoxifen therapy (2-3times more risk)
• DM, HTN (corpus cancer syndrome)
• HNPCC syndrome
• Germ line mutation: p53, PTEN

6. Precursors
• Simple hyperplasia– 1%
• Simple hyperplasia with atypia-8%
• Complex hyperplasia– 3%
• Complex hyperplasia with atypia—28%
30-40% of endometrial cancers are found in a background
of atypical hyperplasia. Overall, these tend to be lower
grade tumors

7. • DECREASED RISK
Oral contraceptive use
Nonmedicated plastic or copper intrauterine device
(IUD) use
Consumption of some phytoestrogens, such as
isoflavones and lignans
Diet rich in fruits, vegetables, and fiber
Physical activity
Cigarette smoking

8. Screening
• Routine screening not recommended & not cost
effective
• High risk women: TVS, Endometrial sampling

9. Patients in Whom a Diagnosis of
Endometrial Cancer Should Be Excluded

10. Histological grading
• Endometroid adenocarcinoma(80%)
• Mucinous carcinoma
• Serous carcinoma
• Clear cell carcinoma
• Squamous cell carcinoma
• Mixed cell carcinoma
• Undiffrentiated carcinoma

11. Clinical Features
• 90% abnormal vaginal bleeding, most commonly
postmenopausal bleeding, occurs early in the course of
the disease.
• Intermenstrual bleeding or heavy prolonged bleeding
• The diagnosis may be delayed, usually ascribed to
“hormonal imbalance.”
• A high index of suspicion for early diagnosis in women <
40 years of age.
• No vaginal bleeding: cervical stenosis, particularly in thin,
elderly, estrogen-deficient patients.
• Hematometra: In some patients with cervical stenosis
• pyometra :a small percentage have a purulent vaginal
discharge

12. • Physical exam:
-obese, hypertensive, postmenopausal woman, 1/3rd not
overweight.
• Abdominal exam :
-unremarkable except in advanced cases: ascites and
palpable hepatic or omental metastases
- hematometra: a large, smooth midline mass arising from
the pelvis.
• Pelvic exam:
-inspect and palpate the vulva, vagina, and
cervix.
- uterus may be bulky, often not significantly enlarged.
• Rectovaginal examination :
- the fallopian tubes, ovaries, and cul-de-sac.
- endometrial carcinoma may metastasize to these sites
- Coexistent ovarian tumors such as a granulosa cell
tumor, thecoma, epithelial ovarian carcinoma

13. • Pattern of spread:
- direct extension
-lymphatic spread
-hematogenous
- retrograde transtubal

14. Clinical evaluation
• History
• Physical examination
• TVS: endometrial thickness>5mm
• Sonosalpingography
• Endometrial tissue for histology
-office biopsy (pipelle),
(false negative 10%)
- FC
• Hysteroscopy

16. • Fractional Curettage
-under anesthesia,
- bimanual rectovaginal examination
- speculum is placed in the vagina
- the cervix is grasped with a tenaculum.
- endocervical canal is curetted before cervical
dilatation,
-The uterus then is sounded, the cervix dilated, and the
endometrium systematically curetted.
- The tissue is placed in a separate container so that
the histopathologic status of the endocervix and
endometrium can be determined separately.

17. Routine pre-op investigations
• Full blood count
• Serum creatinine and electrolytes
• Liver function tests
• Blood sugar
• Urinalysis
• Chest x-ray, ECG
• CT scan of chest, pelvis, and abdomen, particularly for
high-risk histologies

18. Pelvic and abdominal CT scan MRI may be helpful to
determine the extent of metastatic disease in the following
circumstances:
• abnormal liver function test results
• clinical hepatomegaly
• palpable upper abdominal mass
• palpable extrauterine pelvic disease
• clinical ascites
• grade 3 endometrioid or nonendometrioid carcinomas

19. Treatment
• Staging laparotomy:
adequate abdominal incision
peritoneal washings for cytology
exploration of pelvis & abdomen
extrafascial hysterectomy
b/l salpingo-oopherectomy
Pelvic & paraaortic lymphadenectomy
advanced stage- cytoreductive surgery

20. • Lymphadenectomy can be omitted:
stage1A, grade 1, <2cm tumor size with non- clear cell
or non-papillary serous type
• Infracolic omentectomy: serous and clear cell histology

23. Prognostic factors
Race
FIGO stage
Depth of myometrial invasiona
Tumor gradea
Histologic subtypea
Cervical involvement
Adnexal involvement
Positive pelvic washings
Metastases to the pelvic or paraaortic lymph nodes
Lymph-vascular space invasion
DNA aneuploidy

24. Post-operative Adjuvant therapy
Radiotherapy:
• vaginal brachytherapy
• External radiation
pelvic radiation
extended-field radiation
whole abdominal radiation
Chemotharapy: stage III IV and recurrent cancer
• cisplatin
• paclitaxel
• doxorubicin
• cyclophosphamide

25. Hormone therapy
• Progestin therapy:
1. young women- stage1A, grade1, child bearing desired
2. stage III, IV as adjuvant therapy
• Tamoxifen & other SERM

29. THANK YOU