ENDOMETRIAL CARCINOMA

1. CASE STUDY
• Sixty-five-year-old Mrs K wasa retired professor,
lived in a metropolitan city and spent 6 months in a
year with her only daughter in the United States. She
was a diabetic for 10 years, hypertensive and had
dyslipidaemia. She was also obese, with a body mass
index (BMI) of 42. (She weighed 110 kg.) She was
advised weight reduction, diet, exercises and lifestyle
modification, none of which she followed. She
noticed small amount of vaginal bleeding 1 month
ago but ignored it. The bleeding recurred, was
moderate in quantity this time, and she came for
evaluation to the hospital.

2. Endometrial Cancer

3. ENDOMETRIAL CARCINOMA

4. Possible questions
 LAQ
 What are the causes of post-menopausal
bleeding? Discuss the management of endometrial
cancer.
 SAQ
 Endometrial hyperplasia
 Staging of endometrial cancer
 D/D of post-menopausal bleeding

5. POST MENOPAUSAL
BLEEDING
Atrophic Vaginitis
Atrophic Endometrium
Oestrogen Therapy
Endometrial Hyperplasia
Endometrial Polyp
Endometrial Cancer
Cervical Cancer

6. Endometrial Cancer
 Commonest gynecologic cancer in…..
 Not so common in India
 Affects affluent people
 Unopposed estrogen action causally
related
 Best prognosis of all gynecologic
cancers

7. Endometrial hyperplasia
 Protracted unopposed estrogenic stimulation
 Types
 Simple without atypia
 Complex without atypia
 Atypical hyperplasia
 Simple
 Complex
 Cancer risk maximum in atypical hyperplasias
 Role of progestins in therapy

8. Endometrial hyperplasia

9. ENDOMETRIAL CARCINOMA-GROSS

10. Endometrial Cancer
Presentation
 Endometrial cancer presents early in its
natural history
 Median age - 60 years
 Abnormal uterine bleeding
 Early diagnosis is invariably possible

11. Endometrial Cancer
Presentation
 Postmenopausal women
 Commonest subset of women
 Postmenopausal bleeding (PMB) earliest
manifestation
 Single or recurrent episodes
 Obesity, hypertension and diabetes
frequently coexist
 Dirty white discharge or lump abdomen not
very common

12. Endometrial Cancer
Presentation
 Perimenopausal women
 25 % women are premenopausal
 Menorrhagia or menometrorrhagia
 High index of suspicion for early diagnosis
 Endometrial biopsy never to be ignored

13. Endometrial Cancer
Presentation
 Reproductive Age-Group women
 Only 5 % endometrial cancers in women
under 40
 Chronic anovulation with unopposed
estrogen action
 Heavy or irregular bleeding

14. Frank endometrial cancer

15. WHO Classification of
Endometrial Cancer
 Endometrial Adenocarcinoma
 Mucinous carcinoma
 Serous carcinoma
 Clear Cell carcinoma
 Squamous Cell
 Mixed Cell Variant
 Undifferentiated carcinoma

16. FIGO STAGING FOR GRADING
ENDOMETRIOID
(80%)
SEROUS(10%)

17. FIGO STAGING FOR GRADING
CLEAR CELL(<5%)
MUCINOUS

18. FIGO STAGING FOR GRADING

19. Endometrial Cancer
Diagnosis & Work-up
 History
 Age >50 yrs
 Nulliparity
 Symptoms
 Past History: Anovulatory cycles, Early
menarche, Late menopause
 Family History: HNPCC
 Medical Conditions: DM, HTN
 Medications: Oestrogens, Tamoxifen

20.  Transvaginal Sonography
 Endometrial Thickness (> 5 mm )
 Size, shape of uterus
 Endometrial Polyp
 Pyometra
 Ovarian Mass
 Sonosalpingography
 Endometrial Tissue for histology: Curettage
 Hysteroscopy
Endometrial Cancer
Diagnosis & Work-up

22. Endometrial Cancer
Diagnosis & Work-up
 Endometrial Curettage
 Gold Standard in the diagnosis
 Office suction biopsy sufficient
 D&C under anaesthesia necessary in a few
cases
 Fractional curettage not mandatory
 Ask pathologist to grade the tumor

23. Endometrial Cancer
Diagnosis & Work-up
 Hysteroscopy
 Good inv for evaluation of post- and
perimenopausal bleeding
 Helps in identifying hyperplasia, polyps or
fibroids or atrophic endometritis
 Can visualize cervical extension of growth
 Can direct biopsies

25. DIAGNOSIS Cont’d
•Pap smear is not diagnostic, but a finding of abnormal glandular cells of
unknown significance (AGCUS) that leads to further investigations.
•Abnormal Pap smears are the presentation of 1-5% of endometrial carcinoma
cases.
•Pap smear/endocervical curettage is required to evaluate cervical involvement.

26. Endometrial Cancer
Diagnosis & Work-up
 Sonography
 Useful adjunct to endometrial biopsy
 If endometrial thickness is < 5 mm,
chances of endometrial cancer are remote
 May comment about depth of myometrial
invasion
 Saline sonography useful in outlining
certain benign lesions

27. Endometrial Cancer
Diagnosis & Work-up
 CT Scan, MRI Scan, PET Scan
 X-ray Chest
 CA-125 Assay
 Cystoscopy, Proctoscopy, Sigmoidoscopy
 Routine hematological & biochemical
investigations & ECG

28. Endometrial Cancer
Staging
Stage Ia G123 No myometrial invasion
Stage Ib G123 <1/2 myometrial invasion
Stage Ic G123 >1/2 myometrial invasion
Stage IIa G123 Extension to endocervical glands
Stage IIb G123 Cervical stromal invasion

31. Endometrial Cancer
Staging
Stage IIIa G123 Positive uterine serosa, adnexae or
peritoneal cytology
Stage IIIb G123 Vaginal metastasis
Stage IIIc G123 Positive pelvic/para-aortic LNs
Stage IVa G123 Bladder/Bowel invasion
Stage IVb G123 Distant metastasis

32. SPREAD
• Direct extension .. MC
• Lymphatics
• Transtubally- to ovary, pelvis and
peritoneal cavity.
• Haematogenous
Lungs (mc ), liver,
brain and bone.

35. FIGO STAGING

38. Endometrial Cancer
Management
 Surgery - with or without
radiotherapy - is the ‘standard
of care’
 Primary radiotherapy only to those
where surgery contraindicated
 Chemotherapy/Hormone therapy/
Immunotherapy minimal role

40. Endometrial Cancer
Surgical Staging Procedure
 Once diagnosis confirmed – patients
taken up for surgical staging
 Steps
 Laparotomy
 Collection of peritoneal washings
 Search for extra-pelvic / LN disease
 Extra-fascial hysterectomy + BSO
 Pelvic lymphadenectomy + Paraaortic LN
sampling

41. Endometrial Cancer
Management
 Stage I Disease
 > 75 % patients belong to this stage at
diagnosis
 Stage Ia G1 – No adjuvant therapy
required
 Stage Ic or G3 – Adjuvant RT to vault and
pelvis
 Other Stage I cases – Adjuvant RT may or
may not be given

42. Endometrial Cancer
Management
 Stage II
 10-15 % patients are at this stage at
diagnosis
 If cervical involvement diagnosed pre-op –
one may do Wertheim’s Hysterectomy as
primary treatment modality
 If diagnosed after surgical staging –
Adjuvant RT to the vault and pelvis

43. Endometrial Cancer
Management
 Stage III
 Only 5 % patients of endometrial cancer
are in this stage
 Adjuvant RT to the pelvis and vault must
be given
 In case of paraaortic LN involvement –
extended field irradiation or whole-
abdomen irradiation

44. Endometrial Cancer
Management
 Stage IV
 In IVa involving bladder/rectum without
distant metastasis – exenterative
procedures with RT
 In inoperable patients – palliative RT offers
good symptom control
 In IVb patients with distant metastasis –
palliative RT to pelvis and palliative
chemotherapy and progestin therapy

45. Endometrial Cancer
Management
 Recurrent Disease
 Half of the recurrences within two years of
primary treatment
 Locoregional recurrences following primary
surgical treatment respond well to RT
 Isolated distant failures may be resectable
 Otherwise, palliative chemotherapy

46. Endometrial Cancer
Follow-up
 Meticulous follow-up a must to detect
recurrences early
 3-monthly visits for 2 years and then 6-
monthly visits
 Detailed history and examination at each visit
helps detect recurrences most often
 A vaginal smear at each visit
 Role of USG at each visit
 X-ray chest and CA-125

47. Possible questions
 MCQs
 The commonest cause of postmenopausal bleeding is
(a) Endometrial cancer
(b) Senile endometritis
(c) Cervical cancer
(d) Endometrial hyperplasia
 Endometrial hyperplasia with excessive periods is the result of
(a) unopposed progesterone action
(b) unopposed estrogen action
(c) unopposed prolactin action
(d) continuous intake of OC pills

48. Possible questions
 MCQs
 All of the following about endometrial cancer are
correct EXCEPT
(a) Usually affects postmenopausal women
(b) Usually detected in early stages
(c) Unopposed estrogenic action is a known causal factor
(d) Chemoradiation is the treatment of choice

49. Thank you