Endometrial Cancer

Endometrial CancerEndometrial CancerDistrict 1 ACOG Medical District 1 ACOG Medical

Student Teaching Module Student Teaching Module 20092009

SymptomsSymptoms Post menopausal bleedingPost menopausal bleeding Endometrial cells on PapEndometrial cells on Pap Perimenopausal with irregular heavy Perimenopausal with irregular heavy

menses, increasingly heavy mensesmenses, increasingly heavy menses Premenopausal with abnormal Premenopausal with abnormal

uterine bleeding with history of uterine bleeding with history of anovulationanovulation

Differential Diagnosis for Differential Diagnosis for PMBPMB

Exogenous estrogen use- ie Exogenous estrogen use- ie tamoxifentamoxifen

Atrophic endometritis/vaginitisAtrophic endometritis/vaginitis Endometrial/cervical polypsEndometrial/cervical polyps Endometrial hyperplasiaEndometrial hyperplasia Endometrial CancerEndometrial Cancer Other gynecologic cancersOther gynecologic cancers

Risk factors for Endometrial Risk factors for Endometrial CancerCancer

Increased estrogenIncreased estrogen– Hormone therapyHormone therapy– ObesityObesity– Anovulation/PCOSAnovulation/PCOS– Estrogen secreting tumorsEstrogen secreting tumors– Older ageOlder age– InfertilityInfertility– Early menarcheEarly menarche– Late menopauseLate menopause

GeneticsGenetics– HNPCCHNPCC– CaucasianCaucasian

Preoperative Work-upPreoperative Work-up Endometrial biopsyEndometrial biopsy UltrasoundUltrasound For suspected advanced stage may need:For suspected advanced stage may need:

– CystoscopyCystoscopy– SigmoidoscopySigmoidoscopy– Pelvic and Abdominal CTPelvic and Abdominal CT

LabsLabs– CBCCBC– Chem 7Chem 7– Liver function testsLiver function tests– EKG, CXREKG, CXR

Endometrial Hyperplasia Endometrial Hyperplasia (EIN)(EIN)

Precursor to endometrial cancerPrecursor to endometrial cancer– Risk of progression related to cytologic atypiaRisk of progression related to cytologic atypia

Presents with abnormal bleedingPresents with abnormal bleeding SimpleSimple

– Benign irregular dilated glandsBenign irregular dilated glands– No atypia: 1% progress No atypia: 1% progress – Atypia: 8% progress Atypia: 8% progress

ComplexComplex– Proliferation of glands with irregular outlines, Proliferation of glands with irregular outlines,

back to back crowding of glands, but no atypiaback to back crowding of glands, but no atypia– No atypia: 3% progress No atypia: 3% progress – Atypia: 29% progressAtypia: 29% progress

Staging of Endometrial Staging of Endometrial CancerCancer

I: Confined to uterine corpusI: Confined to uterine corpus– IA: limited to endometriumIA: limited to endometrium– IB: invades less than ½ of myometriumIB: invades less than ½ of myometrium– IC: invades more than ½ of myometriumIC: invades more than ½ of myometrium

Staging of Endometrial Staging of Endometrial CancerCancer

II: invades cervix but not beyond II: invades cervix but not beyond uterusuterus– IIA: endocervical gland involvement onlyIIA: endocervical gland involvement only– IIB: cervical stroma involvementIIB: cervical stroma involvement

Staging of Endometrial Staging of Endometrial CancerCancer

III: local and/or regional spreadIII: local and/or regional spread– IIIA: invades serosa/adnexa, or positive IIIA: invades serosa/adnexa, or positive

cytologycytology– IIIB: vaginal metastasisIIIB: vaginal metastasis– IIIC: metastasis to pelvic or para-aortic lymph IIIC: metastasis to pelvic or para-aortic lymph

nodesnodes

Staging of Endometrial Staging of Endometrial CancerCancer

IVA: invades bladder/bowel mucosaIVA: invades bladder/bowel mucosa IVB: distant metastasisIVB: distant metastasis

Five Year SurvivalFive Year Survival Stage I: 81-91%Stage I: 81-91%

– 72% diagnosed at this stage72% diagnosed at this stage Stage II: 71-78%Stage II: 71-78% Stage III: 52-60%Stage III: 52-60% Stage IV: 14-17%Stage IV: 14-17%

– 3% diagnosed at this stage3% diagnosed at this stage

Spread PatternsSpread Patterns Direct extension Direct extension

– most commonmost common Transtubal Transtubal LymphaticLymphatic

– Pelvic usually first, then para-aorticPelvic usually first, then para-aortic HematogenousHematogenous

– Lung most commonLung most common– Liver, brain, boneLiver, brain, bone

TreatmentTreatment Stage IB or less: total Stage IB or less: total

hyst/BSO/PPALND, cytologyhyst/BSO/PPALND, cytology Stage IC to IIB: total hyst/BSO/PPALND, Stage IC to IIB: total hyst/BSO/PPALND,

cytology, adjuvant pelvic XRTcytology, adjuvant pelvic XRT Stage III: total hyst/BSO/PPALND, Stage III: total hyst/BSO/PPALND,

cytology, adjuvant chemotherapycytology, adjuvant chemotherapy Stage IV: palliative XRT and Stage IV: palliative XRT and

chemotherapychemotherapy

Histologic TypesHistologic Types Estrogen dependentEstrogen dependent

– Endometrioid- most commonEndometrioid- most common Non estrogen dependent- worse Non estrogen dependent- worse

prognosisprognosis– Papillary SerousPapillary Serous– Clear cellClear cell– AdenosquamousAdenosquamous– Undifferentiated Undifferentiated

Other Types of Uterine Other Types of Uterine CancerCancer

LeiomyosarcomaLeiomyosarcoma– Rapidly growing fibroid should be Rapidly growing fibroid should be

evaluated evaluated Stromal sarcomaStromal sarcoma Carcinosarcoma (MMMT)Carcinosarcoma (MMMT)

leiomyosarcoma

MMMT