endometrial carcinoma – Flashcards

-It is generally a disease of post-menopausal women with an increasing incidence as the population ages Still about 25% of cases occur before menopause and 5% of cases occur under the age of 40 years

- cause of endometrial cancer is unknown. prolonged unopposed estrogen stimulation plays the main role in pathogenesis

1. early menarche and late menopause 2. nulliparity and low parity 3. obesity I corpus 4. impaired CHO tolerance & DM I cancer 5. hypertension I synd 6. unopposed estrogen excess endogenous: PCOS, E producing ovarian tumour (granulosa theca cell tumour ) exogenous: ERT 7. tamoxifen therapy (proestrogenic effect on endometrium) Ex raloxfen 8. familial inheritance (lynch type 2 s) ass w ovarian cancer, endometrial carcinoma, colon cancer dt defective mismatch repair gene

- oral contraceptives - smoking

Gross: . Localized : polyp,ulcer,mass . Diffuse : tuberous,papillary

1.endometrioid adenocarcinoma: .more than 90% .G 1,2,3 2.adenocarcinoma with Sq diff .adenoacanthoma .adeno sq carcinoma 3.papillary serous adenocarcinoma 4.clear cell carcinoma 5.primary sq cell carcinoma

Type I: related to estrogen Type II: unrelated to estrogen or E-related risk factors

occur in relatively younger premenopausal females frequently associated with endometrial hyperplasia : of low grade minimal myometrial invasion exhibit a stable clinical course associated with good prognosis Type I is typically well diffrentiated endometroid adenocarcinoma - less commonly secretory ,ciliated , villoglandular or squamous variants

In relatively older postmenopausal women Not proceeded or accompanied by hyperplasia High grade Deep endometrial invasion Exhibit a progressive clinical course Associated with poor prognosis Include adeno.sq , papillary serous & clear cell carcinomas

Hyperplasia , obesity & ERT are the most important risk factors Others include: high fat diet , associated medical conditions (DM, hypertension), late menopause, users of tamoxifen , lynch II syndrome Lower risk with smoking (anti estrogenic mechanism) & combined OCP

slowly growing thick myometrial cover poverty of lymphatics 1.direct (M/c cause of death= perforation of uterus and peritonitis) to myometrum, peritoneum, cx(pyometria, hematometria), bladder, colon. 2.lymphatic (when? >50% of myometrium, cx, adnexa)-uppe=paraaortic-middle=int iliac-lower=iliac, sacral, parametric LN. rarely inguinal 3.hematogenous by embolization to lung, brain, lower ant vaginal wall 4.transtubal (isolated) to peritoneum 5.implantation (to cx, peritoneum)

I confined to the corpus uteri a confined to endometrium b invade less than half myometrium c invade more than half II cervix involved a endocervical glands involved b cervical glands & stroma III a extends to ut serosa adnexae ascites or positive peritoneal washing b vaginal involvement c para-aortic or pelvic node involvement IV a involving mucosa of bladder or rectum b distant metastasis , other abd or inguinal lymph nodes

Patients with advanced disease &/or unfit for surgery clinical staging of 1971 is still acceptable Incorporation of imaging in stagin

symptoms: .abnormal ut bleeding (main) = postmenopausal/metrorrhagi/cont bleeding if reproductive life .vaginal discharge: watery/serous (endom hyperplasia) , purulent/offensive dt infenction or pyometria, blood stained dt ulceration .pelvic pain: late, dt extrauterine spread or pyometria, intermittent cocliky pain dt contraction. .cancer cachexia dt persistent bleeding or sepsis signs: uterine size, contour, consistancy; ...etc. exclude the bleeding from cx or vagina on bimanual xm : -cx os: patulous - uterus: small, OR symetrical enlarged and softer dt growth/pyometria, OR enlarged, irregular, fixed dt extention. - certain pathological ass w it: uterine fibroma(uterine enlarge), endometrial polyp( felt or seen from dilated cx os), ovarian neoplam (feminizing ovarian tumour)

imaging assessment of endometrium & endometrial sample histology

Mainstay of treatment is an extrafacial TAH & BSO staging followed in most instances by radiotherapy Chemotherapy Hormonal therapy

Role of frozen section in evaluation & lymph nodes is controversial if non palpable para -aortic nodes 59% chance of affection hysterectomy can be abandoned in frail patients

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age stage, tumor size & grade: histologic type & diffrentiation myometrial invasion endothelial lined space involvement(vascular& lymphatic) peritoneal cytology lymph node metastasis progesterone receptors

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> 50% myometriun involvement gradeIII EEC uterine papillary serous carcinoma clear cell carcinoma 1ry sq cellcarcinoma of the endometrium

paraaortic LN

internal iliac LN

spread like cancercx to iliac LN, sacral LN, parametric LN

1. older pt 2. lean pt 3. advanced stages 4. clear cell carcinoma, papillary serous carcinoma, 1ry sq cell carcinoma 5. stage III EAC 6. > 50 % myometrium involvement 7. adnexia and LN involvement 8. flow cytometry showing aneuploidy

- for high risk women: fx hx of lynch II S(heridatary non-polysis corectal cancer), PCOS, taking unopposed estrogen therapy and tomoxifen. 1. sampling followed by cytological xm sample obtained by? gravlee jet washer, aspiration by vabra aspirator, endometrial brushing by small intrauterine brush, using pipelle cannula. 2. endometrial biopsy by novack's currete or kevorkian curette followed by histopathological xm 3. imaging .Transvaginal US. endometrium N 5mm in postmenopausal on ERT OR >8mm in postmenopausal w/o ERT. also to exclude ovarian pathology. . saline infusion sonography for small polyp or irregularity surface . 3D US to measure endometrial volume 4. office hystroscopy (rare) m/c used: transvaginal US + endometrial sampling

-TVUS >5mm thickness +low/high risk - high risk => D&C biopsy or hysteroscopy directed endometrial biopsy .D&C by endometrial suction instrument or fractional curretage(cx then uterus body) CRITERIA: 1. patulous cx os 2. purulent grayish yellow necrotic material 3. endless curretage 4. absence of grating sensation 5. profuse bleedinf during or after currettage .hysteroscopy: site for biopsy, inspect the cavity

- other causes of postmenopausal bleeding - other causes of symmetrical enlargement

1. stage 1C(>50% myometrium) 2. grade III EAC 3. size >2cm 4. extend to cx 5. UPSC and clear cell carcinoma, primary sq cell carcinoma made during laparotomy

TAH + BSO -> frozen section + peritoneal washing + LN resection tried: laparoscopic assisted vaginal hysterectomy (LAVH) + laparoscopic LN dissection (LLND)

-if occult, done like stage 1 - primary radical hysterectomy +BSO

radiotherapy (post/pre/primary therapy) + hormonal tx (progesteronelike MPA devoprovera, tamoxifen, GnRH agonist like goserelin)+- chemotherapy (cisplastin, doxorubicn, carboplastin, pactilaxel FOLLOW UP (every 3 mo for 2 years, every 6 mo for 3 years and then annualy) take vault pap smear if not had radiation therapy