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Endometrial Cancer

Endometrial Cancer

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Endometrial Cancer

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  1. Endometrial Cancer Patrick Lavoie Geneviève Moreau

  2. Case A 66 yo nulliparous woman who underwent menopause at age 55 complains of a 2-week history of vaginal bleeding. Prior to menopause, she had irregular menses. She denies use of hormone therapy. Her medical history is significant for diabetes mellitus controlled with an oral hypoglycemic agent. On examination, she weighs 100 kg and is 172 cm in height. Her blood pressure is 150/90 and temperature 37.5 degree Celcius. Heart and lung examination is normal. Abdomen is obese, no masses palpable. The external genitalia appear normal, and the uterus seems to be of normal size without any demonstrable pelvic mass.

  3. DDx Post-menopausal Bleeding • Vaginal atrophy • Hormone replacement therapy • Gyne cancer (uterine, endometrial, ovarian) • Uterine hyperplasia • Polyps • Trauma • Infection (ex: STI)

  4. DDx Post-menopausal Bleeding • Vaginal atrophy • Hormone replacement therapy • Gyne cancer (uterine, endometrial, ovarian) • Uterine hyperplasia • Polyps • Trauma • Infection (ex: STI) ENDOMETRIAL CANCER UNTIL PROVEN OTHERWISE

  5. Investigations for Postmenopausal Bleeding • Rectovaginal/pelvic exam, speculum exam • CBC • Pap test • Gynecological US • Endometrial biopsyor D&C • Hysteroscopy if biopsy unattainable or inconclusive • CA-125 marker level

  6. Endometrial Cancer Type I: Estrogen-dependent • About 80% of endometrial cancers • Risk factors: • COLD NUT • Cancer (ovarian, breast, colon) • Obesity • Late menopause • Diabetes mellitus • Nulliparity • Unopposed estrogen (PCOS, anovulation, HRT) • Tamoxifen • Others • Age • Menstrualirregularities • Infertility • Smoking • HNPCC • Hypertension • Gallbladderdisease

  7. Endometrial Cancer Type I: Estrogen-dependent • Presentation: • Postmenopausal bleeding (95% of cases) • AUB in pre-menopausal women (menorrhagia, intermenstrual bleeding) • Vaginal discharge • Hematometra, pyometra • Pelvic discomfort • Histology: • Well-differentiated endometrioidadenocarcinoma • Glands that look normal but contain more solid areas • Less glandular formation • Hyperplasia background

  8. Endometrial Cancer Type II: Estrogen-independent • About 15% of endometrial cancers • Risk factors: • Possibly Tamoxifen

  9. Endometrial Cancer Type II: Estrogen-independent • Presentation: • Less likely to present with bleeding at early stage • More likely to present with advanced stage disease with symptoms resembling ovarian cancer • Bloating • Bowel dysfunction • Pelvic pressure • Histology: • Poorly differentiated • Atrophic background • Subtypes: serous, clear cell carcinoma, grade 3 endometrioid, undifferentiated, carcinosarcoma

  10. She has many risk factors A 66 yo nulliparous woman who underwent menopause at age 55 complains of a 2-week history of vaginal bleeding. Prior to menopause, she had irregular menses. She denies use of hormone therapy. Her medical history is significant for diabetes mellitus controlled with an oral hypoglycemic agent. On examination, she weighs 100 kg and is 172 cm in height. Her blood pressure is 150/90 and temperature 37.5 degree Celcius. Heart and lung examination is normal. Abdomen is obese, no masses palpable. The external genitalia appear normal, and the uterus seems to be of normal size without any demonstrable pelvic mass.

  11. She has many risk factors A 66 yo nulliparous woman who underwent menopause at age 55 complains of a 2-week history of vaginal bleeding. Prior to menopause, she had irregular menses. She denies use of hormone therapy. Her medical history is significant for diabetes mellitus controlled with an oral hypoglycemic agent. On examination, she weighs 100 kg and is 172 cm in height. Her blood pressure is 150/90 and temperature 37.5 degree Celcius. Heart and lung examination is normal. Abdomen is obese, no masses palpable. The external genitalia appear normal, and the uterus seems to be of normal size without any demonstrable pelvic mass. The biopsy reveals an endometrial cancer. Now what?

  12. Staging FIGO Staging of Endometrial Cancer (International Federation of Gynecologists & Obstetricians) • Stage I: Does not extend beyond myometrium • Stage II: Does not extend beyond uterus • Stage III: Local invasion (vagina +/- para-aortic or pelvic lymph nodes) • Stage IV: Invasion of bladder +/- bowel +/- distant metastases (most often to the liver or lungs)

  13. (Sub)Staging FIGO Staging of Endometrial Cancer (International Federation of Gynecologists & Obstetricians) Stage I: Does not extend beyond myometrium • Stage IA: No or < ½ myometrial invasion • Stage IB: Invades through ≥ ½ of myometrium Stage II: Does not extend beyond uterus Stage III: Local invasion (vagina +/- para-aortic or pelvic lymph nodes) • Stage IIIA: Invasion of serosa, corpus uteri +/- adnexae • Stage IIIB: Vaginal +/- parametrial involvement • Stage IIIC: Metastasis to pelvic +/- para-aortic LN • Stage IIIC1: Positive pelvic LN • Stage IIIC2: Positive para-aortic LN +/- positive pelvic LN Stage IV: Invasion of bladder +/- bowel +/- distant metastases • Stage IVA: Invasion of bladder +/- bowel mucosa • Stage IVB: Distant mets, including intra-abdominal mets +/- inguinal LN

  14. Spread • The most common pattern of spreading is direct extension • Lymphatic spread to pelvic and para-aortic nodes • Transtubal spread to peritoneal cavity • Hematogenousspread usually to lungs and liver

  15. Grading FIGO (International Federation of Gynecologists & Obstetricians) Grades of Endometrial Carcinoma G1: Well-differentiated adenomatous carcinoma • < 5% of tumor shows solid growth pattern G2: Moderately differentiated adenomatous carcinoma with partly solid areas • 6%-50% of tumor shows solid growth pattern G3: Poorly differenciated or undifferentiated • > 50% of tumor shows solid growth pattern

  16. Treatment Surgery • Hysterectomy with bilateral salpingo-oophorectomy (+/- lymphadenectomy, +/- omentectomy) and pelvic washing Radiotherapy • Stage I: Reduces recurrence, but does not improve survival • Stage III-IV (positive LN and/or intraperitoneal disease): Greatly improves survival Chemotherapy • Used for systemic (stage IV) disease or high-grade recurrent disease Hormonal therapy (progestins, tamoxifen) • Can be used for recurrent disease (especially if low grade and/or hormone dependent) • Can also be used as palliative treatment for all stages

  17. Prognosis Associatedwith FIGO staging and gradingcriteria • The most important predicting factor istumordifferenciation (grading) • Lessdifferentiated = Lessfavorable prognosis • The 2ndmost important predicting factor isdepth of myometrial invasion 5-Year Survival Rates • 70-80% overall for all stages • 85-90% for stage I disease • 20-25% for stage IV disease

  18. OMGtoomuch info… Just tell me what I needto know!

  19. Whatyoureallyneed to know about endometrial cancer: • Common • Most commongyne cancer in NorthAmerica • 2-3% lifetimerisk • Nearly 1 in 4 womenwithpostmenopausalbleeding • Simple diagnosis • Endometrialbiopsy • Usuallydiagnosedearly • 75% of patients presentwith stage I disease • Respondswell to treatment • 90% 5-year survival rate at stage I

  20. References • Toronto Notes 2014 • Williams’ Gynecology • Obstetrics and Gynecology (Beckman) • Obstetrics and Gynecologyat a Glance • Medscape