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Endometrial Cancer

Endometrial Cancer

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Endometrial Cancer

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  1. Endometrial Cancer ASSOCIATE PROFESSOR Iolanda Blidaru MD, PhD

  2. Incidence corpus 32,000 ovary 21,000 cervix 13,500 other 4500 Mortality 4400 13,000 5600 1000 ACS Statistics, 1992

  3. Epidemiology. Physiopathology.Two different pathogenetic types of endometrial cancer 1. Estrogen-dependent tumors 2. Estrogen-independent tumors no unopposed E exposure no association with hyperplasia of the endometrium; arise on atrophic endometrium Older, postmenopausal, thin women less differentiated poor prognosis. • unopposed E exposure, • hyperplasia of the endometrium as initial step, • younger perimenopausal women, • better differentiated, • better prognosis.

  4. Age Hyperestrogenism (ERT, COC, Tamoxifen) Nulliparity / Infertility Obesity, Hypothyroidism, Hypertension Menstrual characteristics (nulliparity, early menarche, late menopause) Diabetes AtypicalHyperplasia Others: smoking, dietary factors Risk Factors

  5. Endometrial Hyperplasia Simple Hyperplasia Complex Hyperplasia Atypical Hyperplasia: simple / complex (dg. endometrial biopsy, D+C, total hysterectomy) Treatment: progestins (MPA),hysterectomy,GnRH-a Preinvasive Lesions = Endometrial Hyperplasia

  6. Endometrioid Adenocarcinoma (80%): G1, G2, G3; ER, PR. Papillary Serous Adenocarcinoma Clear Cell Adenocarcinoma Squamous Cell Carcinoma Sarcomas (malignant mixed Mullerian tumors, leiomyosarcoma, endometrial stromal sarcoma) Endometrial carcinoma Histopathology

  7. uterine bleedingin postmenopausal patients (90%) recurrent intermenstrual bleeding (over 40 years) atrophic vaginitis the uterus +/- enlarged, +/- fixed (parametrial, adnexial and/or intraperitoneal spread) hematometria or pyometria Clinical findings anddiagnosis

  8. Any genital bleeding occuring during postmenopause must be investigated to exclude endometrial carcinoma.

  9. Investigations • Endometrial biopsy - the diagnostic method endometrial lavage, aspiration cytology, cytology from endocervix and posterior vaginal fornix, hysteroscopy • US, MRI (uterine invasion, lymph node involvement) • Estrogen and progesterone receptors • Chest X-ray, computed tomography of the abdomen, urography, • Routine blood counts, urinalysis, sigmoidoscopy, liver function tests, blood urea nitrogen, serum creatinine, glycemia

  10. Differential diagnosis • leiomyoma, endometrial hyperplasia with DUB, cervical polyps • cervical, tubal, ovarian carcinoma • atrophic vaginitis • in the premenopausal patient - complications of early pregnancy

  11. Surgical Staging:

  12. Endometrial CA StagingSTAGE I (Add tumor grade to each stage) Ia Limited to endometrium Ib <1/2 myometrial thickness Ic >1/2 myometrial thickness

  13. Endometrial CA StagingSTAGE II (Add tumor grade to each stage) IIa Cervical glandular involvement IIb Cervical stromal involvement

  14. Endometrial CA StagingSTAGE III (Add tumor grade to each stage) IIIa Uterine serosa, positive washings, or adnexal involvement IIIb Vaginal metastases IIIc Positive lymph nodes

  15. Endometrial CA StagingSTAGE IV (Add tumor grade to each stage) IVa Bladder or bowel mucosa IVb Distant metastases

  16. Treatment of Endometrial Adenocarcinoma: • Surgery→ staging in majority of patients Extrafascial total abdominal hysterectomy / Bilateral salpingo-oophorectomy, peritoneal washings, +/- LND (lymphadenectomy) • RT • Progestins • Chemotherapy

  17. Radical Hysterectomy • Removes corpus, cervix, parametria, upper third of vagina • Uterine arteries divided at origin • Ureters dissected through tunnel • Uterosacral ligaments divided near rectum • Typically combined with LND • Oophorectomy mandated

  18. Treatment of Endometrial Adenocarcinoma: • Surgery • Radiotherapy -Adjuvant RT for high-risk patients postoperatively -No adjuvant RT if Ia, G1-2 with favorable histology -The only treatment in patients with inoperable stage I and stage II disease • Progestins • Chemotherapy

  19. Acute: Perforation Fever Diarrhea Bladder spasm Chronic: Proctitis Cystitis, UTI Fistula Enteritis Complications of Radiation Therapy

  20. High-Risk Patients • Deep myometrial invasion • Positive nodes • Grade 3 tumor • Clear cell, papillary serous, squamous or undifferentiated histologies • Positive peritoneal cytology • Other extra-uterine spread

  21. Primary Treatment of Uterine Sarcoma • Surgical staging • Single-agent chemotherapy, depending on histology and stage (ADR = adriamycin for leiomyosarcoma, endometrial stromal sarcoma; IFX= ifosfamide for malignant mixed Mullerian tumors) • RT does not appear to alter survival