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Endometrial Cancer. ASSOCIATE PROFESSOR Iolanda Blidaru MD, PhD. Incidence corpus 32,000 ovary 21,000 cervix 13,500 other 4500. Mortality 4400 13,000 5600 1000. ACS Statistics, 1992.
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Endometrial Cancer ASSOCIATE PROFESSOR Iolanda Blidaru MD, PhD
Incidence corpus 32,000 ovary 21,000 cervix 13,500 other 4500 Mortality 4400 13,000 5600 1000 ACS Statistics, 1992
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.
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
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
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
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
Any genital bleeding occuring during postmenopause must be investigated to exclude endometrial carcinoma.
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
Differential diagnosis • leiomyoma, endometrial hyperplasia with DUB, cervical polyps • cervical, tubal, ovarian carcinoma • atrophic vaginitis • in the premenopausal patient - complications of early pregnancy
Surgical Staging:
Endometrial CA StagingSTAGE I (Add tumor grade to each stage) Ia Limited to endometrium Ib <1/2 myometrial thickness Ic >1/2 myometrial thickness
Endometrial CA StagingSTAGE II (Add tumor grade to each stage) IIa Cervical glandular involvement IIb Cervical stromal involvement
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
Endometrial CA StagingSTAGE IV (Add tumor grade to each stage) IVa Bladder or bowel mucosa IVb Distant metastases
Treatment of Endometrial Adenocarcinoma: • Surgery→ staging in majority of patients Extrafascial total abdominal hysterectomy / Bilateral salpingo-oophorectomy, peritoneal washings, +/- LND (lymphadenectomy) • RT • Progestins • Chemotherapy
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
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
Acute: Perforation Fever Diarrhea Bladder spasm Chronic: Proctitis Cystitis, UTI Fistula Enteritis Complications of Radiation Therapy
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
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