Endometrial Carcinoma

Fuat Demirkran, MD
Istanbul University, Cerrahpaa
School Of Medicine, OB&GYN
Department, Gyn Oncology
In developed countries, cancer of the uterine
corpus is the most common malignancy seen in
the female pelvis today

It is the fourth most common cancer in women.

 GTN
Vulva
2%
3%
Endometrium
24%
Ovary
49%

Cervix
22%

49%
Ovary

24%
Endomet

N: 1730 Cervix
22%

3%
Vulva

2%
GTT

CTF Gynecol Oncol 2004

 EPIDEMIOLOGY and Risk Factors

The median age for adenocarcinoma of the uterine

corpus is 61 years, with the largest number of
patients noted between the ages of 50 and 59 years.

Approximately 5% of women will have adenocarcinoma

before the age of 40, and 20% to 25% will be
diagnosed before the menopause.
 EPIDEMIOLOGY and Risk Factors

The use of combination oral contraceptives (OC)

decreases the risk of developing endometrial
cancer.
Cigarette smoking apparently decreases the risk of
developing endometrial cancer. The RR decreased
by about 30% when one pack of cigarettes was
smoked per day
 increased risk
obesity increases the risk.....related to depressed SHBG
in obese women
nulliparity and late menopause have increased risk
.....related to unoppesed estrogen
DDM and hypertansion are frequently associated with EC
The use of continuous estrogen increases the risk of EC
Tamoxifen.......related to its estrogenic effect on
endometrium
PCO
Granulosa cell tumor
Risk factors for Endometrial cancer
Risk factors Risk
Obesity Overweight
21-50 lb 3
>50 lb 10
Nulliparity Compared with
1 child 2
5 or more children 3
Late menopause Age
>52 yr 2.4
 Endometrial cancer filling
endometrial cavity

Endometrial cancer
spreading cervix
 Symptoms of Endometrial Cancer

1. abnormal uterine bleeding in premenopausal

period
(prolonged and heavy menstruel periods and
intermenstruel spoting may be related to EC.)

2. postmenopausal bleeding in postmenopausal

period
as the patients age increases after the menopause,
the probability of EC with uterine bleeding
increases progressively.
 Distribution of endometrial carcinoma by stage
(surgical)

Stage Patients

I 73 %
II 12 %
III 12 %
IV 3%
Classification of Endometrial Cancer

Endometrioid adenocarcinomas (Type I)

Usual
Secretory
Villoglandular or papillary
With squamous differantiation

Special(non-enometrioid) variant carcinomas(Type II)

Papillary serous (UPSC)
Clear cell(CCC)
Mucinous
Pure squamous cell
Mixed
Undifferentiated
 Diagnosis of Endometrial Cancer

Cytology
Endometrial cytology to make the diagnosis of EC have been
less successful than sampling.
only 1/3 and of the patients with EC have abnormal c-v
smear.

Hysterograhpy and hysteroscopy are adjuvants

methods in making the diagnosis of EC

USG is a diagnostic tool particularly in postmenopausal women

to diagnose endometrial pathology and to evaluate depth of MI
of EC
Tumor markers and MRI

Endometrial sampling(Biopsy)
Which technique for
endometrial biopsy ?

D&C
Pipelle-endorette
Hysteroscopy
 D&C
the oldest technique
reasonable accuracy rate
need general anaesthesia
complications

Gold-standard technique !
False negative rates of D&C are
as high as 6 and 10%.

It is found that in
approximately 60% of the D&C
procedures, less than half of
the uterine cavity is curetted

Brooks et al, Grimes et al Am Obstet Gynecol 1988, 1982

Stock et al. Am J Obstet Gynecol 1975
 Pipelle-Endorette
doesnt need anaesthesia
inexpensive
easily used
the rate of adequate sampling!
histopathologic agreement with others techniques!
The Rates of Sufficient Endometrial Sample with
Pipelle (-endorette)

Stovall et al., 1991......Cancer............... 98%

Fothergill et al., 1992......All pathology..... 84%
Momerger et al., 1998......All pathology.... 95%
Monganiello et al.,, 1998..... All pathology..... 99%
Thanuja ve ark, 2000.....All pathology..... 89%
Epstein et al., 2001....All pathology......... 71 %

The failure rate of endometrial sample .......1-30 %

The false negative rate........5-15 %

 Hysteroscopy
end-point diagnostic work-up for endometrial pathology

False negative rate 3%

 PROGNOSTIC FACTORS IN
ENDOMETRIAL ADENOCARCINOMA

Histologic type (pathology)

Stage of disease
Histologic differentiation
Myometrial invasion
Peritoneal cytology
Lymph node metastasis
Adnexal metastasis
 Stage and five-year survival in
endometrial cancer

Stage Survival

I 86 %
II 66 %
III 44 %
IV 16 %
 Tumor differentiation and 5-year
survival rate stage I (surgical)

Grade Survival
1 94%
2 88%
3 79%
Relationship between depth of myometrial invasion
and 5-year survival rate

MI Survival rate

<1/3 82.4 %
1/3-1/2 78.0 %
>1/2 66.8 %
FIGO 2009 IA
IB

II

IIIC1
IIIC2
 Treatment

Total abdominal hysterectomy (TAH) + Bilateral

salpingo-oophorectomy + pelvic and paraaortic
lympadenectomy should be done

After getting pathologic results , adjuvant

treatment is being decided according to risk factors
Adjuvant Therapy Following Surgery

IA IB IC II ve >
Grade I Br-RT Ex-RT

Grade Br-RT ? Br-RT Ex-RT

II
Grade Br-RT Br-RT Ex-RT Ex-RT
III

Ex-RT: External radiotherapy

Br-RT: Brachytherapy
With vertical incision
 Treatment
Low-risk = stage Ia / Ib + grade I-II
( myometrial involvement < 1/2
peritoneal cytology negative No more therapy
lymph node negative )

High- risk = Other conditions greater than low-risk

papiller / clear cell

Adjuvant Radiotherapy (Pelvic / paraaortic )

Treatment of Advanced Stage
Endometrial Carcinoma

Surgery
TAH +BSO

Cytoreduction
Pelvic & para-aortic Lymphadenectomy

Adjuvant Therapy..RT, CT & hormone

 Treatment
Treatment of patients with stage III-IV
disease must be individualized; however, in
most instances hormonal treatment or
chemotherapy, or both, must be used in
addition to surgery and radiation therapy.