Moderator : Dr. V.V. Padhmalatha

Most common malignancy of female genital tract.

4th most common cancer.

Overall incidence – 2%- 3%

80% - age of 60-70 years ; <5% under 40 years.

Exaggerated physiological state

Carcinoma in situ

Due to protracted estrogen

stimulation in the absence of

progestin.

Non Atypical hyperplasia ( without atypia)

Simple hyperplasia - 1%

Complex hyperplasia – 3%

(adenomatous hyperplasia)

Atypical hyperplasia

Simple atypical hyperplasia – 8%

Complex atypical – 29%

(atypical adenomatous hyperplasia)

SIMPLE HYPERPLASIA

(WITHOUT ATYPIA)

ATYPICAL

HYPERPLASIA

Sporadic:

Type 1 ( 75-85%)

estrogen dependant

Type 2 ( 5%)

non- estrogen dependant

more in African – American , Asian women

Hereditory:

HNPCC or Lynch II Syndrome

Autosomal Dominant

32- 60% risk

TYPE I TYPE II

MENOPAUSALSTATUS

PERI-MENOPAUSAL

POSTMENOPAUSAL

ESTROGENRELATED

YES NO

ESTROGEN OR PROGESTRONE

RECEPTOR

POSITIVE NEGATIVE

HISTOLOGY PROLIFERATIVE ATROPHIC

TYPE I TYPE II

BUILT OBESE THIN

GRADE LOW HIGH

HISTOLOGYSUBTYPE

ENDOMTERIOD SEROUS/ CLEAR CELL

CLINICALBEHAVIOUR

INDOLENT AGGRESSIVE

RISK FACTORS REALATIVE RISK

NULLIPARITY 2-3

LATE MENOPAUSE 2.4

OBESITY 3-10

DIABETES MELLITUS 2.8

UNOPPOSED ESTROGEN THERAPY

4-8

TAMOXIFEN THERAPY 2-3

ATYPICAL ENDOMETRIALHYPERPLASIA

8-29

LYNCH-II SYNDROME 20

Tamoxifen:

- competitive inhibitor of estrogen binding to ER.

- ACOG recommends:

• Benefits outweigh the risk

• Annual gynecologic examination

• Report any abnormal vaginal symptoms and investigated

• Hysterectomy if atypical endometrial hyperplasia

• Classify as high and low risk grps prior to starting therapy

• Tamoxifen not found to be benifical beyond 5 years

Unopposed Estrogen:

• Endogenous

functional ovarian tumor

Obesity – androstenedione estrone

- SHBG

• Exogenous - HRT

Protective Factors:

OCPs

Physical activity

Smoking – stimulation of hepatic

metabolism of estrogens

No role of routine screening.

Routine Papanicolaou testing

- 30-50% have abnormal test

Screening of high risk individuals

1. Lynch II syndrome – annual pevic

examination, TVS, EB beginning from

30-35 years of age.

2. risk with positive history in first degree

relative ( CASH study) – 3 fold

Post menopausal bleeding with

exogenous estrogen

Premenopausal with anovulatory cycles.

75% pt older than 50 years.

90% - vaginal bleeding or discharge.

10% of PMB will have endometrial ca.

Pelvic pressure or discomfort

Presence of hematomtera or pyometra, causing purulent vaginal discharge.

5% are asymptomatic

Premenopausal woman –

abnormal uterine bleeding

menometrorrhagia

oligomenorhea

cyclical bleeding beyond usual age

CAUSE PERCENTAGE

Endomterial

atrophy

60-80

estrogen

replacement therapy

15-25

Endometrial polyp 2-12

Endometrial hyperplasia 5-10

Endometrial cancer 10

Local

- endometritis

- cervical polyp

- cervicitis

- senile atrophic vaginitis

- vulval dystrophy

-submucous fibroid

- ca cervix

Systemic – bleeding disorders,

endogenous estrogen

Associated constitutional factors- obesity,

hypertension, diabetes – corpus cancer

syndrome.

Physical examination:

site of metastasis – peripheral lymph node,

breast

abdominal examination- ascites, hepatic or

omental metastasis

Pelvic Examination:

vaginal and cervical examination

suburetheral area

Bimanual rectovaginal examination

-uterine size and mobility

-adnexa for masses

- parametrium

- POD for nodularity

DIRECT :

cavity to cervix

fallopian tube ovaries, peritoneal cavity.

invading endometrium serosal surface, parametrium and pelvic wall

rarely to pubic bone

HEMATOGENOUS :

to lung, live

occurs with recurrent ca.

CLINICAL STAGING:

- for patient not fit for surgery

- due to gross cervical invovement,

parametrial spread,invasion to bladder

and rectum

- distant metastsis- liver, lung,

virchow’s node.

PATHOLOGICAL

CLASSSIFICATION

A. Endometrioidadenocarcinoma

(80%)

- villoglandular or papillary(2%)

- secretory

-with squamousdifferentiation(15-25%)

SQUAMOUS

DIFFERENTIATIONVILLOGLANDULAR

B. Mucinous carcinoma: (5%)

-cells with intracytoplasmic mucin

- should be differentiated from

endocervical carcinoma.

-positive immunohistochemical

staining with vimentin.

C.Papillary serous

carcinoma

-3-4%

-similar to ca

of ovary and

fallopian tube

-psammoma

bodies

- high- risk

lesion

D. Clear Cell

Carcinoma

-< 5%

-Cells arrange in

hobnail

configuration

- Poor prognosis

E. Squamous carcinoma of endometrium

- rare

-associated with cervical stenosis, chronic inflammation, pyometra.

- poor prognosis

F. Synchronous tumor of the endometrium and ovary

- 1.4 – 3.8%

- well diff. adenocarcinoma – good prognosis

FACTORS PROGNOSIS

AGE Increase recurrence by 7%

for every 1 year inc. in age

HISTOLOGIC TYPE Non- endometrioid

HISTOLOGIC GRADE Tumor with grade 3

TUMOR SIZE Size > 2cm

HORMONE RECEPTOR

STATUS

Estrogen and

progesterone + ve tumors

( better prognosis)

DNA Ploidy and

Proliferative index

Inc. aneuploid cells – bad

prognosis

Myometrial invasion Inc. depth of invasion – inc.

spread and recurrence

Lymph-Vascular

invasion

Present – poor prognosis

Isthmus and cervix

extension

Increased recurrence

Peritoneal cytology Recurrence when present

other poor prognostic factors

Adnexal or uterine

serosal involvement

Poor prognosis

Lymph node metastasis 90% - without l.n

54%- with l.n

Intraperitoneal

metastasis

Poor prgnosis

Rare tumor of meodermal origin.

2-6% of uterine malignancies

Increased incidence after radiation therapy for ca cervix or bening condition.

Most common histologic variants:

- leiomyosarcoma and cacinosarcoma(40%)

-endometrial stromal sarcoma(15%)

Endometrial Stromal Tumor

- perimenopausal women

- symptoms – abnormal uterine bleeding, pain

and pressure

-3 types

I. Endometrial stromal nodule

II. Endometrial stromal sarcoma

III. Undifferentiated sarcoma

Leiomyosarcoma43- 53 years

short duration of symptoms

variants-

I. Myxoid lieomyosarcoma

II. Leiomyoblastoma

III. Intravenous leiomyomatosis

IV. Benign metastasizing leiomyomatosis

V. Disseminated peritoneal leiomyomatosis

Carcinosarcoma / malignant mixed

mullerian tumor :

- mixture of glandular and sarcomatous

elements

- median age of 62 years

- post menopausal bleeding(80-90%)

- highly malignant extension beyond

uterus in 40-60%

Berek’s and Novak’s gynecology -15 th ed.

Clinical gynecology, Berek’s and Novak’s

Histopathology of endometrial ca, Lars-

Chrisitan Horn et al

ACOG – Tamoifen and uterine ca, June 2006