Endometrial Endometrial CarcinomaCarcinoma

WomenWomen’’s Hospital, School of Medicine, s Hospital, School of Medicine, Zhejiang universityZhejiang university

General ConsiderationsGeneral Considerations Endometrial carcinoma is one of the Endometrial carcinoma is one of the

most three common pelvic genital most three common pelvic genital cancer in women.cancer in women.

It is malignant epithelioid tumor. It is malignant epithelioid tumor. The incidence of endometrial cancer The incidence of endometrial cancer

has now raised. has now raised. The peak incidence of onset is in the The peak incidence of onset is in the

age 58-61 years.age 58-61 years.

EtiologyEtiology

Etiology of endometrial carcinoma Etiology of endometrial carcinoma may involve two mechanismsmay involve two mechanisms

estrogen-dependentestrogen-dependent estrogen-independentcertainestrogen-independentcertain

PathologyPathology Endometrioid Endometrioid

adenocarcinomaadenocarcinoma Serous adenocarcinomaSerous adenocarcinoma Clear cell carcinomasClear cell carcinomas Mucus adenocarcinoma Mucus adenocarcinoma OthersOthers

METASTASISMETASTASIS

Direct invasionDirect invasion Lymphatic metastasisLymphatic metastasis Vascular metastasis(advanced Vascular metastasis(advanced

stage)stage)

SYMPTOMS SYMPTOMS mostly of the disease occurs in the mostly of the disease occurs in the

elder patients,there is no elder patients,there is no symptoms at the very early stage symptoms at the very early stage and it is only discovered by and it is only discovered by examine. examine.

abnormal vaginal bleeding abnormal vaginal bleeding vaginal fluidingvaginal fluiding pelvic painpelvic pain weakness, weight loss, and anemiaweakness, weight loss, and anemia

Physical examination is usually Physical examination is usually unremarkable at the very early stageunremarkable at the very early stage

The uterus may be enlarged and the The uterus may be enlarged and the mass may move out of the cavity in the mass may move out of the cavity in the advanced casesadvanced cases

Some signs of metastasis can be found Some signs of metastasis can be found of the late stages of the diseaseof the late stages of the disease

SIGNS SIGNS

Diagnosis Diagnosis HistoryHistory ：： clinical representation and clinical representation and

high riskhigh risk factor, family historyfactor, family history

vaginal bleedingvaginal bleeding High-risk factorsHigh-risk factors Long term use of E2,TAMLong term use of E2,TAM Family history of breast cancer and Family history of breast cancer and

endometrial carcinomasendometrial carcinomas SignsSigns

Special ExaminationsSpecial Examinations

Fractional curettage Fractional curettage Endometrial biopsyEndometrial biopsy Endocervical curettageEndocervical curettage

Diagnose of endometrial Diagnose of endometrial carcinoma needs the pathologic carcinoma needs the pathologic resultsresults

Endometrial cytology exam are also used in Endometrial cytology exam are also used in some patientssome patients

Ultrasonography can be helpful in deciding Ultrasonography can be helpful in deciding clinical staging, In postmenopausal women, clinical staging, In postmenopausal women, 4mm is the cut off for a normal unilateral 4mm is the cut off for a normal unilateral endometrial stripeendometrial stripe

The function of cavityscopy is controversyThe function of cavityscopy is controversy MRI and CT appear to improve the accuracy MRI and CT appear to improve the accuracy

of clinical staging and is particularly helpful of clinical staging and is particularly helpful in identifying myometrial invasionin identifying myometrial invasion

Serum CA-125, a well-established tumor Serum CA-125, a well-established tumor marker can also be useful for endometrial marker can also be useful for endometrial cancercancer

Special ExaminationsSpecial Examinations

DifferentiationDifferentiation

Dysfunctional uterine bleeding Dysfunctional uterine bleeding in the menopause women in the menopause women

Senile vaginitisSenile vaginitis Endometrial polypusEndometrial polypus Pelvic genital cancer in womenPelvic genital cancer in women Endometritis in eldersEndometritis in elders

CLINICAL STAGECLINICAL STAGE

According to anatomic sitesAccording to anatomic sites Stage IStage I ： ： endometriumendometrium Stage IIStage II ： ： cervixcervix Stage IIIStage III: :

parametrialparametrial ，， within pelviswithin pelvis Stage IVStage IV ：： beyond metastasisbeyond metastasis

Clinical staging(FIGO1971)Clinical staging(FIGO1971) According to the Fractional curettage and According to the Fractional curettage and

clinical examinationclinical examination Pre-operation stagingPre-operation staging Used in the patients who treat Radiation as Used in the patients who treat Radiation as

primary therapyprimary therapy Surgical-pathological staging Surgical-pathological staging

(FIGO2009)(FIGO2009) the last staging for the patients who choose the last staging for the patients who choose

surgery as the principal therapysurgery as the principal therapy It is the last staging for the majorityIt is the last staging for the majority

StagingStaging

StagingStaging

THERAPYTHERAPY Treatment plan for endometrial carcinoma Treatment plan for endometrial carcinoma

depends on it’s clinical staging and depends on it’s clinical staging and common conditioncommon condition

Surgery , radiation therapy and drugs are Surgery , radiation therapy and drugs are all in useall in use

Primary surgery with concomitant therapy Primary surgery with concomitant therapy is the main treatment in the early stage is the main treatment in the early stage patients patients

While in the late stages of the disease While in the late stages of the disease include radiation, surgery and drugs include radiation, surgery and drugs therapy. therapy.

Surgical treatment :Surgical treatment : Primary treatment, especially in the Primary treatment, especially in the

early stagesearly stages PurposePurpose

Definitude the staging and prognostic Definitude the staging and prognostic factorsfactors

Excise the lesionExcise the lesion

THERAPYTHERAPY

SURGICAL TREATMENTSURGICAL TREATMENT

Clinical stage ⅠClinical stage Ⅰ Simple hysterectomy and bilateral Simple hysterectomy and bilateral

salpingo-oophorectomy has been salpingo-oophorectomy has been recommended recommended

Make sure to obtain peritoneal washings Make sure to obtain peritoneal washings for cytologic identification of occult spreadfor cytologic identification of occult spread

The uterus should be opened in the The uterus should be opened in the operating room to determine the need for operating room to determine the need for lymphadenectomylymphadenectomy

The need for lymphadenectomyThe need for lymphadenectomy Special pathological typeSpecial pathological type Greater than 50% myometrial Greater than 50% myometrial

invasion invasion Low differentiationLow differentiation （（ G3G3 ）） > 50> 50 ％ ％ cavity be involved by the cavity be involved by the

lesionlesion Cervical extension Cervical extension

SURGICAL TREATMENTSURGICAL TREATMENT

SURGICAL TREATMENTSURGICAL TREATMENT

Clinical stage IIClinical stage II Radical hysterectomy and bilateral Radical hysterectomy and bilateral

salpingo-oophorectomy has been salpingo-oophorectomy has been recommendedrecommended

Pelvic and para-aortic lymphadenectomy Pelvic and para-aortic lymphadenectomy is necessaryis necessary

Make sure to obtain peritoneal washingsMake sure to obtain peritoneal washings Open the uterus in the operation Open the uterus in the operation Expect the PR and ER receptors. Expect the PR and ER receptors.

SURGICAL TREATMENTSURGICAL TREATMENT

Clinical stage ⅢClinical stage Ⅲ ，，ⅣⅣ

cytoreductive surgery should be cytoreductive surgery should be attempted if possibleattempted if possible

Radiation therapy simply is used Radiation therapy simply is used in patients with operation in patients with operation forbiddance or in the late stages. forbiddance or in the late stages.

Postoperative adjuvant radiation Postoperative adjuvant radiation therapy is indicated in patients withtherapy is indicated in patients with

extrauterine extensionextrauterine extension lower uterine segment or cervical lower uterine segment or cervical

involvement involvement myometrial invasion >1/2myometrial invasion >1/2 poor histologic differentiationpoor histologic differentiation papillary serous or clear cell histologypapillary serous or clear cell histology

RADIATION THERAPYRADIATION THERAPY

Adjuvant radiation therapy Adjuvant radiation therapy preoperatively is indicated in preoperatively is indicated in reducing tumor size to create reducing tumor size to create operation condition and eliminate operation condition and eliminate the hiding metastasis lesion. the hiding metastasis lesion.

Radiation therapy can be carried out Radiation therapy can be carried out inside or outside body.inside or outside body.

RADIATION THERAPYRADIATION THERAPY

HORMONE THERAPYHORMONE THERAPY

Progesterone has been the treatment of Progesterone has been the treatment of recurrent endometrial carcinoma not recurrent endometrial carcinoma not amenable to irradiation or surgery. amenable to irradiation or surgery. Patients who are young also use Patients who are young also use progesterone therapy to keep fertility. progesterone therapy to keep fertility. The drugs are manual composed with The drugs are manual composed with high dose. curative effect should be high dose. curative effect should be estimated every 2-3 monthsestimated every 2-3 months

Tamoxifen has been used as another Tamoxifen has been used as another hormonal agent in advanced or hormonal agent in advanced or recurrent endometrial cancer recurrent endometrial cancer

ANTITUMOR ANTITUMOR CHEMOTHERAPYCHEMOTHERAPY

Chemotherapy of single drug or Chemotherapy of single drug or combined drugs is appropriate combined drugs is appropriate in the advanced or recurrent in the advanced or recurrent endometrial cancer. endometrial cancer.

Follow-upFollow-up

Time Time ：： 2-32-3rdrd year: once every 3 months year: once every 3 months

3-53-5thth year: once every 6 months year: once every 6 months

>5>5thth year: once every year year: once every year Content Content ：： pelvic examinationpelvic examination

cytological exam of the residual cytological exam of the residual vaginavagina

chest X-Ray, CA125chest X-Ray, CA125