CARCINOMA OF THE ENDOMETRIUM

1. CARCINOMA OF THE ENDOMETRIUM presented by: Dr. RozhanYassinkhalil FICOG,CABOG,HDOG,FICS,MBChB 2014

2. Carcinoma of endometrium: • One of the commonest gynecological cancers，especially in white Americans. • It is a disease of postmenopausal women with a peak incidence in the 6th & 7th decade of life it occurs most often in postmenopausal women（up to 80％of cases）with less than 5％ diagnosed under 40 years of age．

3. A uterus with adenocarcinoma of theendometrium.

4. Screening: • There is no effective screening programme， • but occasionally cervical smears contain endometrial cancer cells or double thickness endometrial • ultrasonic thickness of 4mm or more indicates a need for endometrial sampling．

5. Risk Factors of endometrial ca.

6. Risk Factors:

7. Risk Factors: • 9. The endometrial hyperplasia induced by Tamoxifen produces endometrial polyp suggested a four-fold increase in endometrial carcinoma．

8. Risk factors for endometrial cancer: • • Obesity • • Impaired carbohydrate tolerance • • Nulliparity • • Late menopause • • Unopposed oestrogen therapy • • Functioning ovarian tumours • • Previous pelvic irradiation • • Family history of carcinoma of breast, ovary or colon

9. Protection for endometrial CA. • 1- Oral contraception，especially after long term use.reduces incidence of both endometrial and ovarian carcinomas). • 2-Cigarette smoking has also been associated with the reduced risk of endometrial cancer.

10. :Symptomatology The usual presenting symptom of endometrial carcinoma is : 1.postmenopausal bleedingwhich carries a 10％ risk of associated malignancy in the absence of hormone replacement therapy. Curettage，or endometrial sampling is mandatory. 2.Postmenopausal discharge from pyometra carries a 50％ risk of associated malignancy. 3.Pain may occur with pyometra or metastatic spread．

11. :Diagnosis 1-Hysteroscopy with endometrial curettage 2-endometrial sampling. 3- curettage alone， 4- outpatient endometrial sampling alone，are essential． Curettage is not infallible．On the other hand，if a Pipelle has been correctly introducedand the pathology is benign, or no tissue is obtained，it is most unlikely that malignancy exists．

12. :Diagnosis • Hysteroscopy，cervical smear（>1％risk of concurrent cervical malignancy）and • vaginal or abdominal ultrasound for ovarian pathology are advised，when endometrial malignancy is found．

13. Carcinoma of the Endometrium

14. Carcinoma of the Endometrium

15. Carcinoma of the Endometrium

16. :HISTOPATHOLOGY • 1-Adenocarcinomas  60 – 70 %. • 2- Adenosquamous Ca  10-20% • 3- Papillary Serous Ca  10%. • 4- Clear cell Ca  4%. • 5- Mucinous Ca  9%. • 6- Secretory Ca  1-2%. • 7- Squamous cell Ca  extremely rare

17. Carcinoma of the Endometrium

18. Carcinoma of the Endometrium

19. Staging Carcinoma of the Endometrium

20. Carcinoma of the Endometrium

21. Carcinoma of the Endometrium

22. :Spread • In general this cancer is slow to spread from the uterine cavity, probably because the endometrium lacks lymphatics. • A chest X-ray helps detect lung metastases. • Magnetic resonance imaging is preferable to ultrasound for detection of myometrial invasion and pelvic spread.

23. :Local Spread

24. :Venous Spread • Venous Spread • This pathway might account for the occasional appearance of a low vaginal metastasis; • but venous spread is not a common feature of uterine cancer.

25. :Lymphatic Spread • Lymphatic Spread • The incidence of this seems to be between 10 and 30%. • All pelvic nodes, including the internal iliacs, the parametrium, the ovaries, and the vagina may be involved, probably with equal frequency. • Lymphatic spread is more likely to occur when the tumour is anaplastic and the uterine wall is deeply invaded.

26. Tubal Spread: • Tubal Spread • Malignant cells can pass along the tube in the same way that peritoneal spill may occur during menstruation. • This may account for isolated ovarian metastases.

27. Carcinoma of the Endometrium

28. PROGNOSIS OF ENDOMETRIAL CARCINOMA • With the exception of stage 1 tumors of histological grades I and II, the prognosis is less favourable than many gyaecologists believe， • with an overall 5 year survival of 70％ approximately． • Fortunately over 80％of cases are diagnosed at stage 1．

29. :prognostic factors • 1.Staging diagnosis, • 2. extent of myometrial invasion . • 3. histological grading(differentiation). are the most important prognostic factors apart from competence of treatment.

30. Stage5 year survival • I 85% • II 68% • III 42% • IV 22%

31. TREATMENT OF ENDOMETRIAL CARCINOMA • This is essentialysurgical，with postoperative radiotherapy added when : • 1.unfavourable prognostic features are found at surgery, • 2.Pre-operative clinical Staging is inaccurate． • Progestogen therapy is probably only of value in recurrent disease．

32. Women un fit for op.: • Few women are unfit for surgery，and caesium insertion radioactive therapy may be employed for these, • but radiation alone is less effective than combined surgical and radiation treatment．

33. Stage I:(treatment) • Total abdominal hysterectomyand bilateral salpingo-oophorectomy without partial removal of vagina. • Peritoneal saline washings are taken for cytology on opening the abdomen and the Abdominal contents carefully examined．

34. Stage II: • Stage IIacarries a similar prognosis to Stage I and may be treated as stage I． • Stage IIb，with clinical invasion of the cervix，has a poorer prognosis than Stage I and radical hysterectomy，pelvic lymphadenectomy and para-aortic lymph node sampling are indicated， • with a combination of local and external radio therapy as an alternative treatment．

35. Stage III: • Following the Staging laparotomy， • radical hysterectomy，lymphadenectomy，para-aortic node sampling and removal of as much malignant tissue as possible，omentectorny is carried out． • Stage III diseases limited to the pelvis may be treated by radiotherapy．

36. Stage IV: • Treatment of this Stage is designed to control tumour growth and alleviate symptoms． • Surgery，radiation therapy，cytotoxic therapy and adjuvant progestogentherapy all have a place．

37. Carcinoma of the endometrium compared with ca cervix: • The overall results are better than for carcinoma of the cervix，not because it is less malignant tumour，but because treatment is usually given earlier． • Post－menopausal bleedingis much more difficult to ignore than the irregular bleeding of the younger woman．

38. RECURRENCE OF ENDOMETRIAL CARCINOMA • The incidence of recurrence within 5years is in the region of 30％and is accepted along with the 5-year survival rate as a measure of the effectiveness of the various systems of treatment． • The majority recurrences appear within 3 years of treatment. Early recurrence has a poor Prognosis.

39. :PROGESTOGENS • Many endometrial carcinomata are hormone dependent and progestogens have been used as part of a combined primary treatment , recurrent or metastatic growths． • Between 15％and 50％of recurrences will respond．Medroxyprogesterone acetate，400 mg to 600 mg daily

40. :Chemotherapy • Chemotherapy Cytotoxic chemotherapy has a limited place in advanced recurrence． • Single agent therapy with adriamycin, cisplatinum ,cyclophosphamidegives response rates between 20％and 40％．

42. THANKS