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Endometrial Cancer

Endometrial Cancer

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Endometrial Cancer

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  1. Endometrial Cancer Brought to you by: Kathryn Bezzina and LL Chepelev

  2. Objectives 4392: List the risk factors for endometrial carcinoma. 4393: Describe the important pathologic features of endometrialcarcinoma which predict prognosis. • DDxof Post-menopausal Bleeding and Necessary Investigations • List Risk Factors for Endometrial Cancer • Types of Endometrial Cancer • Management Principles – Surgical Staging • Describe how histology and stage affect prognosis

  3. Uterus in Review

  4. Endometrium

  5. Endometrial Carcinoma: Epidemiology #1 gynecological malignancy in North America (40%) • 4th most common cancer in women 2-3% of women develop endometrial carcinoma during lifetime Mean age is 60 years, with peak incidence in 7th decade • 25% are diagnosed in premenopausal women • 75% are postmenopausal Majority with early diagnosis due to symptom detection • 85-90% 5-yr survival for Stage I disease • 70-80%overall 5-yr survival for all stages • HIGHEST CURE RATE of gynecological CA

  6. Endometrial Carcinoma: Classification

  7. Endometrial Cancer RiskFactors COLD NUT Cancer (Ovarian, Breast, Colon) Obesity Late Menopause Diabetes Mellitus Nulliparity Unopposed Estrogen (PCOS, Anovulation, HRT) Tamoxifen: Chronic Use

  8. Endometrial Carcinoma: RiskFactors

  9. Presentation, Signs & Symptoms Postmenopausal bleeding = Endometrial CA UPO  lesion Bx 95% Px w vaginal bleeding

  10. Postmenopausal Bleeding: DDx • Atrophy (60%) – irregular sloughing of the cells • Polyps (12%) • Endometrial cancer (10%) • Endometrial Hyperplasia (10%) • Simple  Complex  Cancerous • Hormonal effect (7%) • Cervical Cancer (<1%) • Other (eg. Hematometra, trauma, etc.) Postmenopausal bleeding = Endometrial CA UPO  lesion Bx 95% Px w vaginal bleeding

  11. Workup for Post-Menopausal Bleeding PEx • Calculate BMI • Speculum examination • Rectovaginalexamination Investigations • Endometrial biopsy as the INITIAL DIAGNOSTIC TEST • or D&C • Cervical CA screening Hx • When did bleeding start? • Were there precipitating factors (trauma)? • What is the nature of the bleeding (temporal pattern, duration, post-coital [cervical CA], quantity) • Sx: fever, pain, changes in bowel/bladder function? • PMHx, Meds (hormones, anticoagulants, tamoxifen) • FHx: endometrial, breast, colon, CA?

  12. Ultrasonographic Evidence

  13. Ultrasonographic Evidence

  14. T1: Endometrioid Adenocarcinoma

  15. T2: Clear Cell

  16. Staging: FIGO Classification (2010)

  17. Stage I

  18. Stage II

  19. Stage IIIA+B

  20. Stage III C

  21. Stage IV

  22. Prognostic Factors • FIGO Stage • Tumor Histological Grade • Histopathologic Type • Progesterone Receptor Levels (i.e. Type I or Type II) • Myometrial Invasion • Lymphovascular Space Invasion • Lymph Node Involvement • Lower Uterus Involvement • Age • Tumor Remnants after Surgery • Race: better prognosis and more Type 1 in Caucasians over Blacks • Molecular Markers

  23. Histological Grade Well-Differentiated Cells Intermediate Grade Poorly-Differentiated Cells

  24. FIGO Staging Stage I Above Stage I

  25. Therapy OptionsIt Depends • Surgery when staging would be extended to mass excision. • Exploratory laparotomy • Total abdominal hysterectomy • Bilateral salpingo-oophorectomy • Peritoneal cytology • Pelvic and para-aortic lymphadenectomy • Medications: Cisplatin • Radiotherapy

  26. Surgery

  27. Stratification

  28. Adjuvant Therapy • Low Risk + Fertility: Progestin • Low-Intermediate: Observation • High-Intermediate: Radiation Therapy, Vaginal Brachytherapy • High: Chemotherapy +/- RT • Post-Treatment Surveillance

  29. Emerging Therapies

  30. Case A 66 yo nulliparous woman who underwent menopause at age 55 years complains of a 2-week history of vaginal bleeding. Prior to menopause, she had irregular menses. She denies use of hormone therapy. Her medical history is significant for diabetes mellitus controlled with an oral hypoglycemic agent. On examination, she weighs 100 kg and is 172 cm in height. Her blood pressure is 150/90 and temperature 37.5 degree Celcius. Heart and lung examination is normal. Abdomen is obese, no masses palpable. The external genitalia appear normal, and the uterus seems to be of normal size without any demonstrable pelvic mass.