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CARCINOMA OF THE ENDOMETRIUM. presented by: Dr. Rozhan Yassin khalil FICOG,CABOG,HDOG,FICS,MBChB 2014. Carcinoma of endometrium :. One of the commonest gynecological cancers , especially in white Americans.
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CARCINOMA OF THE ENDOMETRIUM presented by: Dr. RozhanYassinkhalil FICOG,CABOG,HDOG,FICS,MBChB 2014
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.
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.
Risk Factors: • 9. The endometrial hyperplasia induced by Tamoxifen produces endometrial polyp suggested a four-fold increase in endometrial carcinoma.
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
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.
: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.
: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.
: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.
: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
Staging Carcinoma of the Endometrium
: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.
: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.
: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.
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.
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.
: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.
Stage5 year survival • I 85% • II 68% • III 42% • IV 22%
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.
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.
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.
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.
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.
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.
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.
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.
: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
:Chemotherapy • Chemotherapy Cytotoxic chemotherapy has a limited place in advanced recurrence. • Single agent therapy with adriamycin, cisplatinum ,cyclophosphamidegives response rates between 20%and 40%.