1 / 47

Endometrial cancer

Novak 2002. Endometrial cancer. Introduction Epidemiology and risk factors Endometrial hyperplasia Screening for endometrial Ca. = Most common malignancy in the ♀ genital tract = ½ ♀ genital tract malignancy in USA

tangia
Download Presentation

Endometrial cancer

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Novak 2002 Endometrial cancer

  2. Introduction • Epidemiology and risk factors • Endometrial hyperplasia • Screening for endometrial Ca

  3. = Most common malignancy in the ♀ genital tract = ½ ♀ genital tract malignancy in USA = 4th most common cause of malignancy after breast, lung, and bowel = 7th leading cause of death from M = 2 – 3 % in the female introduction

  4. Recently ↑ awareness of EC due to: • ↓ Ca cervix • ↑ life expectancy • HRT • Earlier diagnosis due to: - Easier diagnostic tools - Understandingof premalignant lesions

  5. EC occur primary in postmenopausal women and virulence ↑ by age • Although EC is usually presented in an earlier stage, deaths from EC > that from cervical cancer • Unopposed estrogen ↑ risk of EC

  6. In the past decades management of EC evolved from: • Preoperative intrauterine radium packs • External pelvic irradiation followed 6 months later by hysterectomy • Single brachytherapysession followed by hysterectomy • Hysterectomy and PO ttt depending on surgical or pathological findings

  7. EC is 2 types: (1) (2) Young Old Hormone-dependent Hormone-independent Due to hyperplasia Due to atrophy Well differentiated Undifferentiated Good prognosis Poor prognosis The 2nd type ↑ in: Elderly – thin – obese – postmenopausal Epidemiology and risk factors

  8. Risk factors: • Unopposed estrogen as in: - Nullipara X 2 – 3 times - Infertile - Anovular - Irregular bleeding • Overweight 21 – 50 pounds X 3 “ > 50 pounds X 10 “

  9. Menopause > 52 years X 2.4 times • PCO • Functioning ovarian tumors • HRT X 4 – 8 times ↑ risk by ↑ dose and duration • Tamoxifen X 2 - 3 • DM X 1.3 – 2.8 times • HTN and hypothyroidism

  10. A spectrum of: biological/ morphological alteration in endometrial gland/stroma Ranging from: exaggerated physiological changes to cancer insitu Due to: estrogen over stimulation of the endometrium without progesterone Endometrial hyperplasia

  11. EH may be associated with: • Bleeding • Functioning ovarian tumors • HRT • EC Recent classification depends on: • Architectural features • Cytological features

  12. Architectural depends on: • Crowdening of the glands • Complexty of the glands Non atypic EH: • Simple: Cystic dilatation of the glands Slightly irregular glands No atypia

  13. Complex: Crowedening, budding, infulding of the glands with less stroma Atypia: Nucleus = large, variable in size & shape Cytoplasm = ↑ nuclear/cytoplasmic R = loss of polarity Nucleolus = prominent

  14. Chromatin = irregular, clumping = parachromatin clearance Transformation to malignancy: Nonatypic: Simple 1% Complex 3% Atypic: Simple 8% Complex 29%

  15. ER is stable in 18% regress in 74% If D&C show atypia Hystrectomy show EC in 25% of cases Prognosis depends on: • Age • Ovarian disease • Exogenous hormones • Obesity • Endocrine function

  16. MPA 10 – 20 mg/day treatment results: NonatypicAtypic Regression 84% 50% Recurrence 6% 25% Malignancy 25% Megestrol acetate treatment in atypia: Regression = 93% Recurrence = 20%

  17. Progestines treatment of EH is less effective in atypic EH than nonatypic EH Treatment in nonatypic EH: • Ovulation induction • Cyclic progestines: MPA 10 – 20 mg/day for 14 days/month Treatment in atypic EH: • Continues progestines

  18. Megestrol acetate: 20 – 40 mg/day X 2 – 3 months followed 3 – 4 weeks by EB Follow up by U/S or EB is important due to: • 25% undiagnosed malignancy • 29% malignancy transformation • ↑ recurrence rate

  19. No screening test is: appropriate acceptable cost effective ↓ mortality • Pap smear = inadequate • Cytology = ↓ sensitivity & specificity • Progesterone challenge test = only Screening of endometrial Cancer

  20. for estrogen primed endometrium • TVS & EB = too expensive Screening discover only 50% of EC Screening of high risk women: • HRT without progesterone • Familial nonpolypoid colon cancer Pap smear is +ve only in 30 – 50% of EC

  21. 90% of EC represent by abnormal bleeding • Some EC complain of pelvic discomfort or heaviness = uterine enlargement or extrauterine extension • Elderly women with cervical stenosis complain of excessive offensive discharge with no bleeding = hematometria or pyometria poor prognosis symptoms

  22. 5% of EC are asymptomatic and discovered accidently by: - Abnormal pap smear in advanced cases - CT/ US for other reasons - Hysterectomy for other reasons Any perimenopausal bleeding must be evaluated even if minimal or recurrent

  23. Causes of vaginal bleeding: • Nongenital • Genital extrauterine • Uterine Extrauterine causes are evaluated by: • History • Examination • Search of blood in urine/stools

  24. Vulval/vaginal/cervical lesions: Can be seen and biopsy is taken Vaginal atrophy = 15% of vaginal bleeding  thin and friable vagina Causes of uterine bleeding: • Endometrial atrophy = 60 – 80% EB  insufficient endometrial tissue

  25. ( blood and mucus only ) No bleeding after EB • Polyps: = 2 – 12% Difficult to diagnose by D&C or EB Diagnosed by hystroscopy, TVS or sonohystrography If not diagnosed  unnecessary hystrectomy

  26. HRT: = 15 – 25%  X 4 – 8 ↑ risk of EC ↑ risk by ↑ duration and dose ↓ risk by progesterone and follow up by TVS and EB annually and if recurrent bleeding occur • Hyperplasia = 5 – 10% • Cancer = 10%

  27. Bleeding in EC: • Menometrorrhagia • Oligomenorrhia • Cyclic > menopausal age Cancer is suspected if: • Persistent • Recurrent • Obese • anovular

  28. General examination: Obesity – HTN Breast - Peripheral LN Abdominal examination in advanced EC: • Ascitis • Nodular liver • Nodular omentum signs

  29. Genital examination: - Inspection & palpation: Vaginal introitus Vagina Suburetheral area Cervix - Bimanual rectovaginal examination: • Uterus  size – mobility • Adnexa  masses • Parametrium  induration • Doglas pouch  nodularity

  30. I – Office endometrial aspiration: Accurate in 90 – 98% • Inexpensive • No tenaculum • No cramps • Well tolerated • Adequate tissue sample diagnosis

  31. 2 – Pap smear: unreliable  +ve in 30 – 50% of EC 3 - Hystroscopy/D&C for: • cervical stenosis • patient intolerance • inadequate tissue sample • recurrent bleeding with –ve EB

  32. 4 – TVS/EB: To select patients for hystroscopy or sonohystrography Patents with endometrial thickness ≥ 5 mm or with polypoidal mass or fluid require further evaluation

  33. Endometrial cancer

  34. Symptoms • Signs • Diagnosis • Pathology • Preoperative evaluation • Staging • Prognostic variables

  35. 90% 0f the patients represent by abnormal bleeding • Some women complain of heaviness and pelvic discomfort = uterine enlargement or extrauterine extension • Some elderly women may have cervical stenosis  hematometria – pyometria – offensive discharge = poor prognosis symptoms

  36. 5% of patients are asymptomatic and discovered accidently at: - Pap smear  advantage stage - Hystrectomy for other reason - CT/ US for other reason Any perimenopausal bleeding should be evaluated even if minimal or nonpersistant Causes of bleeding may be:

  37. Nongenital • Genital but extrauterine • Uterine Nongenital causes are diagnosed by: C/P + C/E + blood in urine/stool Vaginal atrophy = 15% of vaginal bleeding  Thin and friable vagina Uterine cause should be excluded

  38. Causes of uterine bleeding: • Atrophy 60 – 80% • HRT 15 – 25% • Polyp 2 - 12% • Hyperplasia 5 - 10% • Cancer 10% Atrophy: usually occur in women > 10 years postmenopausal

  39. EB  insufficient tissue ( blood + mucus)  no bleeding after EB Polyp: difficult to diagnose by EB/D&C Hystroscopy/sonohystrography  better If not diagnosed  unnecessary hystrectomy HRT: ↑ risk X 4 – 8 times if no progesterone ↓ risk by progesterone and follow up by annual TVS/ EB

  40. Cancer: Present by abnormal bleeding: • Menometrorrhgia • Oligomenorrhia • Cyclic bleeding beyond menopause Consider malignancy if: • Persistent /recurrent bleeding • Obese/anovular patient

  41. General examination: Obesity – HTN Breasts – peripheral LN Abdominal examination: Ascetis Nodular liver/omentum Genital examination: - Inspection & palpation: signs

  42. Vaginal introitus Vagina Suburethral area Cervix - Bimanual rectovaginal examination: • Uterine size/mobility • Adenexal masses • Parametrialinduration • Doglas pouch nodularity

  43. I – Office endometrial aspiration: Accurate in 90 – 98% • Inexpensive • No tenaculum • Minimal uterine cramps • Well tolerated • Adequate tissue sample in 90% diagnosis

  44. - If cervical stenosis paracervical block  cervical dilatation - If cervical pathology suspected  endocervical sample - Premedication by antiprostaglandins II – Pap smear: Unreliable  +ve in 30 – 50% of EC

  45. III – Hystroscopy/ D&C: Indicated in: • Cervical stenosis • Patient intolerance • Inadequate sample • Recurrent bleeding with –ve EB IV – TVS / sonohystrography:

  46. Helps to select patients with minimal or adequate endometrial thickness Evaluated any patient with: • Endometrial thickness > 4 mm • Polypoidal mass • Fluid

More Related