ENDOMETRIAL

CANCER

Dr G Tshuma

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Endometrial carcinoma

 This tumour constitute 25-30% of all

gynaecological malignancies
 Incidence is low before 40 years (4%),rises
sharply until 55 years and then falls slightly.
 A greater portion of women with this cancer
are postmenopausal (75-80%)
 Nulliparous women are 2-3 times more likely
to develop endometrial carcinoma

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Risk factors

 Unopposed exogenous oestrogens (without progestogen)

increase the rate 4-10 fold. COCP and HRT are protective
 Obesity
 PCOS
 Nulliparity
 Late menopause
 Ovarian granulosa and theca tumours
 Tamoxifen therapy
 HTN and DM common but probably not independent risk
factors
 History of breast or ovarian carcinoma

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Pathology

 Usually adenocarcinoma ,but there may be

benign squamous elements(adenoacanthoma) or
malignant squamous elements(adenosquamous)
 May be diffuse or circumscribed

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Histology
 In most cases the diagnosis is clear-cut due to the
disordered architecture, atypical glands and abnormal
activity and characteristics of the cells
 Benign cystic glandular hyperplasia is not liable to become
malignant
 Atypical hyperplasia may become malignant (removal of
the uterus is recommended)
 Spread is direct within the endometrium and ,to a lesser
extent into the myometrium. penetration to the serosa is
uncommon
 Lymphatic spread is along the ovarian vessels to para
-aortic nodes or through the myometrium and cervix to
pelvic nodes

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Clinical features

 Irregular vaginal bleeding –intermenstrual or

postmenopausal
 Watery vaginal discharge may be present in
postmenopausal women
 Abdominal and pelvic examination are
unremarkable ,except in late cases

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Population screening
 There is no certain method for screening the
population at risk
 Outpatient endometrial sampling is useful but not
foolproof
 Transvaginal ultrasound to measure endometrial
thickness is non-invasive and quite accurate
(thickness greater than 5mm in postmenopausal
women is abnormal)

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When to do an endometrial
biopsy for abnormal bleeding
 All post menopausal bleeds
 Intermenstrual bleeds in women >35
 Intermenstrual bleeds in <35 unresponsive to
medical treatment
 Recent onset menorrhagia in >35

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Endometrial carcinoma :staging-
surgical pathological
 Stage 0: atypical hyperplasia suspicious of
malignancy
 Stage I: carcinoma confined to the body of
the uterus
 Stage Ia: tumour limited to the endometrium
 Stage Ib: invasion to< half myometrium
 Stage 1c:invasion to > half myometrium but not
reaching the serosa

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 Stage II: carcinoma involving the body and
cervix
 Stage IIa: endocervical gland involvement only
 Stage IIb: cervical stromal involvement
 Stage III: carcinoma outside the uterus but
not outside the true pelvis
 Stage IIIa: tumour invades serosa and /or adnexa
and /or positive peritoneal cytology
 Stage IIIB: metastases to pelvic and/or para-aortic
nodes

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 Stage IV: carcinoma involving the bladder or
rectal mucosa (IVa) or outside the true pelvis
(IVb)
 Each stage is further subdivided according to
the histology
 Grade 1: well differentiated tumour
 Grade 2:differentiated tumour but with partly solid
areas
 Grade:3 undifferentiated tumour or predominantly
solid

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Management

 Initial management
 Investigations
 To confirm and help stage disease ,
 endometrial biopsy at hysteroscopy (or D&C) EUA
confirms diagnosis
 Chest X-ray to exclude rare pulmonary spread
 Ultrasound ,CT,MRI may be useful
 To assess patient`s fitness
 FBC, U/Es, Blood sugar , ECG
 Pre-operative radiotherapy does not improve the
prognosis and makes histological grading of the
tumour more difficult
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 Total abdominal hysterectomy and bilateral
salpingo-oophorectomy is the operation of choice.

 Careful surgical staging is necessary including

 Aspiration of peritoneal fluid or peritonael washings
 Palpation and inspection of all peritoneal structures
 Palpation with biopsy of pelvic and para –aortic lymph
nodes

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Further management
 Low - risk patients (i.e stage 1a and 1b with G1 or
G2 tumours) usually require no further therapy
 Some surgeons perform radical hysterectomy as
in Cacx stage II. Adjuvant radiotherapy may be
indicated in patients at high risk of recurrence
 Recurrent or advanced disease can be treated
with progestogens and /or radiotherapy
 Overall 5 year survival is 65%

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Sarcoma of the uterus
 These are rare tumours.
 50% due to Malignant degeneration in a leiomyoma.
 They may arise from normal myometrium or
endometrial stroma
 Leiomyosarcoma
 Most patients between ages 40 and 60
 Commonest symptoms are abdominal pain and vaginal
bleeding
 Uterine mass frequently palpable
 Lymphatic spread not common
 Treatment TAH and BSO

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 Endometrial sarcoma
 Patients between 50 and 70
 Signs ,symptoms and treatment as above
 Sarcoma botryoides
 Rare tumour of mixed mesodermal origin usually occuring
in children( any lesion in this age group should arouse
suspicion)
 Is polypoidal, either single or multiple
 Staging as for carcinoma
 Treatment combines chemotherapy with radiotherapy and
then radical surgery (extended hysterectomy and
vaginectomy)

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