Reminders: Please check the manual for the ILO’s for this topic.

The Pink boxes are

from the book and/or a trans from the previous batch. Gyne Pearls/Key points and Metformin 0.80-0.95
Sample Exam questions may be provided at the end of the trans. Enjoy and have
fun studying! Aspirin 0.85-0.99
ENDOMETRIAL CANCER
LNG-IUD 0.33-0.64
● 3rd most common gynecologic malignancy in the Philippines
● Majority are post menopausal women Coffee 0.72-0.89
● Median age is 62 years old
● EMCA is a surgico-pathologically staged and the mainstay of Smoking 0.66-0.88
treatment is surgery.
Additional notes:
Enumerated below are the following risk factors for Relative
● Combined Oral Contraceptive use in contrast to Cervical
Endometrial Hyperplasia; which is also similar for Risk
Malignancy that if you have more 5 to 10 years of use you have
Endometrial Cancer (EMCA) (RR)
a risk for such. (vs. EMCA)
● Breastfeeding in Ovarian Malignancy increases the risk
Unopposed Estrogen Therapy 10-20 ● LNG-IUD: this is one form of treatment actually for
Endometrial Hyperplasia (Check EndoHype Trans!)
Tamoxifen Use 2.5-7.0

Obesity (due to: increased conversion of estrogen to Diagnostics Used for Endometrial Malignancy (EMCA)
estrone(E1), decreased SHBG, insulin resistance) 2-5
Primarily for patients with a BMI of 30 (2-3 fold inc. risk) TRANSVAGINAL -Maybe used to triage patients for endometrial
ULTRASOUND sampling
Diabetes (especially the obese diabetic) 2-3 -Endometrial thickness of >4mm has a sensitivity of
(For symptomatic 95%-100% for endometrial cancer in women with
Nulliparity (3.5x more risk than fertile women) 2-3 postmenopausal postmenopausal bleeding
women; it cannot -International Endometrial Tumor Analysis (IETA)
Menstrual factors (Early menarche [12 years old], Late 1.5-3.0 be done if the px. maybe included in the evaluation of women with
menopause [>/= 52 years old]) If asymptomatic!) postmenopausal bleeding.

Lynch Syndrome (HNPCC) -- For Asymptomatic POSTmenopausal women

Additional Notes:
Lynch Syndrome: Hereditary Nonpolyposis Colon Cancer
-This is an (AD) Autosomal Dominant type of heritable cancer
susceptibility syndrome caused by DNA Mismatch repair.
-These women HAVE 40-60% LIFETIME RISK for developing EMCA and
also 40-60% LIFETIME RISK for developing Colon Ca; 12% LIFETIME RISK
for developing Ovarian Ca.
-Take note: In contrast to the general population risk which is: 3% , 5%
and 1.7% for the mentioned cancers respectively!
● Routine UTZ should not be performed
● ACOG recommends that an incidental finding of endometrial
thickness GREATER THAN 4 mm in a PMW WITHOUT VAGINAL
BLEEDING does not lead (automatically) to an intervention
For Asymptomatic PREmenopausal women
● Routine endometrial thickness measurement SHOULD NOT
BE PERFORMED
Diagnosis for Endometrial Malignancy (EMCA)
It is is very easy for you to think of the possible differential diagnosis
because the presentation of patients with EMCA is Vaginal Bleeding
FIGO AUB Classification (Check AUB Trans!)

STRUCTURAL NON-STRUCTURAL
-Patients with LYNCH SYNDROME are at risk for several malignancies
either endometrial, colonic or breast cancer.
P POLYP C COAGULOPATHY

A ADENOMYOSIS O OVULATORY
DYSFUNCTION
Enumerated are the Protective Factors for Relative
Endometrial Hyperplasia Risk (RR)
L LEIOMYOMA I IATROGENIC

Combined Oral Contraceptives (COCs) 0.42-0.79

M MALIGNANCY E ENDOMETRIAL

Raloxifene Use 0.36-0.83

N NOT YET
CLASSIFIED
Physical Activity 0.70-0.94
For correct classification of you vaginal bleeding, it is written as: AUB-M1 (recall the
NOMENCLATURE taught to us during 1st Prelims)
Diet 0.73-0.98
-The gold standard for diagnosis of endometrial
Breastfeeding 0.81-0.98
HYSTEROSCOPY cancer in SYMPTOMATIC POSTMENOPAUSAL
WOMEN

1/5 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches
 Best for focal lesion [direct visualization of the Tumor Grade G1 TO G2 (moderate) G3 (poor)
(For symptomatic lesion in the uterine cavity via the instrument used]
postmenopausal Myometrial SUPERFICIAL DEEP
women) SISH (Hydrosonography) can be used as the INITIAL Invasion
STEP of investigation to disclose the presence of a
focal lesion Stage I/II III/IV

Office endometrial biopsy using a PIPELLE device Receptor HIGH sensitivity LOW sensitivity
has a sensitivity of 99.6% in the detection of Positivity to progestins to progestins
endometrial cancer in PMW.
ENDOMETRIAL PTEN (m/c) Tp53 (m/c)
Using Pipelle POST-MW PRE-MW
SAMPLING ARID1A (regular chromatin) Aneuploidy( common
Mutated PIK3CA also)
Sn (EMCA) 99.6% (Higher) 91%
(For symptomatic KRAS mutation PIK3CA
genes/Genetic
postmenopasual FGF2(growth factor) FBXW7 (regulator of myc,
Sn (Atypical 81% (Same) abnormalities
MSI cyclin E)
women) Hyperplasia) CTNNB1 (Wnt signaling) CHD4 (regulator of
[An OPD p53 chromatin)
procedure] Endometrial biopsy and D&C have a comparable
PPP2R1A (PP2A)
accuracy in diagnosing EMCA, the latter more
accurately reflecting FINAL TUMOR GRADE.
INDOLENT AGGRESSIVE
Behaviour Spread via the Spread via the
Additional Notes:
LYMPHATICS ONLY LYMPHATICS and
● For patients who have undergone D&C: they are admitted and
INTRAPERITONEALLY
anesthesia is applied. But looking at the comparison to
Endometrial biopsy, they have COMPARABLE ACCURACY Additional Notes:
● The advantage of D&C is on the GRADING of the tumor sample. ● As you can see in the HER-2-NEU amplification seen in the uterine
● Sampling can be done either at the OPD (via Pipelle) or serous carcinoma → associated with advanced stage and poor
Admitting the patient (via D&C) prognosis
● Remember you have to get in the way in the so-called
Diagnostics: PRE-OPERATIVE ENDOMETRIAL CANCER
“FRACTIONAL D&C” so it is no longer necessary for getting the
sample from the endocervix just to diagnose EMCA. So ang
sample lang na manggagaling ay sa loob lang ng matres / Imaging Parameter Sensitivity (%) Specificity(%)
bahay-bata (uterus) at hindi na kailangan ng sample galing sa Modality Measured
cervix. Enough na yung sa endometrial sampling.
Deep myometrial 83 72
invasion
ULTRASOUND
(UTZ) Cervical involvement 49 72
(m/c
available) LN Involvement 33 100

Deep myometrial 83 42
● These are the instruments used for endometrial sampling: invasion
CT SCAN
(Left) Pipelle cannula which is flexible (Middle) Randall
curette (Right) Novak curette [more serrated than the Randall] Cervical involvement 25 70
● MVA -> Manual Vacuum Aspirator ; can also be used in
endometrial sampling which is an OPD procedure. LN Involvement 45 88

Must know!!!
Deep myometrial 92 90
Histogenic Types of Endometrial Cancer invasion
MRI
TYPE I TYPE II Cervical involvement 86 97

LN Involvement 72 97
Age Pre and post MW Post MW

PET/CT LN involvement 51-69 90-100

Clinical Obesity, HYPERestrogenism, NONE
Setting Hyperlipidemia
Distant Metastasis 100 94

Parity Nulliparous Multiparous Additional Notes:

● What would be the role of these imaging modalities? Why will you
Endometrium ENDOMETRIAL HYPERPLASIA ATROPHIC request as such? What can be measured?
ENDOMETRIUM ● Knowing all of the 3 parameters which are: (1) Deep myometrial
invasion (2) Cervical Involvement (3) LN involvement; you can

2/5 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous
Batches
 tailor the management. But remember these are not used for
○ It is an Integral part of comprehensive staging
pre-operative staging.
procedure and allow tailoring of adjuvant
● Deep myometrial Invasion: the highest SN is requesting an MRI
treatment
and SP also
○ LN palpation is NOT ACCEPTABLE
● Cervical Involvement: MRI (both Sn and Sp)
○ The decision to omit LN Dissection must be made
● Lymph Node metastasis: UTZ (highest Sn) and PET/CT(highest
with a Gynecologic oncologist
also Sn)
○ LAN does not improve survival nor decrease
○ But comparing the availability and affordability of the
disease recurrence in women with early stage, low
two: Ultrasound is the best choice
grade EMCA
○ Not all institutions have a PET-CT scan
● But comparing the specificity for LN involvement: the highest will INDICATIONS FOR AORTIC NODE SAMPLING (Must Know!)
still be the MRI
○ It depends on the availability and affordability. ★ Suspicious ★ GROSSLY POSITIVE
● If you are entertaining a possible Distant metastasis (an extension para-aortic or ADNEXA
of the malignancy in other parts of the body eg. pelvis): the common iliac node ★ High grade tumors
PET-CT scan is the modality of choice (high Sn and Sp) ★ Grossly positive pelvic (G3)
Preoperative Work Up in Endometrial Cancer LN ★ Lymphovascular
★ Clear cell or Papillary space invasion (LVSI)
serous or ★ Lower Uterine
Complete Blood Count, Renal Routinely tested in corpus uteri
Carcinosarcoma segment Involvement
and Liver function test
★ Cervical Involvement
More than or equal to
Chest X-ray Universally available, low cost,
50% of myometrial
rarely positive in early disease
invasion

Tumor Markers: CA-125 Only advantageous/ Valuable in

advanced disease and Poor
histologic type
Conservative Management in Patients with EMCA
CT Scan of the CHEST, ABDOMEN In high risk to determine the
and PELVIS (or PET-CT) surgical approach Desirous of Pregnancy (<40 years old)

Cystoscopy and/or Proctoscopy Maybe helpful if direct extension to Conservative management must be done by Multidisciplinary team
the bladder or rectum is suspected
● Pretreatment ★ Endometrioid
Evaluation Adenocarcinoma
Definitive Management of Endometrial Cancer ● Patient ★ Confined to the UTERUS!
understands and ○ No myometrial
Extrafascial Hysterectomy Type 1 extended hysterectomy accepts that this is Invasion
(remove the uterus) not the standard ○ No adnexal
of care involvement
Bilateral Salpingo-oophorectomy Take out the FT and Ovaries ● Reasonable ○ No extrauterine
chance of fertility spread
Peritoneal Fluid Cytology (PFC) During surgery, you also collect (dapat may ○ No cervical
peritoneal fluid for analysis in the partner) involvement
laboratory. ● No medical ○ No LVSI
contraindication ○ No vaginal
Pelvic LN Dissection (PLND) Assess/ Evaluate the Lymph nodes to progesterone Involvement
involved
Para-aortic LN Sampling (PALS) To check for all the parameters mentioned, you have to utilize MRI! :D

Additional Notes: Exceptions to Initial Surgery (There are certain patient who cannot
● Ovarian Preservation in EMCA receive the standard treatment which is surgery
○ Feasible in young women with EMCA but it is
INDIVIDUALIZED
○ However, this is still controversial*
Option 1: Primary RT Option 2: High dose Progestin
○ This is not recommended in: (Remember!)
with/without Chemo followed by
■ Non-endometrioid Histology
appropriate surgery
■ Deep Myometrial Invasion
■ Cervical Stromal Invasion
-Poor surgical risk patients -Grade 1 Lesion (applied to well
■ Family Hx of HNPCC or Genetic Cancer
-Non-resectable disease (IE differentiated tumors)
● Lymphadenectomy (LAN) in EMCA

3/5 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous
Batches
 mucosa
revealed parametria is nodular -For patients who are
and the fixed to the pelvic contraindicated for Anesthesia
IVB Distant metastasis, including intra-abdominal
sidewalls) -For patients who are unsuited
metastases, and/or inguinal Lymph Nodes
for Radiotherapy (RT)
Memorize!
Note: If these cases might happen (those who are exempted to undergo surgery) ,
you cannot apply the 2009 FIGO staging for Endometrial Cancer [since it was
mentioned that the lesions are surgico-pathologically staged

Instead, what you will use is the staging presented below for patients who
cannot undergo surgery! Stratification and Management (or Adjuvant TX.) of EMCA

1988 CLINICAL STAGING FOR ENDOMETRIAL CANCER Stage 1A G1 G2 no LVSI [very early stage]
(Surgico-pathologically staged) -Myometrial invasion of less than 50%; the
grading is well-moderately differentiated.
Stage I Confined to the corpus LOW RISK -The size is < 2cm; <60 years old.
-No LVSI
Stage II With cervical extension -Not need any form of adjuvant tx, but
surveillance after administration of
Stage III With extrauterine spread surgery.

Stage IV With Distant Metastasis INTERMEDIATE RISK Stage 1B G1 G2 No LVSI

If for example the patient received the standard management for EMCA
(which is surgery); EH-BHSO, LND with PF Cytology. Then the patient can be
staged using the 2009 FIGO below Stage 1A G1 G2 > 2cm.
Surgico-pathologic Staging for Endometrial Cancer
Stage 1A G1 G2 >60 y/o
STAGE I: Tumor confined to the corpus HIGH INTERMEDIATE
RISK Stage 1A G1 G2 (+) LVSI
IA No or Less than HALF of the Myometrial
(All STAGE 1 cancers Invasion Stage 1A G3
are confined to the
tumor of origin) Stage 2 G1 G2

IB Tumor Invasion equal to or MORE THAN HALF

(50%) of the myometrium

STAGE II Stage 1B G3
HIGH RISK
Tumor invades the cervical STROMA, but does not extend beyond the Stage 2 G3
uterus
Note: The glandular involvement as what was the staging before is no longer a Stage 2 Any grade (+)LVSI
Stage 2 disease but rather a Stage 1!

STAGE III: Local and/or regional spread of the tumor

Memorize!

IIIA Tumor invades serosa and/or adnexa Stage III and Stage IV Combination of RT and Chemotherapy

IIIB Vaginal and Parametrial metastases Paclitaxel 175mg/m2 + Carboplatin AUC 6

Cisplatin 50mg/m2 + Doxorubicin mg/m2
IIIC Metastasis to the lymph nodes Cyclophosphamide + Cisplatin + Doxo
Anti-Neoplastic Drugs
IIIC1* POSITIVE PELV(1)C LNs (The tx.scheme are the same with ovarian
[to remember yung number 1 parang letter i] malignancy)

IIIC2* POSITIVE PAR(A-A)ORTIC LN +/- Pelvic LN Progestins for ADVANCED or RECURRENT

[to remember, 2 letter A in between the hyphen] DISEASE
Side Effects: Weight gain, edema,
STAGE IV: Tumor invades the bladder and/or bowel mucosa, and/or thrombophlebitis, headache, occasional
distant metastasis HTN
Hormone Therapy
IVA Tumor invasion of the bladder and/or bowel Megestrol acetate, MPA, DMPA [same

4/5 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous
Batches
 with the Endometrial Hyperplasia
Updates!]

Note: ER/PR is also part of the

Tumor characteristics: Low grade tumors,
diagnosis of EMCA. This is an
ImmunoHistochemical ER/PR (+) [good prognosis] ; a longer
method. disease free survival

Must Know!

Prognosis of EMCA “The earlier the better”

SURVIVAL FIGO STAGE FOR ENDOMETRIAL CANCER

IA 90.9%

IB 88.2%

IC 81.0%

II 71.6%

III 51.4%

IV 8.9%

In case you want to read more: Scan ME!

5/5 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous
Batches