ENDOMETRIAL CARCINOMA

•	Epidemiology.
•	Etiology. 
•	Pathology.
•	Clinical presentation.
•	Investigations.
•	Management.

Epidemiology

1.	Third most common genital tract tumor: accounts for 3.9% of all cancers in the female.

2.	ASR: 8.2 / 100,000 / yr.

3.	A rapid increase in incidence over the last 30 years, especially in the 40 – 49 years age group.

4.	Average age is 58; peaks at 80.

5.	Occurrence:

a.	75% post-menopausal.

b.	25% peri-menopausal.

c.	> 90% present with post-menopausal bleeding.

Etiology

1.	Obesity.

2.	Impaired carbohydrate tolerance.

3.	Nulliparity.

4.	Late menopause.

5.	Unopposed estrogen therapy.

6.	Functioning ovarian tumors.

7.	Previous pelvic irradiation.

8.	Sequential oral contraceptives.

9.	Family history of carcinoma of breast, ovary or colon.

Pathology

1.	Adenocarcinoma starts from the fundus and then spreads downwards.

2.	In 50% of cases, the uterus is not enlarged.

3.	Types of tumor:

a.	Adenocarcinoma (95%).

b.	Adenocanthoma.

c.	Adenosquamous carcinoma.

4.	Morphology:

a.	Polypoidal growth filling up uterine cavity.

b.	Single or multiple polyps.

c.	Endocervical.

d.	Infiltrative.

5.	Routes of spread:

a.	Direct: ovaries, broad ligament, myometrium, fallopian tubes, cervix.

b.	Lymphatics via ovarian vessels to the para-aortic nodes.

6.	Complications:

a.	Haemorrhage.

b.	Perforation of uterus.

c.	Pyometra.

Clinical presentation

1.	Abnormal vaginal bleeding:

a.	Post or perimenopausal bleeding.

b.	Inter-menstrual bleeding.

c.	Menorrhagia.

2.	Vaginal discharge:

a.	Watery discharge precedes bleeding several months.

b.	Probably secretion of malignant glands before ulceration occurs.

c.	Brownish to pinkish in color.

d.	May be foul smelling if infected.

3.	Abdominal mass.

4.	LOA and LOW.

5.	Differentials:

a.	Mucous polyp.

b.	Fibroid polyp.

c.	Senile endometritis.

d.	Senile vaginitis.

e.	Estrogen withdrawal bleeding and breakthrough bleeding.

f.	Granulosa-cell tumor of ovary.

Investigations

1.	Baseline tests:

a.	Full blood count.

b.	Serum urea and electrolytes.

c.	Urine FEME.

d.	ECG.

e.	CXR.

2.	Methods of screening:

a.	Pap smear: 10% detection rate.

b.	Endometrial pipelle.

c.	Endometrial aspiration.

d.	Hysteroscopy.

e.	Hysterosalpingography.

f.	Ultrasound.

3.	Diagnosis and staging:

a.	Pelvic examination.

b.	Pap smear for cervical cytology.

c.	Examination under anaesthesia:

i.	bimanual palpation.

ii.	measure the length of the uterine cavity.

iii.	cystoscopy performed for staging.

iv.	IVU considered if greater than Stage I tumor suspected.

d.	Fractional curretage:

i.	aim is to determine if the cervix is involved.

ii.	endocervix curetted before cervical dilatation by use of Novak’s curette.

iii.	the corpus is then curetted.

iv.	the anterior and posterior walls may also be fractionated.

Management

Stage	Treatment	5-year survival %	
Pre-cancerous:
Cystic stromal hyperplasia

Adenomatous hyperplasia and CIS	
Progesterome 5/10mg tds cyclically:
- stop treatment if improves in 6 months.
- if remains cystic then THBSO.

THBSO for old ladies.
If young, then give progesterone for 9 months, then ask to complete pregnancy before THBSO.	
< 5% becomes Ca.

25 – 50% becomes Ca.	
I: confined to uterine body	Surgery with local radiotherapy.	90	
II: involve cervix	Surgery with irradiation of whole pelvis	50	
III: extending outside uterus but confined to pelvis	Irradiation of whole pelvis with surgery if possible. 	25	
IV: extending outside pelvis or including bladder or rectum.	As for stage 3 + irradiation of isolated metastases or progestagen therapy.	5