Endometrial Carcinoma

CLASSIFICATION:

Endometrial carcinomas can be classified into two pathogenetic groups:

Type I: 

• These cancers occur most commonly in pre- and peri-menopausal women, often with a history of unopposed estrogen exposure and/or endometrial hyperplasia. 
• They are often minimally invasive into the underlying uterine wall, are of the low-grade endometrioid type, and carry a good prognosis.

Type II: 

• These cancers occur in older, post-menopausal women, and are not associated with increased exposure to estrogen. 
• They are typically of the high-grade endometrioid, papillary serous or clear cell types, and carry a generally poor prognosis

RISK FACTORS:

• High levels of estrogen
• Endometrial hyperplasia( Complex hyperplasia with atypia histological pattern)
• Polycystic ovary syndrome
• Nulliparity
• Infertility
• Early menarche
• Persistent anovulation
• Diabetes mellitus
• Hypertension
• Obesity, 
• Family History,  
• Use of Hormone Replacement Therapy
• Late menopause
• Endometrial polyps or other benign growths of the uterine lining
• Tamoxifen
• Hyperplasia
• Pelvic radiation therapy
• Breast cancer
• Ovarian cancer

CLINICAL FEATURES:

• A Pap smear may be either normal or show abnormal cellular changes.
• Most common cause of postmenopausal vaginal bleeding 
• Endometrial curettage is the traditional diagnostic method.
• If endometrial curettage does not yield sufficient diagnostic material, a dilation and curettage (D and C) is necessary for diagnosing the cancer.
• Endometrial biopsy or aspiration may assist the diagnosis.
• Transvaginal ultrasound to evaluate the endometrial thickness in women with postmenopausal
• The most malignant endometrial carcinoma is Clear cell carcinoma

PATHOLOGY:

• The most common finding is a well-differentiated endometrioid adenocarcinoma, which is composed of numerous, small, crowded glands with varying degrees of nuclear atypia, mitotic activity, and stratification.

FURTHER EVALUATION:

• Colonoscopy is recommended due to the etiologic factors common to both endometrial cancer and colon cancer.
• D and C is useful in the diagnosis 

STAGING:

Endometrial carcinoma is surgically staged using the FIGO cancer staging system.

• Stage IA: tumor is limited to the endometrium
•  Stage IB: invasion of less than half the myometrium
• Stage IC: invasion of more than half the myometrium
• Stage IIA: endocervical glandular involvement only
• Stage IIB: cervical stromal invasion
• Stage IIIA: tumor invades serosa or adnexa, or malignant peritoneal cytology
• Stage IIIB: vaginal metastasis
• Stage IIIC: metastasis to pelvic or para-aortic lymph nodes
• Stage IVA: invasion of the bladder or bowel
• Stage IVB: distant metastasis, including intraabdominal or inguinal lymph nodes (bleeding PV and en­larged inguinal nodes)

TREATMENT:

• Abdominal hysterectomy is recommended over vaginal hysterectomy because it affords the opportunity to examine and obtain washings of the abdominal cavity to detect any further evidence of cancer.
• Fractional curettage can be done in endometrial carcinoma
• Penetration into half of myometrium, Clear cell Ca &  Fundal involvement are  indications of direct lymph node dissec­tions in endometrial carcinoma
• Treatment for stage IV  is Radiotherapy, Chemotherapy and hormonal therapy