Endometrial Carcinoma (Endometrial Hyperplasia's, Staging Of Ca Endometrium)

Endometrial carcinoma is the most common gynecologic malignancy and is responsible for a significant number of cancer-related deaths in women worldwide.

Early detection of endometrial carcinoma is crucial for effective treatment and improved outcomes. NEET PG exam tests a candidate's knowledge of the different diagnostic modalities and management options available for this condition.

Read this blog further for a quick overview of this important OBGYN topic for NExT/NEET PG exam preparation.

ENDOMETRIAL CA

Etiology: High estrogens

• HRT: estradiol 1-2 mg/ day, CEE (conjugated equine estrogen 0.625- 1.25 mg/day). Must add progesterones to protect endometrium
• Tamoxifen: SERM: Highly estrogenic on uterus, anti-estrogenic on breast, used in Ca breast
• Early menarche and Late menopause: more menstrual cycles, more E exposure
• Estrogen producing ovarian cancers → Granulosa cell tumor
• Anovulatory conditions → PCOD: persistent high Estrogen
• Obesity: Fats (1.5-2.5 times more likely)
• Corpus cancer syndrome (Corpus= uterine body)
  • DM – HTN – Obesity
• Abnormal liver function tests: altered estrogen metabolism
• LYNCH II: HNPCC (Hereditary Non-Polyposis Colon Cancer): 40% association with Ca endometrium
• Familial predisposition 
  • 1^st degree female relatives can have either of these (even 2^nd degree are predisposed)
    • Ca Breast
    • Ca Endometrium
    • Ca Ovary

• Nulliparous woman: no break from Estrogen exposure. Each pregnancy gives around a 2 year break from menstruation. Thus it is not a common Indian cancer

Etiology

• Hyperplasias: Cancer
• Age group: 45-55 yrs

ENDOMETRIAL HYPERPLASIAS

Simple Hyperplasia without atypia: 1% Complex Hyperplasia without atypia: 3%	Give Progesterone Therapy
Simple Hyperplasia with atypia: 8% Complex Hyperplasia with atypia: 29%	Do Simple Hysterectomy

Histopathology

• Endometrioid adenocarcinoma
  • Papillary /villo glandular
  • Secretory
  • With Squamous differentiation  (mc)15-25%
• Mucinous Ca
• Serous Ca: Poor prognosis
• Clear Cell Ca: poor prognosis

Symptoms

• Co-existent obesity, DM, HTN
• Irregular acyclical bleeding : Menometrorrhagia
• Cyclical bleeding beyond age of menopause
• Post menopausal bleeding
• Pyometra: Dirty foul smelling vaginal discharge

Diagnosis

• 1st step: Local examination and Pipelle Endometrial Biopsy
  • On OPD basis, may use paracervical block
  • 90% sensitive

• Fractional curettage [D & C]
  • Biopsy done from all walls, isthmus
  • 95-99% sensitive 
  • Done in OT
• Hysteroscopic biopsy
  • 100% sensitive
  • Best 
• Transvaginal sonography: 
  • Not best/ first
  • Good adjunctive investigation
  • ET should be ≤ 4mm is normal
  • 5mm or more should be investigated in menopausal women

Staging Laparotomy

• TAH + BSO: total abdominal hysterectomy + B/L salpingo-oophorectomy
• Peritoneal cytology
• LN assessment: if involved ? do a biopsy

STAGING OF CA ENDOMETRIUM

2009 FIGO staging system for carcinoma of the endometrium

Prognostic Factors

• Staging: most significant
• Grading : Differentiation of cancer: Solid areas on HPE slides
  • Grade I: <5% solid areas
  • Grade II: 5-50% solid areas 
  • Grade III: > 50% solid areas

• Age
• Type: clear cell, serous type: poor prognosis
• LN metastasis: most important
• Estrogen & Progesterone receptors status: more the receptors, better prognosis
• Myometrial invasion: bad prognosis
• Previous Rx taken

TREATMENT

• Hysterectomy is already done
• Stage I
  • Grade I, No Myometrial involvement: No more Rx required 
  • Grade I-II, Myometrium < 1/2 involved: Vaginal irradiation 
  • Grade III, Myometrium > ½ involved: Pelvic irradiation
• Stage II
  • Adnexal or cervical involved: Whole abdominal irradiation
• Stage III/ Stage IV
  • Individualized treatment 
  • Radiotherapy/ Chemotherapy/ Surgical / Hormonal therapy (Progesterone)
• Vault of the vagina
  • Left over vagina after hysterectomy
  • MC site of recurrence
  • 1^st line Mx of recurrence → High Progesterone [200-250 mg/day]

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