2003-10-27 Carcinoma of the Endometrium 1
CARCINOMA OF THE
ENDOMETRIUM
Wen Di,M.D.,Ph.D
2003-10-27 Carcinoma of the Endometrium 2
? One of the commonest gynecological
cancers,especially in white Americans,
? it occurs most often in postmenopausal
women（ up to 80％ of cases） with less
than 5％ diagnosed under 40 years of
age,
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There is no effective screening
programme,but occasionally
cervical smears contain endometrial
cancer cells or double thickness
endometrial ultrasonic thickness of
4mm or more indicates a need for
endometrial sampling,
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Risk Factors
The actual cause of this cancer is unknown,
Estrogen
given estrogen alone as
postmenopausal hormone replacement
therapy
Estrogen secreting tumors of the
ovary are associated with an increased
incidence of endometrial carcinoma,
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There can be no doubt that oestrogen
can alter the behaviour of this tumour but
there is still a question about oestrogen as a
primary causal agent,
Approximately 75％ of cases of
endometrial cancer occur in the
postmenopausal period when estrogen values
are low and progesterone is
absent,Nulliparity and PCO syndrome（ with
defective progesterone synthesis） carry an
increased risk,
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Only a proportion of obese,diabetic and
hypertensive women develop endometrial
cancer and similarly only a proportion of
women with endometrial cancer are obese，
diabetic or hypertensive,The question
remains whether estrogen is a causal agent，
or is acting in its normal capacity as a
growth factor and is really to be regarded
as a co－ carcinogen,
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Oral contraception,especially after
long term use,reduces the incidence
of both endometrial and ovarian
carcinomas,
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The endometrial hyperplasia induced
by Tamoxifen produces endometrial
polyps,A report in the Lancet in
1999 suggested a four-fold increase
in endometrial carcinoma．,
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Symptomatology
The usual presenting symptom of endometrial
carcinoma is postmenopausal bleeding
which carries a 10％ risk of associated
malignancy in the absence of hormone
replacement therapy,Curettage,or
endometrial sampling is mandatory,
Postmenopausal discharge from
pyometra carries a 50％ risk of associated
malignancy,Pain may occur with pyometra
or metastatic spread,
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Diagnosis
Hysteroscopy with endometrial curettage
or endometrial sampling,curettage alone，
or outpatient endometrial sampling alone，
are essential, Curettage is not
infallible,On the other hand,if a Pipelle
has been correctly introduced（ record how
many cm） and the pathology is benign,or no
tissue is obtained,it is most unlikely that
malignancy exists,
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Hysteroscopy,cervical smear（ >1％
risk of concurrent cervical malignancy）
and vaginal or abdominal ultrasound
for ovarian pathology are advised，
when endometrial malignancy is
found,
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Further groups have been described,
Adeno-squamoid group
This has been divided into two groups,
1,If the squamous cells are well
differentiated the tumour is termed
adeno-acanthoma (Histological Grade 1)
2.Poorly differentiated squamous cells
merit the name adeno-squamous carcinoma
(Grade 2),
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Staging
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In general this cancer is slow to
spread from the uterine cavity,
probably because the endometrium
lacks lymphatics,A chest X-ray helps
detect lung metastases,Magnetic
resonance imaging is preferable to
ultrasound for detection of
myometrial invasion and pelvic spread,
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Local Spread
Slow invasion of the myometrium is
the commonest spread,It may
produce considerable uterine
enlargement; or spread may involve
the vaginal vault,
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Venous Spread
This pathway might account for the
occasional appearance of a low vaginal
metastasis; but venous spread is not a
common feature of uterine cancer,
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Lymphatic Spread
The incidence of this (it is much debated)
seems to be somewhere between 10 and
30%,All pelvic nodes,including the internal
iliacs,the parametrium,the ovaries,and
the vagina may be involved,probably with
equal frequency,Lymphatic spread is more
likely to occur when the tumour is
anaplastic and the uterine wall is deeply
invaded,
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Tubal Spread
Malignant cells can pass along the
tube in the same way that peritoneal
spill may occur during menstruation,
This may account for isolated ovarian
metastases,
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PROGNOSIS OF ENDOMETRIAL CARCINOMA
With the exception of stage 1 tumors
of histological grades I and II,the
prognosis is less favourable than
many gyaecologists believe,with an
overall 5 year survival of 70％
approximately,Fortunately over 80
％ of cases are dagnosed at stage 1,
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Staging diagnosis,extent of myometrial
invasion and histological grading
（ differentiation） are the most
important prognostic factors apart
from competence of treatment,
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Stage 5 year survival
I 85%
II 68%
III 42%
IV 22%
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Using both methods on similar cases we
and that the 5-year survival rates for
Stage I are the only ones altered
significantly,
Stage and histology 5-years survival
I,G1 and 2 80%
I,G3 60%
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TREATMENT OF ENDOMETRIAL CARCINOMA
This is essentialy surgical,with
postoperative radiotherapy added when
unfavourable prognostic features are found
at surgery,Pre-operative clinical Staging is
inaccurate,Progestogen therapy is
probab1y only of value in recurrent
disease,
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Few women are unfit for surgery，
and caesium insertion radioactive
therapy may be employed for
these,but radiation alone is less
effective than combined surgical and
radiation treatment,
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Stage I
Total abdominal hysterectomy and bilateral
salpingo-oophorectomy without partial
removal of vagina,Peritoneal saline
washings are taken for cytology on opening
the abdomen and the Abdominal contents
carefully examined,Vaginal hysterectomy
with removal of ovaries,sometimes
laparoscopy-assisted,has equal 5 year
survival and lower operative mortality,in
appropriate hands,
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Stage II
Stage IIa carries a similar prognosis to
Stage I and may be treated as stage I,
Stage IIb,with clinical invasion of the
cervix,has a poorer prognosis than Stage
I and radical hysterectomy,pelvic
lymphadenectomy and para-aortic lymph
node sampling are indicated,with a
combination of local and external radio
therapy as an alternative treatment,
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Stage III
Following the Staging laparotomy,radical
hysterectomy,lymphadenectomy,para-
aortic node sampling and removal of as
much malignant tissue as possible，
omentectorny is carried out,Stage III
diseases limited to the pelvis may be
treated by radiotherapy,
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Stage IV
Treatment of this Stage is designed
to control tumour growth and
alleviate symptoms,Surgery，
radiation therapy,cytotoxic therapy
and adjuvant progestogen therapy all
have a place,
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The overall results are better than
for carcinoma of the cervix,not
because it is less malignant tumour，
but because treatment is usually
given earlier,Post－ menopausal
bleeding is much more difficult to
ignore than the irregular bleeding of
the younger woman,
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RECURRENCE OF ENDOMETRIAL CARCINOMA
The incidence of recurrence within
5years is in the region of 30％ and is
accepted along with the 5-year
survival rate as a measure of the
effectiveness of the various systems
of treatment,The majority
recurrences appear within 3 years of
treatment,Early recurrence has a
poor Prognosis,
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PROGESTOGENS
Many endometrial carcinomata are
hormone dependent and progestogens
have been used as part of a combined
primary treatment as well as for
recurrent or metastatic growths,
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Between 15％ and 50％ of recurrences
will respond,Medroxyprogesterone
acetate,400 mg to 600 mg daily,is
most commonly employed and the
addition of tamoxifen may improve
the response,
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Chemotherapy
Cytotoxic chemotherapy has a limited
place in advanced recurrence,Single
agent therapy with adriamycin,
cisplatinum,cyclophosphamide and
hexamethylmelamine gives response
rates between 20％ and 40％,
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Surgery gives poor results but
chernotherapy,using vincristine，
actinomycin D and cyclophosphamide
has been reported as curative in 80％
of children treated,