Carcinoma of the endometrium is one of the most common gynecological cancers, especially in postmenopausal white women between the ages of 60-70. There is no effective screening program, but abnormal cervical smears or thickened endometrial lining on ultrasound may indicate further testing is needed. Risk factors include prolonged estrogen exposure without progesterone, obesity, nulliparity, and family history. Postmenopausal bleeding is the most common symptom. Diagnosis involves endometrial biopsy or hysteroscopy. Treatment options depend on staging and include surgery, radiation, chemotherapy, or hormonal therapy. Prognosis depends on stage, with 5-year survival rates ranging from 85% for stage

1. CARCINOMA OF THE
ENDOMETRIUM
presented by:
Dr. Rozhan Yassin khalil
FICOG,CABOG,HDOG,MBChB

2. CARCINOMA OF ENDOMETRIUM:
• One of the commonest gynecological
cancers，especially in white Americans.
• It is a disease of postmenopausal women
with a peak incidence in the 6th & 7th
decade of life
it occurs most often in postmenopausal
women（up to 80％of cases）with less than
5％ diagnosed under 40 years of age．

3. SCREENING:
 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．

4. RISK FACTORS OF ENDOMETRIAL CA.
 1. The
actual cause of this cancer is
unknown (idiopathic).
. -Early menarche < 12 Y
- Late menopause > 52 Y
 2. Estrogen
 given estrogen alone as postmenopausal
hormone replacement therapy .
 3. Estrogen secreting tumors of the ovary
are associated with an increased incidence
of endometrial carcinoma．

5. RISK FACTORS:
4.Nulliparity and PCO syndrome（with
defective progesterone synthesis）carry an
increased risk．
 5. obese，diabetic and hypertensive
women develop endometrial cancer．
6.  risk in women with breast, ovarian 
(endometrial type) & colorectal Ca.
 7.Previous pelvic radiation therapy
 Family Hx of endometrial Ca

6. RISK FACTORS:
 6.
The endometrial hyperplasia induced by
Tamoxifen produces endometrial polyp
suggested a four-fold increase in
endometrial carcinoma．
( Oral contraception，especially after
long term use.reduces incidence of both
endometrial and ovarian carcinomas).

7. SYMPTOMATOLOGY
The usual presenting symptom of endometrial
carcinoma is 1.postmenopausal bleeding
which carries a 10％ risk of associated
malignancy in the absence of hormone
replacement therapy. Curettage，or
endometrial sampling is mandatory.
2.Postmenopausal discharge from
pyometra carries a 50％ risk of associated
malignancy.
3.Pain may occur with pyometra or metastatic
spread．

8. 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
and the pathology is benign, or no tissue is
obtained，it is most unlikely that malignancy
exists．

9. DIAGNOSIS
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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13. HISTOPATHOLOGY
 1-Adenocarcinomas  60 – 70 %.
 2- Adenosquamous Ca  10-20%
 3- Papillary Serous Ca  10%.
 4- Clear cell Ca  4%.
 5- Mucinous Ca  9%.
 6- Secretory Ca  1-2%.
 7- Squamous cell Ca  extremely rare

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Staging

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19. SPREAD
 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.

20. LOCAL SPREAD
 Local Spread
 Slow invasion of the myometrium is
the commonest spread.
 It may produce considerable uterine
enlargement;
 or spread may involve the vaginal
vault.

21. VENOUS SPREAD
 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.

22. LYMPHATIC SPREAD
Lymphatic Spread
 The incidence of this seems to be between 10
and 30%.
 Allpelvic 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.

23. TUBAL SPREAD:
 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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25. 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
diagnosed at stage 1．

26. PROGNOSTIC FACTORS
 1.Staging diagnosis,
 2. extent of myometrial invasion .
 3. histological grading
（differentiation）are the most
important prognostic factors apart
from competence of treatment.

27.  Stage 5 year survival
 I 85%
 II 68%
 III 42%
 IV 22%

28. TREATMENT OF ENDOMETRIAL
CARCINOMA
 This is essentialy surgical，with
postoperative radiotherapy added when :
 1.unfavourable prognostic features are
found at surgery ,
 2.Pre-operative clinical Staging is
inaccurate．
 Progestogen therapy is probably only of
value in recurrent disease．

29. WOMEN UN FIT FOR OP.:
 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．

30. STAGE I:(TREATMENT)
 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．

31. STAGE II:
 StageIIa 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．

32. 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．

33. 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．

34. CARCINOMA OF THE ENDOMETRIUM
COMPARED WITH CA CERVIX:
 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．

35. 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.

36. PROGESTOGENS
 Many endometrial carcinomata are
hormone dependent and progestogens
have been used as part of a combined
primary treatment , recurrent or
metastatic growths．
 Between 15％and 50％of recurrences will
respond．Medroxyprogesterone acetate，
400 mg to 600 mg daily

37. CHEMOTHERAPY
 Chemotherapy Cytotoxic
chemotherapy has a limited place in
advanced recurrence．
 Singleagent therapy with adriamycin,
cisplatinum ,cyclophosphamide gives
response rates between 20％and 40％．

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39. THANKS