Understanding Endometrial Cancer: Risk Factors, Diagnosis, and Management

 
Endometrial Cancer
 
Dr. Khalid Akkour MD FRCSC
Assistant professor and consultant
Gynecologic oncologist
 Department of Obstetric and Gynecology
College of Medicine, King Saud University
 
OBJECTIVES
 
Describe
 
the
 
classification
 
of
 
uterine
 
malignancy.
Learn
 
how
 
malignant
 
disease
 
of
 
the
 
uterus
 
presents.
Describe
 
which
 
investigations
 
are
 
needed  for
 
women
 
with
 
 suspected
 
endometrial
 
 cancer.
Know
 
the
 
International
 
Federation
 
of
 
Gynecology
 
and
 
Obstetrics
 
(FIGO)
 
staging
 
of
 
endometrial cancer.
Understand
 
how
 
endometrial 
 
cancer
 
is
 
managed.
 
Endometrial Cancer
 
The
 
most
 
common
 
gynaecological
 
malignancy
 
affecting
 
UK
women
 
with
 
an
 
age related
 
incidence
 
of
 
95
 
per
 
100,000
 
women.
The
 
life-time
 
risk
 
of
 
developing
 
endometrial
 
cancer
 
is
approximately
 
1
 
in
 
46.
The
 
mean
 
age
 
of
 
diagnosis
 
is
 
62
 
years,
 
although
 
cancers
 
can
 
be
 
diagnosed
 
in women
 
throughout
 
their
 
reproductive
 
life.
Approximately 
 
25%
 
of
 
endometrial
 
cancers
 
occur
 
before
 
the
menopause.
 
Risk factors…
 
 
Risk related to hormonal stimulation
 
or unrelated to estrogen at all.
 
 
Estrogen-related endometrial cancer (Type I) tends to 
 
be a lower grade
histologically.
 
 
Endometrial 
cancers unrelated to hormones (Type II)
 
tend to be a higher grade and stage eg. Papillary serous or 
 
clear cell
tumors.
 
 
How endometrial hyperplasia is
associated with endometrial cancer
 
Endometrial hyperplasia is a continum…
Simple hyperplasia
complex hyperplasia without
atypia
complex hyperplasia w/ atypia
 endometrial cancer
(well differentiated adenocarcinoma)
 
How endometrial hyperplasia is
associated with endometrial cancer
 
Simple hyperplasia without atypia– 1% progress to endometrial cancer
Complex hyperplasia without atypia– 3%
Simple hyperplasia with atypia_ 10%
Complex hyperplasia with atypia—28%
 
Clinical presentation
 
The “classic symptom” is abnormal uterine bleeding
 
 
20-30% of women with post-menopausal bleeding will have
uterine cancer.
 
 
Diagnosis
 
Easy to do with office EMB
Hysteroscopy w/ D & C (gold standard)
 
 
Detection rates of endometrial ca. by pipelle was between 91 and 99%
 
Detection of hyperplasia was 81%
 
Recommendation:  EMB as initial test; Hysteroscopy/D&C if EMB inconclusive or
high suspicion (hyperplasia with atypia, pyometria, presence of necrosis, or
persistant bleeding)
 
Transvaginal ultrasound
 
In postmenopausal women, an endometrial thickness of 4-5 mm or less is pretty
reassuring.
 
(only 1% will have endometrial ca. if normal endometrial thickness)  ?? If normal
TVS do you need an EMB w/abnormal bleeding.
A thicker endometrium requires EMB, hysteroscopy/D&C
Especially useful for women on estrogen who have bleeding who have bleeding,
but overall TVS is not recommended as a screening tool.
 
 
Cancer Staging
 
Staging is always done surgically
Requires a total hysterectomy, BSO + PLND
 
Cancer Staging
 
Pre-op imaging
 
  
CXR
  
CT CAP
 
Cancer Staging
 
Labs
  
CA-125
  
LFT’s , RFT’s
  
CBC
 
 
 
 
 
Other risk factors for endometrial
cancer
 
Familial predisposition
 
Eg Lynch syndrome II :  hereditary nonpolyposis colorectal
cancer (HNPCC), endometrial carcinoma.
 
(up to 43% of women of affected families will develop ovarian
cancer)
 
Other risk factors for endometrial
cancer
 
Parity
Nulliparity in and of itself is not a risk factor as much as the
anovulatory cycles that are associated with infertility
Diet– especially high fat
Menarche/Menopause:  early menarche and late
menopause
 
essentially prolonged estrogen exposure 
 
without the
protection of progesterone.
 
Protective Factors
 
  Oral contraceptives:
 
 Decreases both the risk of ovarian and 
 
endometrial cancer
(RR = 0.6 if used for one year…effect lasts for 15  years!)
 
 
Protective effect probably due to 
 
progesterone.
 
Histopathology
 
Most common types of endometrial cancer:
 
Endometriod adenocarcinoma (70-80%)
 
Clear cell and serous tumors are more aggressive and
probably present at a more advanced age. (together 5-10%)
 
Mucinous and squamous about 2%
 
 
 
 
 
 
 
 
 
 
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Endometrial cancer, the most common gynecological malignancy in women, presents with abnormal uterine bleeding and affects women mainly during menopause. Risk factors include hormonal stimulation and estrogen levels. Differentiating between types of endometrial cancer can impact treatment decisions. Endometrial hyperplasia, a precursor to cancer, has varying progression rates to malignancy. Proper diagnosis and staging are essential for effective management of endometrial cancer.


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  1. Endometrial Cancer Dr. Khalid Dr. Khalid Akkour Akkour MD FRCSC MD FRCSC Assistant professor and consultant Assistant professor and consultant Gynecologic oncologist Gynecologic oncologist Department of Obstetric and Gynecology Department of Obstetric and Gynecology College of Medicine, King Saud University College of Medicine, King Saud University

  2. OBJECTIVES Describe the classification of uterine malignancy. Learn how malignant disease of the uterus presents. Describe which endometrial cancer. investigations are needed for women with suspected Know Obstetrics the International (FIGO) staging of Federation of endometrial cancer. Gynecology and Understand how endometrial cancer is managed.

  3. Endometrial Cancer Themost common gynaecological malignancy womenwith an age related Thelife-time risk of developing approximately1 in 46. Themean age of diagnosis is 62 years, although cancers be diagnosed in women throughout Approximately 25% of endometrial cancers menopause. affecting UK incidence of 95 per100,000 women. endometrial cancer is can their reproductive life. occur beforethe

  4. Risk factors Risk related to hormonal stimulation or unrelated to estrogen at all. Estrogen-related endometrial cancer (Type I) tends to be a lower grade histologically. Endometrial cancers unrelated to hormones (Type II) tend to be a higher grade and stage eg. Papillary serous or tumors. clear cell

  5. How endometrial hyperplasia is associated with endometrial cancer Endometrial hyperplasia is a continum Simple hyperplasia complex hyperplasia without atypia complex hyperplasia w/ atypia endometrial cancer (well differentiated adenocarcinoma)

  6. How endometrial hyperplasia is associated with endometrial cancer Simple hyperplasia without atypia 1% progress to endometrial cancer Complex hyperplasia without atypia 3% Simple hyperplasia with atypia_ 10% Complex hyperplasia with atypia 28%

  7. Clinical presentation The classic symptom is abnormal uterine bleeding 20-30% of women with post-menopausal bleeding will have uterine cancer.

  8. Diagnosis Easy to do with office EMB Hysteroscopy w/ D & C (gold standard) Detection rates of endometrial ca. by pipelle was between 91 and 99% Detection of hyperplasia was 81% Recommendation: EMB as initial test; Hysteroscopy/D&C if EMB inconclusive or high suspicion (hyperplasia with atypia, pyometria, presence of necrosis, or persistant bleeding)

  9. Transvaginal ultrasound In postmenopausal women, an endometrial thickness of 4-5 mm or less is pretty reassuring. (only 1% will have endometrial ca. if normal endometrial thickness) ?? If normal TVS do you need an EMB w/abnormal bleeding. A thicker endometrium requires EMB, hysteroscopy/D&C Especially useful for women on estrogen who have bleeding who have bleeding, but overall TVS is not recommended as a screening tool.

  10. Cancer Staging Staging is always done surgically Requires a total hysterectomy, BSO + PLND

  11. Cancer Staging Pre-op imaging CXR CT CAP

  12. Cancer Staging Labs CA-125 LFT s , RFT s CBC

  13. Other risk factors for endometrial cancer Familial predisposition Eg Lynch syndrome II : hereditary nonpolyposis colorectal cancer (HNPCC), endometrial carcinoma. (up to 43% of women of affected families will develop ovarian cancer)

  14. Other risk factors for endometrial cancer Parity Nulliparity in and of itself is not a risk factor as much as the anovulatory cycles that are associated with infertility Diet especially high fat Menarche/Menopause: early menarche and late menopause essentially prolonged estrogen exposure protection of progesterone. without the

  15. Protective Factors Oral contraceptives: Decreases both the risk of ovarian and endometrial cancer (RR = 0.6 if used for one year effect lasts for 15 years!) Protective effect probably due to progesterone.

  16. Histopathology Most common types of endometrial cancer: Endometriod adenocarcinoma (70-80%) Clear cell and serous tumors are more aggressive and probably present at a more advanced age. (together 5-10%) Mucinous and squamous about 2%

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