Transcript Endometrial Cancer

Endometrial Cancer
Tseng Jen-Yu
02/05/2007
Overview
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Origin => Uterine endometrial lining
Most common gynecologic malignancy
35,000 cases diagnosed each year
Resulting in 4000 ~ 5000 deaths
Normally occurs in postmenopausal
Average age at diagnosis => 60 y/o
< 5% under age of 40
Lifetime risk: 1.1%
Lifetime risk of dying: 0.4%
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Estrogen dependent disease
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Prolonged exposure without the balancing effects
of progesterone
Premalignant potential
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Endometrial hyperplasia
Simple => 1%
Complex => 3%
Simple with atypia => 8%
Complex with atypia => 29%
Incidence and Prevalence
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Most common gynecologic cancer
4th most common in women (US)
2nd most common in women (UK)
5th most common in women (worldwide)
Western developed > Southeast asia
35,000 new cases annually
5,000 death annually
Increase in the 1970’s
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Increased use of menopausal estrogen therapy
Types
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90% endometrial adenocarcinoma
Arise from the epithelium
Tumor grading
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Grade 1
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Grade 2
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Well differentiated
Moderately differentiated with solid component
Grade 3
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Poorly differentiated with solid sheets of tumor
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10% rare cell types
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Papillary serous carcinoma
Clear cell carcinoma
Papillary endometrial carcinoma
Mucinous carcinoma
Rarer cancers
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Onset at later age
Greater risk for metastases
Poorer prognosis
50% of treatment failure
Risk Factors
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Obesity
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Diabetes Mellitus and Hypertension
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Excess weight have 2 ~ 5 x greater risk
Fat cells (adipocytes) produce estrogen
DM women have 2 x greater risk
Nulliparity
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Progesterone counterbalances estrogen
Pregnancy lowers risk
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Early Menarche and Late Menopause
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Estrogen Replacement Therapy
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Associated with more estrogen exposure
Place women at high risk
Risk reduced when + progesterone
Tamoxifen
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Anti-estrogenic drug for breast cancer
Side effect
Induces non-cancerous uterine tumors
 Some may develop into endometrial cancer
 Long term use => endometrial cancer
 Only 1 in 500 develop endometrial cancer
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Genetic Predisposition
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Previous Cancer
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Risk may approach 50% in some families
History of breast / colon / ovarian cancer are at
increased risk
Time interval can be as long as 10 years
Diet
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Association is still unclear
Diet rich in animal fat and protein => risk ^
Diet rich in vegetable, fruits, grain=> risk v
Reduced Risk
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Oral Contraceptives
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Combined OC => 50% reduced rate
Actual reduction number small because
uncommon in women of child bearing age
Long term offers protection
Reduced risk presumably => progesterone
Tobacco Smoking
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Some evidence that it reduces the rate
Smokers have lower levels of estrogen and lower
rate of obesity
Prevention and Survival
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Early detection is best prevention
Treating precancerous hyperplasia
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Hormones (progestin)
D&C
Hysterectomy
10 ~ 30% untreated develop into cancer
Average 5 year survival
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Stage I => 72 ~ 90%
Stage II=> 56 ~ 60%
Stage III => 32 ~ 40%
Stage IV => 5 ~ 11%
Signs
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Postmenopausal vaginal bleeding
Abnormal uterine bleeding
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Bleeding in between periods
Heavier / longer lasting menstrual bleeding
Abnormal vaginal discharge / Pyometra
Pelvic or back pain
Pain on urination
Pain on sexual intercourse
Blood in stool or urine
Diagnosis
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Endometrial sampling
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Image
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Hysteroscopy + targeted biopsy
Tumor marker
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TVS / CT scan / MRI
Standard
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Dilation and curettage / Endometrial
aspiration
Ca 125 / 199
Cystoscope / Proctoscope
Staging
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Stage I
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Tumor confined to uterine body
Stage Ia
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Stage Ib
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Tumor invades less than ½ of myometrium
Stage Ic
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Tumor limited to endometrium
Tumor invades more than ½ of myometrium
Stage II
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Tumor extends to the cervix
Stage IIa
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Cervical extension limited to endocervical glands
Stage IIb
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Tumor invades cervical stroma
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Stage III
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Regional tumor spread
Stage IIIa
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Stage IIIb
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Vaginal involvement / metastases present
Stage IIIc
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Tumor invades serosa / adnexa / peritoneum / ascites (+)
Tumor spread to pelvic LN
Stage IV
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Bulky pelvic disease or distant spread
Stage IVa
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Tumor has spread to bladder or rectum
Stage IVb
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Distant metastases present / inguinal LN
Spread
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Direct spread
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Lymphatic spread
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Through endometrial cavity to the cervix
Through fallopian tubes to ovary / peritoneum
Invade myometrium reaching serosa
Rare: invasion to pubic bone
Pelvic and para-aortic LN
Inguinal LN ( rare )
Hematogenous spread
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Rare but may spread to lungs
Treatment
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Surgery
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Early stage ( I and II )
Typical surgery is ATH + BSO + BPLND
 VTH + BSO + laparoscopic BPLND
 LAVH + BPLND
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Advanced stage
Debulking surgery
 Radiotherapy +/- hormone / chemotherapy
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Radiation
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External beam pelvic radiation
Reserve use of radiotherapy until post-ATH
 Adjuvant radiation therapy is controversial
 Regional pelvic radiation proven to decrease pelvic
recurrence
 Not necessarily improve survival rate
 Most beneficial for patients with tumor confined to
the pelvis
 Patients with increased likelihood of recurrence
( Stage Ic to IIIc)
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Brachytherapy
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Prevent vaginal cuff recurrence
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Hormonal therapy
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Progesterone => for metastatic cancer
Less than 20% response rate
Chemotherapy
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No clear results on effectiveness
Potentially most useful in metastatic cancer
Not as important as surgery and radiation
Only used in advanced or recurrent tumor after
definitive treatment with surgery and radiation
Recurrence
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Likely in women with advanced disease
Within 3 years of original diagnosis
Hormone therapy can be considered
Use of chemotherapy is being evaluated
External beam pelvic radiation or
brachytherapy
Thank you for your attention