1. ENDOMETRIAL CARCINOMA
Oncology
Human Population about
Women Population about
Women > 50 years about
ENDOMETRIAL CARCINOMA
new cases annually

2. Endometrial carcinoma
Uterine Corpus Tumors
Endometrial polyps
ENDOMETRIUM
MYOMETRIUM
Endometrial carcinoma
Endometrial glands
Stromal Nodule
Endometrial stroma
Stromal Sarcoma
Mixed Mesodermal
Tumors
LEIOMYOMA
LEIOMYOSARCOMA

3. Endometrial Carcinoma
Second most common genital tract malignancy
(after cervical carcinoma)
annually all over the world
annually in USA
Number of cases still rising

4. Endometrial Carcinoma
The best example of en estrogen-depended neoplasm
Risk factors associated with the
estrogen-rich environment
With early diagnosis survival rate
can be excellent

5. Epidemiology Incidences
USA (white women)
Swiss, Denmark, Germany
France, Sweden
Norway
POLAND
India, Japan, Kuwait, Filipina

6. POLAND morbidity - V place (11,8%) mortality- XIV place (2,5%)
Epidemiology
POLAND
morbidity - V place (11,8%)
mortality- XIV place (2,5%)

7. Epidemiology 55-90 r.ż. 5% < 40 r.ż.
Almost all cases in postmenopausal age
(two picks of morbidity: about 55 y. and 78 y.)
5% < 40 r.ż.

8. Pathogenesis Estrogen dependent carcinoma
(progressing of changes about 10 years)
endometrial typical atypical
proliferation hyperplasia hyperplasia Carcinoma
Estrogen independent carcinoma
normal Carcinoma
endometrium

9. Sexual Hormones Activity
ESTROGENS
stimulating division of cells
PROGESTAGES
breaking divison of cells

10. Sexual Hormones production Reproductive age
E1, E2, E3
OVARIES Progesterone
Testosterone
Androstendione
ADRENAL GLANDS Androstendione

11. Sexual Hormones production Premenopausal period
E1, E2, E3
OVARIES Progesterone
Testosterone
Androstendione
ADRENAL GLANDS Androstendione
Reletive Hyperestrogenisms

12. Sexual Hormones production Postmenopausal Period
OVARIES Testosterone
ADRENAL GLANDS Androstendione
Androgens aromatization into estrogens
Androstendione Estron
Testosterone Estradiol

13. Pathogenesis hormonal factors
ESTRONE
ESTRADIOL
ANDROGENS
ESTRIOL
PROGESTERONE

14. RISK FACTORS Obesity Late menopause > 52 years-old women
Nulliparity
Anovulatory cycles
PCOs
Ovarian tumors (hormonal active)
Diabetes mellitus type II
Hepatic cirrhosis
Hypothyroidism
Hyperprolactinemia

15. Protective Factors Oral contraception
Complex hormonal replacement therapy
Cigarettes smoking

16. Endometrial Carcinoma Symptoms
Postmenopausal bleeding
Acyclic bleeding in premenopausal
period
ill – smelling leucorreas
pelvic pain
ascites

17. Postmenopausal bleeding main reasons
Endometrial atrophy 50 %
Endometrial polyp 15 %
Submucosus uterine myoma 10 %
Endometrial hyperplasia 10 %
Endometrial carcinoma 5 %
Cervix disease (CA, polyps) 10 %

18. Asymptomatic cases Ultrasonography Estimated Features
thickness
echogenicity et structure
middle echo
fluid in uterine cavity
endo-myometral border
focal lesions

19. Normal ultrasonographic image of endometrium of postmenopausal women

20. Abnormal ultrasonographic image of endometrium of postmenopausal women

21. Precancerous Lesions Simple endometrial hyperplasia without atypia
Complex hyperplasia without atypia
Endometrial polyps
Atypical endometrial hyperplasia
( simple or complex)

22. Endometrial Carcinoma Diagnosis
On base
morphological research
The material
received from uterine cavity

23. Methods of Receiving of Material from Uterine Cavity
Endometrial Cytology
(Gynoscan, Endo-Pap, Jet-Wash)
Endometrial Biopsy
(Pipella, Vabra)
D & C
Diagnostic Hysteroscopy

24. Dilatation and Curettage
Recamier 1843
Most often diagnostic intervention
executed in world
„gold standard”

25. Dilatation and Curettage
blind procedure
general anaesthesia
high grade of uterine perforation 1/99
risk of haemorrhage
risk of infection
most often only 50 % of
endometrial surface is received

26. Diagnostic Hysteroscopy
estimation under eye-control
all endometrial surface is accessible to
investigation
target biopsy
local anaesthesia
video documentation
low grade of uterine perforations

27. Diagnostic Hysteroscopy – WHEN ?
abnormal USG image of endometrium
at asymptomatic woman
focal changes in USG image of
endometrium
abnormal USG D&C /-/
recurrent uterine bleeding + D&C /-/
unsuccessful D&C

35. FIGO Surgical Staging of Endometrial Carcinoma
I A Tumor limited to endometrium
I B Invasion to less then one half of the myometrium
I C Invasion to more then one half of myometrium
II A Endocervical glandular involvement
II B Cervical stromal involvement
III A Tumor involving serosa and/or adnexa or positive peritoneal cytology
III B Vaginal metastases
III C Metastases to pelvic and/or periaortic lymph nodes
IV A Tumor invades bladder mucosa or bowel
IV B Distant metastases

36. FIGO Surgical Staging of Endometrial Carcinoma
First Stage
Tumor Limited to Uterine Corpus
I A Tumor limited to endometrium
I B Invasion to less then one half of myometrium
I C Invasion to more then one half of myometrium

37. FIGO Surgical Staging of Endometrial Carcinoma
Second Stage
Tumor Invading Uterine Cervix
II A Endocervical glandular involvement
II B Cervical stromal involvement

38. Histological Grading of Endometrial Carcinoma
G 1 Less then 5 %
undifferentiated cells
G 2 5 – 50 % undifferentiated cells
G 3 More then 50 %
G X Number of undifferentiated cells
is unknown

39. FIGO Surgical Staging of Endometrial Carcinoma
Third Stage
Tumor Out of Uterus
III A Tumor involving serosa and/or adnexa
or positive peritoneal cytology
III B Vaginal metastases
III C Metastases to pelvic and/or
periaortic lymph nodes

40. FIGO Surgical Staging of Endometrial Carcinoma
Forth Stage
IV A Tumor invades bladder mucosa or bowel
IV B Distant metastases

41. Endometrial Carcinoma hystological types, WHO classification
Adenocarcinoma - endometrioide type
Mucinous adenocarcinoma
Serous adenocarcinoma
Clear cell adenocarcinoma
Carcinoma planoepitheliale
Carcinoma mixtum
Undifferented carcinoma

42. Treatment of Endometrial Carcinoma
Surgery
Radiotherapy
Hormonotherapy
Chemotherapy

43. Treatment of Endometrial Carcinoma SURGERY dependent of stage
TAH with bilateral oophorectomy
and 1/3 part of vagina
Radical Hysterectomy
Tumorectomy (debulking operation)

44. Treatment of Endometrial Carcinoma Radiotherapy dependent of stage
Neo-adjuvant brachytherapy
Adjuvant brachytherapy
Radium, Cobalt, Cesium, Iridium
Teletherapy
X-ray, gamma-ray, electron-ray

45. medroxyprogesterone, megestrol etc inhibitor of aromatase
Treatment of Endometrial Carcinoma Hormonotherapy dependent of receptors status
Gestagens – high doses
medroxyprogesterone, megestrol etc
inhibitor of aromatase
aminoglutetymid

46. Treatment of Endometrial Carcinoma Chemotherapy last chance therapy
Mono - chemotherapy
Cis-platinum, Carboplatinum, Taxol
Poly - chemotherapy
Cis-platinum, cyclophosphamidum, Malfelan,
5-fluorouracyl, Doxorubicin
PAC, CAP, FAC, AC

47. Treatment of Endometrial Carcinoma Stage I a Grade 1
TAH with bilateral oophorectomy
Brachytherapy
(when surgery is contraindicated)

48. Treatment of Endometrial Carcinoma Stage I a Grade 2, 3
TAH with bilateral oophorectomy
and
Brachytherapy

49. Treatment of Endometrial Carcinoma Stage I b, c, Stage II Stage III a
TAH + BO or Radical Hysterectomy
Brachytherapy
Teletherapy
Hormonotherapy ( E2R +, PgR + or
E2R -, PgR + )

50. Treatment of Endometrial Carcinoma Stage III b, c Stage IV
Tumorecromy
Hormonotherapy ( E2R +, PgR + or
E2R -, PgR + )
Chemotherapy

51. Endometrial Carcinoma Prognostic Factors
Age
Stage
Grade
Presence of myometrial invasion
Presence of NEO cells in peritoneal fluid
Lymph node metastases
Receptor status
DNA content in neoplastic cells

52. Prognosis in Endometrial Carcinoma 5 YEAR SURVIVAL
Stage I 75 – 100 %
Stage II 50 – 65 %
Stage III 20 – 40 %
Stage IV below %

54. 5 YEAR SURVIVAL Endometrial Carcinoma 75 % Vulnar Carcinoma 42 %
Cervical Carcinoma 38 %
Ovarian carcinoma 35 %

57. Diagnostic of asymptomatic women

58. INDIRECT METHOD OF ENDOMETRAL ASSESSMENT
Conventional USG
Transvaginal USG
Doppler Method
Sonohysterogrphy
3D-ultrasonography
Magnetic Resonance
Computer Tomography

59. Conventional Ultrasonography (problems)
Obesity
Fill up bladder problems
(urinary incontinence)
retroflexion of uterine corpus
low frequency 3,5-5 MHz

60. Transvaginal Ultrasonography
USG head near the uterus
Empty bladder
High frequency 6-15 MHz
Low range

61. USG Doppler Method uterine artery flow small endometrial arteries flow
neoangiogenesis
uterine artery flow
small endometrial arteries flow
RI PI

62. HYSTEROSONOGRAPHY 3D - hysterography
5-10 ml 0,9 NaCl, Ringer, H2O
when unclear TV-USG image
special to detect focal lesion
T. C. Dubinsky - J Ultrasound Med

63. Computer Tomofraphy Magnetic Resonance
comparable with TV-USG in
assessment of endometrium
better in invasion assessment
of myometrium by endometrial CA
rather expensive

64. Diagnostic method which most contributed to development of gynaecology in the course last decades is certainly transvaginal ultrasonography
Kratochwill 1969
Fleischer 1984

65. USG image of endometrium in postmenopausal period
„Pencil line”
FLAICHER 6,0 mm
GOLDSTEIN 5,0 mm
GRANBERG 5,0 mm
NASSRI 5,0 mm
OSMERS 4,0 mm
WIKLAND 4,0 mm

66. Operative Hysteroscopy indications et postmenopausal women
removing of endometrial polyps
removing of submucosus myomas
( type 0 and I)
electroresection of endometrium

67. Endometrial hyperplasia treatment
Stimulating ovulation MDs
Gestagens – High dose
IUD with gestagens
hysteroscopic endometrial resection
brahy - therapy
hysterectomy

68. Endometrial hyperplasia importance of using gestagens
blocking of E-receptors synthesis
blocking of gonadotropin
increase activity of 5α-reductase
increase activity E2-dehydrogenase