D Incidence: 2-3%

D Two Different Pathogenetic Types of Endometrial Cancer:

¬ Estrogen-Dependent: better differentiated, favorable prognosis.

­ Estrogen-Independent: less differentiated, poorer prognosis.

D Risk Factors for Endometrial Cancer:

　

Characteristic	Relative Risks
Nulliparity	2-3
Late menopause	2.4
Obesity
21-50 lbs	3
> 50 lbs	10
Diabetes mellitus	2.8
Unopposed estrogen therapy	4-8
Tamoxifen	2-3
Atypical endometrial hyperplasia	8-29

D Symptoms/Signs:

¬ vaginal bleeding or discharge (90%)

­ pelvic pressure or discomfort

Ø indicative of uterine enlargement or extrauterine spread

® hematometra or pyometra ( in old female with cervical stenosis )

v Causes of Postmenopausal Bleeding:

　

Cause	Frequency (%)
Endometrial atrophy	60-80
Estrogen replacement therapy	15-25
Endometrial polyps	2-12
Endometrial hyperplasia	5-10
Endometrial cancer	10

D Diagnosis:

¬ Endometrial Aspiration Biopsy: first step

- diagnostic accuracy: 90-98%

­ Hysteroscopy and Diagnostic D&C:

• reserved for patienst with cervical stenosis, patient intolerance, or bleeding recurrence after negative endometrial biopsy

® TVS: a useful adjunct

• conditions requiring further evaluation:

1). ET > 5 mm

2). A polypoid endometrial mass

3). Collection of fluid within the uterus

D Histologic Classification of Endometrial Carcinomas:

　

Classification	Distribution
Endometrioid Adenocarcinoma	80%
Usual type
Variants
Villoglandular/papillary
Secretory
With squamous differentiation
Mucinous carcinoma	5%
Papillary serous carcinoma	3-4%
Clear cell carcinoma	< 5%
Squamous carcinoma
Undifferentiated carcinoma
Mixed carcinoma

v Differentiation of carcinoma ( Grade ):

D Pretreatment Evaluation:

X History:

systemic diseases ( eg. DM, HTN ), bladder/intestinal complaints, etc.

X Physical Examination:

lymphadenopathy, abdominal masses, possible areas of cancer spread, etc.

X Lab. Survey:

CBC, BG, serum chemistry, U/A, stool occult blood, EKG,

tumor marker ( eg. CA-125 )

X Image Study:

ultrasound, CxR

D Surgical Staging:

- Most patients with endometrial cancer should undergo surgical staging based

on the 1988 FIGO system.

- Surgical procedure should at least includes:

1). Peritoneal Washing:

subdiaphragmatic area, paracolic gutters, and pelvis

2). Exploration of Abdomen and Pelvis:

diaphragm, liver, omentum, pelvic lymph node, and para-aortic lymph node

3). Biopsy of any suspicious-looking lesions

4). ATH + BSO

ð Open the uterus to evaluate tumor size, myometrial invasion, and cervical

extension.

- Indications for Selective Pelvic and Para-arotic Lymph Node Dissection in

Ednometrial Cancer:

1). Tumor histology clear cell, serous, squamous, or grade 3 endometrioid

2). Myometrial invasion ³ 1/2

3). Isthmus-cervix extension

4). Tumor size ³ 2 cm

5). Extrauterine disease ( eg. adnexal or cervical involvement )

- 1988 FIGO Surgical Staging for Endometrial Carcinoma:

　

Stage Ia	G123	Tumor limited to endometrium
Ib	G123	Invasion < 1/2 myometrium
Ic	G123	Invasion ³ 1/2 myometrium
Stage IIa	G123	Endocervical glandular involvement only
IIb	G123	Cervical stromal invasion
Stage IIIa	G123	Tumor invading serosa and/or adnexa, and/or positive peritoneal cytology
IIIb	G123	Vaginal metastases
IIIc	G123	Metastases to pelvic and/or para-aortic lymph nodes
Stage IVa	G123	Tumor invasion of bladder and/or bowel mucosa
IVb		Distant metastases including intra-abdominal and/or inguinal lymph nodes

D Treatment:

1). Stage I and Stage IIa: primary surgery, followed by other adjunant therapy

based on surgical-pathologic findings and stage

( see Novak’s p1078 and p1081 )

2). Stage II:

• initial surgical approach followed by irradiation (« )
• combined radiation and surgery
• radical hysterectomy

3). Stage III and IV:

usually combined surgery, radiation therapy, and chemotherpay or hormone

therapy

4). Recurrent Disease:

• radiation therapy
• chemotherapy
• hormone therapy:

Ÿ if progesterone receptor (+):

i). megace(20) 80 mg bid, or

ii). provera(5) 50-100 mg tid

　

D Follow-Up after Treatment:

? 初2-3年: q3-4months

‚ 3年後: q6months

  History, PE, CA-125, CxR.