1. CARCINOMA ENDOMETRIUM
Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.

2. INTRODUCTION
Most frequently encountered gynaecologic
cancer in west because of decline in Ca Cx
 Account for 7.0%of all cancer in women
Peak incidence is in the age group of 55 to
69 years.
Over three-fourth of these women are
diagnosed when the disease is still localized and
surgery offers satisfactory results.

3. PREDISPOSING FACTORS
1. Unsupervised administration of ERT in
menopausal women.
2. Women suffering from Hyperestrogenic
states i.e. Endometrial hyperplasia as cases
of DUB.
3. Familial predisposition to it and may be due
to genetic factors or dietary habits.
4. Tamoxifen prescribed to women with breast
cancer.

4. CONTN..
5. OCPs containing only estrogen while OCPs
with E & P have protective effect.
6. Obesity, HT, Diabetes, Infertility, nulliparity
are associated with endometrial cancer in
30% cases.
7. PCOD patients are more prone to this
disease.

5. PATHOLOGY
 Uterus is enlarged and Endometrial cancer may
be localized or diffuse.
 Localized form may appear as a nodule or polyp
or localized carcinomatous patch.
 Diffuse form may be involving the entire uterine
cavity stopping short of internal os.
 It may infiltrate uterine myometrium and remain
restricted to its boundaries for a long time.
 In advanced stages growth may directly spread
beyond uterine body to cervix, vagina, adnexa
and may metastesize into nodes and distant
sites.

6. THIS ADENOCARCINOMA OF THE ENDOMETRIUM IS MORE OBVIOUS. IRREGULAR
MASSES OF WHITE TUMOR ARE SEEN OVER THE SURFACE OF THIS UTERUS THAT
HAS BEEN OPENED ANTERIORLY. THE CERVIX IS AT THE BOTTOM OF THE PICTURE.
THIS ENLARGED UTERUS WAS NO DOUBT PALPABLE ON PHYSICAL EXAMINATION.
SUCH A NEOPLASM OFTEN PRESENT WITH ABNORMAL BLEEDING.

7. THE ENDOMETRIAL ADENOCARCINOMA IS PRESENT ON THE LUMENAL
SURFACE OF THIS CROSS SECTION OF UTERUS. NOTE THAT THE
NEOPLASM IS SUPERFICIALLY INVASIVE. THE CERVIX IS AT THE RIGHT.

8. This uterus is not enlarged, but there is an irregular mass in the upper
fundus that proved to be endometrial adenocarcinoma on biopsy.
Such carcinomas are more likely to occur in postmenopausal women.
Thus, any postmenopausal bleeding should make you suspect that
this lesion may be present.

9. HISTOPATHOLOGY
 It is adeno carcinoma
 Grading of these tumors is based on
differentiation and ability to maintain gland
formation, morphology and anaplasia of the
tumour lining cells and presence of infiltration
in stroma
 Tumor grading affects the prognosis of the
disease in any individual case

12. THE ENDOMETRIAL ADENOCARCINOMA IN THE POLYP AT THE LEFT
IS MODERATELY DIFFERENTIATED, AS A GLANDULAR STRUCTURE
CAN STILL BE DISCERNED. NOTE THE HYPERCHROMATISM AND
PLEOMORPHISM OF THE CELLS, COMPARED TO THE UNDERLYING
ENDOMETRIUM WITH CYSTIC ATROPHY AT THE RIGHT.

13. THIS IS ENDOMETRIAL ADENOCARCINOMA WHICH CAN BE SEEN INVADING
INTO THE SMOOTH MUSCLE BUNDLES OF THE MYOMETRIAL WALL OF THE
UTERUS. THIS NEOPLASM HAS A HIGHER STAGE THAN A NEOPLASM THAT
IS JUST CONFINED TO THE ENDOMETRIUM OR IS SUPERFICIALLY INVASIVE.

14. SYMPTOMS
1. May be asymptomatic to begin with.
2. Menometrorrhagia in perimenopausal
women
3. Post menopausal bleeding.

15. SIGNS
1. Per vaginal examination: may or may not
reveal a bulky uterus.
2. Enlarged uterus may be associated with Ca
endometrium along with fibroid or pyometra
3. Sub-urethral Vaginal metastatic growth may be
noted in advanced cases.
4. When adnexa is involved in late stages
enlarged uterus with unilateral or bilateral
adnexal enlargement and fixed nodules in
Pouch of Douglas may be present.

16. INVESTIGATIONS
1. Routine Haematogram and blood chemistry, urine
examination, X-ray chest and ECG should be done.
2. USG- often reveals thickened and hyperplastic,
polyp in uterine cavity.
Post menopausal endometrial thickness >4mm is
abnormal
3. Endometrial cell sampling by aspiration cytology.
4. Diagnostic hysteroscopy followed by selective
biopsy of suspected area.
5. Fractional curettage and histopathological
examination- this will help in differentiating whether
Ca endometrium is involving cervical canal or not.
6. CT/MRI help in defining the extent of disease into
the myometrium , nodes and distant organs.

17. DIFFERENTIAL DIAGNOSIS
1. Senile endometritis
2. Genital tuberculosis
3. Atypical endometrial hyperplasia
4. Any other cause of post menopausal
bleeding like senile vaginitis, foreign body,
ERT abuse, cervical polyp, urethral
caruncle, Ca cervix and ovarian carcinoma
etc

18. SCREENING OF ENDOMETRIAL CARCINOMA
1. Routine screening of all asymptomatic
women on HRT and tamoxifen therapy
2. Perimenopausal women with
menometrorrhagia should be investigated
and screened to exclude endometrial
carcinoma.
3. All women with postmenopausal bleeding
should be screened by pv examination,
TVS, Pipelle aspiration cytology.
4. Fractional curettage along with diagnostic
hysteroscopy.

19. • Local and/or regional spread
• 3A-Tumor involves serosa, spreads to adnexae,
positive peritoneal cytology.
3 • 3B- Presence of vaginal metastasis
• 3C- Node metastasis to pelvis and para aortic
nodes.
• Tumour Widespread
• 4A Tumor involves bladder and /or
4 bowel mucosa
• 4B Tumor shows distant metastasis (
intra-abdominal and inguinal nodes)

20. STAGE • DESCRIPTION
• Cancer confined to corpus uteri
• 1A- Tumor limited to endometrium
1 • 1B- Tumor involving half or less than half the
myometrial thickness
• 1C – Tumor involves more than half the
myometrial thickness
• Tumor involves cervix but does not extend
beyond uterus
2 • 2A- Endocervical gland involvement only.
• 2B- Cervical stromal invasion

21. TREATMENT
 cases of simple hyperplasia develop in
malignancy in 10-20%
60-70% cases of atypical hyperplasia
develop into malignancy.
Stage 0-(Endometrial hyperplasia)-
Abdominal Pan Hysterectomy is the ideal
treatment.
Young women may be kept under
observation and 30-40 mg
medroxyprogesterone daily therapy may be
offered for 6-12 months.

22. RX CONTN..
 Stage IA: (low risk Grade 1 and 2of
endometrium HPR) TAH and BSO is
sufficient because involvement of nodes is
seen in only 2% cases while myometrial
invasion is only 4%.
 Stage IB- High risk > 50% myometrium
involved and HPR shows grade 3 tumor or
there is presence of lymphatic involvement
then chances of lymph node metastasis is
10-40% therefore TAH and BSO followed by

23. RX: CONTN..
 Stage II- Pre operative radiotherapy followed by
TAH and BSO, or Wertheims Hysterectomy as
done for Ca cervix.
Post operative radiotherapy is needed
if lymph nodes are Ca positive.
 Stage III- Advanced disease not suitable for
surgery. Chemotherapy plus Radiotherapy plus
weekly injection of Medroxy progesterone.
 Stage IV- Palliative Radiotherapy, chemotherapy
and hormonal therapy using large dose of
progesterone. Progesterone helps in regression
of lung metastasis in 30% cases.

24. SURVIVAL RATE
 Stage I 75 %
 Stage II 55 %
 Stage III 30%
 Stage IV 10%

25. SARCOMA OF UTERUS

26. SARCOMA OF THE UTERUS
 Introduction:
 These are rare tumors comprising 4.5% of all
malignant growths of the uterus.
 About 0.5% of myomas undergo sarcomatous
changes at menopausal age.
 Common in the age of 40-60 yrs.
 Rare before 30 yrs.
 8% of sarcomas occur in women who have
received radiation for Ca cervix 8-10 yrs ago.

27. VARIETIES OF UTERINE SARCOMAS
1. Intramural- arise in the myometrium
2. Mucosal- Develops from endometrium.
3. Sarcomatous changes in pre-existing myoma.
4. Grape like sarcoma of the cervix.
Intramural is most common . Histologically
tumour may be round cell, spindle-celled,
mixed cell or giant cell type.
Spindle- cell type is most common and called
leiomyosarcoma.

28. GROSS APPEARANCE
 Cut surface: is hemorrhagic and irregular
without whorled appearance like myoma. It is
friable and soft. Margins are not clear and
invasion into surrounding myometrium is
common. There is no definite capsule.
 Mucosal form- projects in cavity like polyp or
spreads around the cavity of the uterus to
produce uniform enlargement.

29. THIS IS A LEIOMYOSARCOMA PROTRUDING FROM MYOMETRIUM INTO
THE ENDOMETRIAL CAVITY OF THIS UTERUS THAT HAS BEEN OPENED
LATERALLY SO THAT THE HALVES OF THE CERVIX APPEAR AT RIGHT
AND LEFT. FALLOPIAN TUBES AND OVARIES PROJECT FROM TOP AND
BOTTOM. THE IRREGULAR NATURE OF THIS MASS SUGGESTS THAT IS
NOT JUST AN ORDINARY LEIOMYOMA.

30. HERE IS THE MICROSCOPIC APPEARANCE OF A LEIOMYOSARCOMA. IT IS
MUCH MORE CELLULAR AND THE CELLS HAVE MUCH MORE
PLEOMORPHISM AND HYPERCHROMATISM THAN THE BENIGN
LEIOMYOMA. AN IRREGULAR MITOSIS IS SEEN IN THE CENTER.

31. SARCOMAS, INCLUDING LEIOMYOSARCOMAS, OFTEN HAVE VERY
LARGE BIZARRE GIANT CELLS ALONG WITH THE SPINDLE CELLS.
A COUPLE OF MITOTIC FIGURES APPEAR AT THE LEFT AND
LOWER LEFT.

32. METASTASES
 Relatively earlier, occurs via blood stream,
lymphatics, direct spread and by
implantation.
 Lymphatic nodes-35% cases in stage I and II
and Para-aortic lymph nodes in 15% cases.
 Direct spread in the peritoneum leads to
multiple metastasis leading to ascites and
omental cake.

33. SYMPTOMS AND SIGNS
 Profuse and irregular vaginal bleeding which
is often painful.
 60% patients have fever due to degeneration
and infection of the tumour.
 Rapid enlargement of the tumour usually
occurs due to sarcoma.

34. TREATMENT
 Pan Hysterectomy, omentectomy and
debulking of metastasis foci is done.
 Followed by radiation therapy.
 Chemotherapy of VAC combination reduces
the recurrence rate.
 5 yr cure rate is <30% and largely depends
on the type of growth, being worst in
endometrial sarcoma i.e. round cell type.

35. BOTRYOID AND GRAPE-LIKE SARCOMA
 Pathologically the tumour is mesodermal
mixed tumour as the often contain cartilage,
striated muscle fibres, glands and fat.
 Stroma is embryonic in type.
 Grape sarcoma of cervix arises typically in
adult women somewhat similar tumor are
known to develop in cervix and vagina in
children in very early age. In these cases
prognosis is very poor and rapid recurrence
follows their removal.