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Case Report

General data

• P.P.

• 72 y/o

• Married

• Quezon City

• Roman Catholic

Chief Complaint

• Post-menopausal vaginal spotting x 4-5months

Past Medical History

• (+) Hypertension x 20 years, controlled– On Amlodipine 10 mg, 1 tab OD– Combizar, 5mg

• Dyslipidemia– Simvastatin, 40mg

Past Medical History

• s/p thyroidectomy (1977)

• s/p dilatation and curretage (1976)

Family History

• (-) hypertension, DM, asthma, thyroid disease, cancer

Menstrual History

• Menarche: at the age of 10

• Interval: regular, monthly

• Duration: 5 days

• Amount: 3-4 ppd, moderately soaked

• (-) dysmenorrhea

• LMP: 1995 (55 y/o), menopause x 15 years

OB History

• G0P0

• Married nulligravid

Gynecologic History

• Coitarche: at the age of 22

• # of sexual partner: 1

• (-) OCP or HRT use

• Last PAP Smear: (-)

• (-) vaginal discharge

• (+) vaginal spotting x 4-5 months

History of present illness

5 months PTA (+) vaginal spotting, 1-2ppd

(-) abdominal pain / mass

(-) bladder / bowel habit changes

(-) weight loss (+) Consult

USG: uterus slightly enlarged for age

History of present illness

3 mos. PTA (+) vaginal spotting, persistent

(-) abdominal mass

(-) bladder or bowel habit changes

(-) weight loss

History of present illness

1 mo. PTA (+) vaginal spotting, persistent

Consult SLMC Endometrial Biopsy

Secretory carcinoma, endometrium

Review of Systems

• General: no to minimal weight loss (-)loss of appetite and body weakness

• Skin: No rash and active skin lesions• Hair: No abnormal loss or growth• Nails: No color changes, brittleness and clubbing • Eye: No blurring of vision, redness, discharges • Ear: No pain and ear discharge• Nose: No discharge, obstruction and itching • Mouth: No bleeding gums and sores • Throat: No soreness and swollen tonsils• Neck: No mass and cervical lymphadenopathies

Review of Systems

• Pulmonary: No dyspnea, cough and shortness of`breath• Cardiac: No chest pains, palpitations, easy fatigability,

syncope• Gastrointestinal: No masses or tenderness• Genito-urinary: see HPI• Musculo-skeletal: No joint swelling and abnormal

posture• Hematopoietic: No pallor and easy bruisability• Neurologic: No headache, altered sensorium, numbness

and motor dysfunction

Physical Examination

• General survey– Conscious, coherent, ambulatory, not in CP distress

• Vital signs– BP 110/80 PR 80 RR 20 Temp 36.9°C– Wt: 50kg Ht: 155cm BMI: 20.8 (normal)

• Skin – No lesions, hyper/hypopigmentations

Physical Examination

• HEENT– Normocephalic, anicteric sclerae, pink palpebral conjunctivae,

patent ear canal, TM intact,

no nasal discharge, tonsils not enlarged

• Neck– No neck vein engorgement, no masses,

no CLADs

• Breast exam– No skin color changes, nipple retraction or discharge, no

masses, no axillary lymphadenopathies

Physical Examination

• Chest and lung– Symmetrical chest expansion, no retractions, clear

breath sounds

• Heart– Adynamic precordium, PMI at 5th LICS MCL,

regular rate and rhythm– No thrills, heaves and murmurs

• Abdomen– Globular, normoactive bowel sounds, soft, non-

tender

Physical Examination

• Internal exam: – cervix is short and closed– uterus palpable, nontender – no adnexal mass or tenderness

• Extremities– full and equal pulses, no cyanosis and edema

Salient Features

• 72 y/o• Married nulligravid

• Menarche: 10 y/o

• Menopause: 55 y/o

• No history of OCP or HRT use

• Hypertensive

• Dyslipidemic

Salient Features

• NO family history of Cancer

• Vaginal spotting x 4-5 months

• (-) hypogastric pain

• Normal BMI (20.81)

• TVS: uterus slightly enlarged for age

Assessment

• Secretory carcinoma, endometrium; s/p endometrial biopsy (3/8/10)

• Hypertension, dyslipidemia, s/p thyroidectomy (1977), s/p dilatation and curettage (1976)

• Married nulligravid x 37 years

What is Endometrial Cancer?

What is Endometrial Cancer?

• The most common gynecologic cancer in developed countries

• 7% of ca in women

• Lifetime incidence ~2-3%

(American Cancer SocietyFemale Cancers: 2000 Statistics)

Lifetime risk

• 5% occur before age 40• Early occurence• Bothersome symptoms, i.e. bleeding early

consultation and diagnosis

• 20-25% before onset of menopause• Perimenopausal women

Cancers of the Uterine Corpus:Histologic Types

• Carcinoma (94%)– Endometrioid (87%)– Adenosquamous (4%)– Papillary Serous* (3%)– Clear Cell* (2%)– Mucinous (1%)– Other (3%)

• Sarcoma (6%)– Carcinosarcoma* (60%)– Leiomyosarcoma* (30%)– Endometrial Stromal Sarcoma (10%)– Adenosarcoma (<1%)

*poor prognosis histology

Endometrial Cancer:Type I/II Concept

• Type I (Obese-type)– Estrogen Related– Younger and heavier patients– Low grade– Background of Hyperplasia– Perimenopausal– Exogenous estrogen

• Type II (Non-obese type: ~10% of total cases)– Aggressive– High grade– Unfavorable Histology– Unrelated to estrogen stimulation– Occurs in older & thinner women

• Familial/genetic (~15% of total cases)• Lynch II syndrome/HNPCC• Familial trend

• Replaced Clinical Staging 1989• Conceptual rationale

– Better defines extent of disease (metastases, depth of invasion, cervix involvement, etc.)

– Minimizes over/under treatment– Minimally increases perioperative

morbidity/mortality– Decreases overall Rx risks and costs– Better allows comparison of therapeutic results

Uterine Cancer: Surgical Staging

Stage I

(73%)Confined to uterus

Stage II

(11%)Cervix involved

Stage III

(13%)

Uterine serosa, adnexae, positive cytology, vaginal metastases, pelvic/aortic node metastases

Stage IV

(3%)Bladder, bowel, inguinal node, distant metastasis

Endometrial Cancer: FIGO Surgical Stage

• Aggressive Histologic Subtypes (Clear-cell, Serous, poorly differentiated)

• Increasing age (over 65)• Vascular invasion• Aneuploidy• Altered oncogene/tumor suppressor gene

expression ( “molecular staging” concept- p53, PTEN, microsatellite instability, MDR-1, HER2/neu, ER/PR, Ki 67, PCNA, CD 31,EGF-R, MMR genes)

• Race?

Endometrial Cancer: Poor Prognostic Factors

Diagnosis of disease

• History of having symptoms– Postmenapausal bleeding– Menorrhagia– Metrorrhagia– Bloody Discharge

• Endometrial biopsy main diagnostic tool – performed either in the office or via D&C in OR

• D&C is the gold standard sampling method – preoperative D&C will agree with diagnosis at

hysterectomy 94% of the time

• Normal endometrial stripe:• Postmenopausal 4- 8 mm

• Postmenopausal on HRT 4- 10 mm

• U/S for Detection of any uterine pathology

• Sensitivity: 85-95%

• Specificity: 60-80%

Transvaginal Ultrasound Screening

Normal Endometrium

Endometrial Polyp

Diagnosis

Sampling of the Endometrium

• Office biopsy procedures (Pipelle, Vabra aspirator, Karman cannula) will agree with a D&C performed in the OR ~95% of the time

• Office biopsy has a 16% false negative rate when the lesion is in a polyp or the cancer covers less than 50% of the endometrium– Guido et al. J Reprod Med. 1995;40:553

Endometroid carcinoma, Grading

• FIGO- Gr 1 - < 5% solid tumor

- Gr 2 - 6 % - 50% solid

- Gr 3 - > 50% solid tumor• NUCLEAR GRADE

– Size, shape , staining and chromatin, variability, prominent nucleoli.

– High nuclear grade adds one point to FIGO grade

Grade 1 Endometroid Carcinoma

Grade 3 Endometroid Carcinoma

Endometrial carcinoma:Poor Prognosis Cell Types - Papillary Serous

Endometrial Carcinoma - Poor Prognosis Cell Types Clear Cell

•CA125•Chest X-ray•Mammograms•Colon Evaluation•Others as indicated

Uterine Cancer: Pre-op Evaluation

Treatments

Endometrial Cancer: Adjuvant Therapy

• Brachytherapy• External beam radiotherapy• Hormonal therapy• Cytotoxic chemotherapy• Combination therapy

Endometrial Cancer: Recurrence

• Pelvic examination• Pap smears• CA125 (high-risk)• Chest X-ray (high-risk)

Endometrial Cancer: Follow-Up

• 75-95% of recurrences are in first 36 months• 60% of patients have symptoms (pain,

weight loss, vaginal bleeding) • Rare to cure distant recurrences• 50% vaginal recurrences cured

Prevention Early reporting of any abnormal vaginal bleeding

or discharge to the doctor.

Controlling comorbidities: obesity, high blood pressure, and diabetes

Using birth control helps prevent endometrium cancer.

If taking medication that increases/produces estrogen, ask about receiving progesterone.

If you are at risk, get screened regularly.

Thank you!