Endometrium

Several risk factors as associated with endometrial cancer: 2 The following are the most common signs and symptoms of Endometrial cancer. 3 Tests used in the detection and diagnosis of endometrial cancer include: The most common form of carcinoma of the endometrium is endometrioid adenocarcinoma. Endometroid adenocarcinoma is divided into four subtypes: I. Papillary II. Secretory III. Ciliated cells IV. Adenocarcinoma with squamous differentiation Pure squamous cell, clear-cell and serous carcinomas are the most aggressive of endometrial cancers.4 || Endometrial cancers are capable of spreading through regional lymph nodes in the pelvis, as well as along the aorta (para-aortic lymph nodes).5 Lymph node involvement in endometrial cases have a particularly significant effect on the risk of recurrence. Metastasis to distant lymph nodes is also a possibility. || In endometrial cacner, cellular differentiation determines the pattern of spread. Thus, well-differentiated tumors limit spreading to the surface of the endometrium, while myometrial extension is less common. Myometrial invasion occurs much more frequently in patients with poorly differentiated tumors. Myometrial invasion often indicates lymph node involvement and distant metastases. Metastatic spread occurs in a characteristic pattern, commonly spreading to the pelvic and para-aortic nodes. When distant metastasis occurs, it most commonly involves the lungs, inguinal and supraclavicular nodes, liver, bones, brain, and vagina. 6 || || Endometrial cancer is most commonly surgically staged. The following table is the guidelines of the International Federation of Gynecology and Obstetrics staging system:7
 * **Epidemiolgy:** || Kevin Tsai
 * Carcinoma of the endometrium is the most common gynecologic malignancy 1
 * Incidence peaks – 50 to 70 years old
 * 75% of all cases occur in postmenopausal women ||
 * **Etiology:** || Erin
 * Hormone factors – producing more estrogen than progesterone can increase the risk of developing endometrial cancer (after menopause, the ovaries stop making these hormones, but a small amount of estrogen is still made naturally in fat tissue).
 * Estrogen therapy – used to treat symptoms of menopause, estrogen is available in the form of pills, skin patches, creams, shots, and vaginal rings. However, using estrogen alone (without progesterone) can lead to an increased risk of endometrial cancer in women who still have a uterus. Progesterone-like drugs can be given along with estrogen to reduce the increased risk of endometrial cancer.
 * Birth control pills – the use lowers the risk of endometrial cancer
 * Total number of menstrual cycles – having more menstrual cycles during a woman’s lifetime increases the risk of endometrial cancer. Starting menstrual periods before age 12 and/or going through menopause later in life raises the risk.
 * Pregnancy – Having many pregnancies decreases the risk of endometrial cancer since the hormonal balance shifts towards more progesterone during pregnancy.
 * Obesity – Having more fat can increase a women’s estrogen levels, which increases the risk of endometrial cancer. Endometrial cancer is twice as common in overweight women, and more than three times as common in obese women compared to women with a healthy weight.
 * Tamoxifen – is a drug that is used to prevent and treat breast cancer. It acts as an anti-estrogen in breast tissue, but acts like an estrogen in the uterus. It can cause the uterine lining to grow, which increases the risk of endometrial cancer (~1 in 500 chance)
 * Ovarian tumors – Certain types can make excess estrogen
 * Polycystic ovarian syndrome – condition that causes abnormal hormone levels, such as higher estrogen levels, which can increase the chance of endometrial cancer.
 * Age
 * Diet and exercise
 * Family history
 * Diabetes – endometrial cancer may be as much as 4 times more common with diabetes.
 * Prior pelvic radiation therapy
 * Breast or ovarian cancer – have an increased risk of developing endometrial cancer. ||
 * **Signs & Symptoms:** || Spencer
 * Vaginal Bleeding (most common)
 * Back Pain
 * Pressure on bowel and bladder (usually caused by the enlarged uterus)
 * Blood in the vagina emanating from the cervical os is one of the most common physical findings. ||
 * **Diagnostic Procedures:** || Pablo
 * Complete history and physical exam
 * Transvaginal ultrasound / sonography
 * Cystoscopy and proctoscopy
 * Computed tomography (CT)
 * Magnetic resonance imaging (MRI)
 * Position emission tomography (PET)
 * Chest x-ray
 * Complete blood count
 * CA 125 blood test¹ ||
 * **Histology:** || Becky
 * **Lymph node drainage:** || Adam
 * **Metastatic spread:** || Megan
 * **Grading:** || Kevin Tsai 1
 * **Staging:** || Erin

Stage Grade Description IA G123 Tumor limited to endometrium IB G123 Invasion to <1/2 myometrium IC G123 Invasion to >1/2 myometrium IIA G123 Endocervical glandular involvement only IIB G123 Cervical stromal invasion IIIA G123 Tumor invasion of serosa or adnexa or positive peritoneal cytology IIIB G123 Vaginal metastases IIIC G123 Metastases to pelvic or periaortic lymph nodes IVA G123 Tumor invasion of bladder or bowel mucosa IVB -- Distant metastases, including intraabdominal or inguinal LN || Some of the most common side effects of radiation therapy to the endometrium include. 3 The prognosis of endometrial cancer is highly dependent on several factors such as the stage of the disease at the time of diagnosis, the overall health of the patient and the treatment options available. For the most part, endometrial cancer is diagnosed at an early stage. the 1- year survival rate is 92%. The 5-year survival rate for endometrial that has not yet spread is around 95%. If there is metastasis to distant organs, the 5-year survival rate drops down to 23%.² || Surgery is the treatment of choice with endometrial carcinoma; it can be used alone for early stage tumor or used along with radiation therapy and/or chemotherapy.
 * **Radiation side effects:** || Spencer
 * Fatigue
 * Diarrhea
 * Cystitis (Can be a late complication as well)
 * Desquamation of the vulvar skin
 * Anorexia and vomiting may occur if the periaortic region is treated.
 * Bowel obstruction and/or fistula formation
 * <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">Vaginal Stenosis ||
 * **Prognosis:** || Pablo
 * **Treatments:** || Becky

Radiation can be used anywhere from low risk tumor to inoperable endometrial tumors.
 * Low-risk: stage IA, grades 1 & 2 and stage IB, grade 1 without evidence of lymphovascular involvement (LVI) may just receive external beam radiation therapy (EBRT). For those with presence of LVI, intracavitary vaginal brachytherapy (IVB) may be considered.
 * Intermediate-risk: Depending on extensive surgical staging, stage and grade, the patient may be offered pelvic EBRT with or without IVB, versus IVB alone.
 * High-risk: Stage IC, grade 3 should receive EBRT with or without IVB boost. Patients with stage IIA, grade 3 and stage IIB, all grades should be offered EBRT + IVB.

Chemotherapy (cisplatin + doxorubicin) studies seem to show some improvement, especially in the advance stages. 4 || Uterus - 7500 cGy - Stricture Ovary - 200-300 cGy - Sterilization 8 || Back to Week 5
 * **TD 5/5:** || Adam
 * **Reference** || # Chao KC, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA; Lippincott Williams & Wilkins. 2011: 579-589.
 * 1) American Cancer Society. Endometrial (Uterine) Cancer. [] . Revised January 17, 2013. Accessed June 26, 2013.
 * 2) <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif; font-size: 13px; line-height: 1.5;">Chao C, Perez C, Brady L. Radiation Oncology Management Decisions. 3rd ed. PA: Lippincott Williams and Wilkins; 2011:579-590.
 * 3) Chao KSC, Perez CA, Brady LW. Endometrium. In: Chao KSC, Perez CA, Brady LW, eds. // Radiation Oncology Management Decisions // . Philadelphia, PA: Lippincott, Williams and Wilkins; 2011: 579-589.
 * 4) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
 * 5) National Cancer Institute. Endometrial Cancer Treatment. [] . Accessed June 19, 2013.
 * 6) Chao KSC, Perez CA, Brady LW. Radiation Oncology Management Decisions. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002:513.
 * 7) Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 2nd ed. St. Louis, MO: Mosby Inc; 2004. ||