Endometrial Carcinoma
 
The most common pelvic gynecologic malignancy (13% of all cancers in women in India).
 
Signs and Symptoms
 
Abnormal vaginal bleeding (most common -90% of cases). Premenopausal women with prolonged and/or heavy menses, or intermenstrual spotting require endometrial biopsy. All postmenopausal women with vaginal bleeding should be evaluated for endometrial cancer (20% of these patients will ultimately be diagnosed with the malignancy). Biopsy is also recommended in women taking estrogen therapy for menopausal symptoms who may have withdrawal bleeding.
 
Prognostic Factors
 
Uterine
·          Histologic type.
 
·          Histologic differentiation
 
·          Stage of disease (5-year survival (%) distribution by stage : 1-86%; II-66%; III-44%’ IV-16%)
 
·          Myometrial invasion
 
·          Vascular space invasion (gives – 25 % rate of disease recurrence.
 
Extra uterine
·          Positive peritoneal cytology (rate of disease recurrence seen was – 15%)
 
·          LN metastasis : Involvement of pelvic LN or peritoneal metastages poses – 25% risk for disease recurrence, whereas metastasis to periaortic LN increases this risk to 40%.
 
·          Adnexal metastasis (-15% recurrence risk). Aslo :
 
·          Tumor homone-receptor status : The presence of estrogen receptor (ER)/progesterone receptor (PgR) and their levels were found to be inversely proportional to histologic grade and associated with a longer survival.
 
·          Tumor size : Tumors of more than 2 cm have worse prognosis.
 
Management
 
1.       Total abdominal hysterectomy with bilateral salpingo-orphorectomy : Selected pelvic LN may be removed) This is considered adequate for patients with well or moderately differentiated tumors with negative peritoneal cytology (if no peritoneal fluid is found during surgery, peritoneal washing with normal saline should be done); no vascular space invasion: and less than 50% myometrial invasion.
 
2.       TAH/BSO combined with paraortic and selective pelvic LN sampling/dissection. If there are no medical or technical contraindications (e.g. morbid obesity), this should be done in: tumors involving more than 50% of outer myometrium. Tumor presence  in cervical is thmus, or the adnexal and other extrauterine metastases in case of serous clear cell, undifferentiated or squamous histology, as well as in case of LN enlargement (visible or palpable)
 
3.       Followed by postoperative total pelvic irradiation for tumors with deep myometrial invasion, grade 2 or 3 histology, and vascular space invasion, as well as with cervical involvement. Radiation doses of 45 to 60 Gy of standard fractionation and daily treatments of multiple fields with small-bowel protection are applied.
 
Stage II B
 
Hysterectomy, bilateral salpingo-oophorectomy, and periaortic LN sampling . followed by postoperative radiation.  The radiation therepy is administered as an external beam to a dose of 45 to 50 Gy alongwith vaginal irradiation with vaginal cylinder or colpostats to bring the vaginal surface dose to 80 to 90 Gy.
 
Stage III
 
Combination of intracavitary and external beam radiation
 
Stage IV and recurrent Disease
·          Therapy recommendations depend on the sites of metastasis or recurrent and the disease-related symptoms.
·          Pelvic exenteration can be considered for patients with disease extending only to the bladder or rectum.