Endometrial malignancy

         Endometrial malignancy is the most rare tumour of Uterus , particularly in India. The prevalence is in child bearing age group and in menopausal women.
         The major Symptoms and Signs are :-

•   Bleeding leads to an evaluation of the endometrium . In the vast majority of cases , no gross evidence of disease is noted.
•    The uterus may be of normal size upon pelvic examination, or may be enlarged in size.
•                   Cancer can be present upon cervical evaluation and , less frequently, in the upper part of vagina or peri uretheral region . In current practice , occult cervical involvement is very unusual , as is clinically metastasis , such as in the vagina. Multiple epidemiological risk factors have been identified in patients who have adenocarcinoma of the endometrium.
• Endogenous Factors :                                                                 Obesity                                                                             Increases the risk of devepoling endometrial cancer, and some stidies suggest that a 2 to 3 fold increase in risk occurs if an individual is more than 60 lb. heavier than the ideal weight for that person.                                                                      Nulliparity                                                                              Also increases risk many folds in comparison to parous women .                                                                       Late Menopause                                                                     Aged above 55 years also appears to have an increased risk.
• Unopposed estrogen                                                       Unopposed oestrogen , incrases the risk of cancer several times.

                      Obesity is known to increase endogenous oestrogen because of the presence of fat that in turn is responsible for the conversion of androstenedione to oestrogen compounds at a much higher rate than if fat is not present.

                   Anovulation , which may be secondary to unopposed oestrogen , also appears to contribute to this situation.

•     Tamoxifen                                                                                The most widely used anticancer drug is tamoxifen, and this drug has been suggested by some studies to cause an increased incidence of adenocarcinoma of the endometrium.
• Combined Oral Contraceptives                                               In contrast to tamoxifen , incresing data indicates that the use of combination oral contraceptives ( OCs) decreases the risk of developing endometrial malignancy.
• Cigarette Smoking                                                             Smoking apparently decreases the risk of developing endometrial malignancy.
• Associated medical condition                                             Some associated medical conditions have been found to increase the incidence of endometrial malignancy. Studies suggest that , the women , who have had Breast cancer have more risk of subsequently developing endometrial malignancy.
• Family History                                                                     Individuals with a family history of endometrial cancer appears to have an increased risk .
• Phenotype Characteristics                                                        At one time , a classical phenotype was thought to exist for a woman who would develop endometrial malignancy. This phenotype included patients with Obesity , Nullipara , and anovulatory in many instances. More recently, the existense of 2 pathogenic types of endometrial malignancy were appreciated. These women are Obese and have hyperlipidemia, Signs of hyper oestrogenism, Uterine Bleeding , Infertility and late onset of menopause . They may have Hyperplasia of the ovary and endometrium. These patients are tends to be White , Obese , nulliparous, and have well-differentiated superficially invasive cancers that are sensitive to progesterone. They have a very favourable prognosis, and extrauterine disease is unusual in this group of patients. Fortunately, most women with endometrial cancer are in this category.The diagnosis can be made by the symptoms, signs and following diagnostic adds.
• Vaginal ultrasonography                                                       One of the difficulties with using the endometrial stripe as a criterion for further diagnostic tests (eg. endometrial biopsy) is that several conditions may be present that yield a false reading on the endometrial stripe. This is particularly true in a patient who might have an endometrial polyp, is obese or diabetic, or who has been taking tamoxifen.
• Hydroultrasonography                                                              If a thickened endometrium is present, obtain a hydroultrasonogram to make sure a false positive result is not present. This is accomplished by placing a small volume of saline into the endometrial cavity and then repeating the vaginal ultrasonogram. If Vaginal Ultrasonogram shows significant endometrial thickness , an ultrasonogram can help differentiate other pathology from endometrial thickness. 
• Other diagnostic adds are :  
•              Endometrial Biopsy.
•               Hystroscopically directed Biopsy.
•               CT Scan of Abdomen & Pelvis.
•                MRIs ( Not to be performed routinally )                     On all the relevent examination , surgery is to be planned , the routine investigation must be carried out and proceed for Surgery as, surgeon feels good for patient -

HYSTO PATHOLOGY OF ENDOMETRIAL MALIGNANCY

1.                 Exploratory Laparotomy
2.            Total Abdominal Hysterectomy
3.             Bilateral Salpingo oophrectomy
4.             Peritoneal Cytology
5.              Para aortic Lymphadenectomy etc. Staging is then determined based on surgical pathologic findings. Subsequent therapy , if needed is then determined , depending on the surgical pathological findings of the operative procedure. The goals of Pharmacotherapy is to eradicate the carcinoma , to reduce morbidity , and to prevent complications.