Endometrial hyperplasia is known to be a precursor lesion for development of endometrial adenocarcinoma

1. Endometrial Hyperplasia & Cancer
Uterus
DR. LAXMI SHRIKHANDE
CONSULTANT - SHRIKHANDE HOSPITAL, NAGPUR
https://facebook.com/laxmi.shrikhande | https://.linkedin.com/in/dr-laxmi-agrawal-shrikhande

2. Dr. Laxmi Shrikhande - MD; FICOG; FICMU;FICMCH
Medical Director-Shrikhande Fertility Clinic, Nagpur
Chairperson Designate Indian College of OB/GY ICOG
National Corresponding Editor-The Journal of
Obstetrics &Gynecology of India
Senior Vice President FOGSI 2012
Patron & President -Vidarbha Chapter ISOPARB
Received Nagpur Ratan Award at the hands of Union
Minister Shri Nitinji Gadkari
Received Bharat excellence Award for women’s health
Received Mehroo Dara Hansotia award for Best
Committee of FOGSI
National Governing Council member ICOG 2012-2017
National Governing Council Member ISAR 2014-2019
Chairperson-HIV/AIDS Committee, FOGSI (2007-09)
President Nagpur OB/GY Society 2005-06
Immediate Past President Menopause Society, Nagpur
Associate member of RCOG & ESHRE
Member of European Society of Human Reproduction
Visited 96 FOGSI Societies as invited faculty
Delivered 11 orations and 450 guest lectures
Publications-Twenty National & eleven International
Presented Papers in FIGO, AICOG, SAFOG, AICC-RCOG
conferences
Conducted adolescent health programme for more
than 15,000 adolescent girls
Conducted health awareness programme for more

3. Endometrial Hyperplasia
& Cancer Uterus
DR LAXMI SHRIKHANDE
NAGPUR

4. Overview
What do we mean by EH?
Types of EH
Diagnosis
Does all EH lead to Ca ?
Medical Management of EH
When to do hysterectomy?
EH in special cases
Ca endometrium mgt
Take home message

5. Definition
Endometrial hyperplasia is known to be a precursor lesion for
development of endometrial adenocarcinoma
It is defined as irregular proliferation of the endometrial glands with an
increase in the gland-to-stroma ratio when compared with proliferative
endometrium.
uterine corpus: epithelial tumours and precursors. In: Kurman RJ, Carcanglu ML, Herrington CS, Young RH,
editors. WHO classification of tumours of female reproductive organs. 4th ed. Lyon: WHO Press; 2014:125-6.

6. Classification
Previously, the most widely adopted classification for endometrial hyperplasia was
the WHO 1994 classification system, based on the glandular architectural
complexity and nuclear atypia:
(i) simple hyperplasia, with 1% risk of progression to endometrial cancer;
(ii) complex hyperplasia, with 3% risk of progression to endometrial cancer;
(iii) simple hyperplasia with atypia; and
(iv) complex hyperplasia with atypia.
The last two have a higher risk of progression to endometrial cancer of 8% and 29%,
respectively
Kurman RJ, Kaminski PF, Norris HJ. The behavior of endometrial hyperplasia. A long-term study of “untreated” hyperplasia in 170 patients. Cancer 1985; 56:403-12.
Palmer JE, Perunovic B, Tidy JA. Endometrial hyperplasia.Obstet Gynecol 2008; 10:211-6.

9. Management approach
Depends on-
Risk factors for recurrence or progression (eg, obesity, ovulatory
dysfunction, increased genetic risk, increased age).
Desire for fertility.
Contraceptive needs.
Postmenopausal women with endometrial thickness on transvaginal
ultrasound ≥20 mm have a greater risk for concomitant endometrial
cancer

10. MANAGEMENT OPTIONS
The three most common options for the management of EH are
surveillance,
progestin therapy, and
 hysterectomy.

11. Fertility sparing options
Women who wish to retain their fertility or refuse hysterectomy should be
counselled about the risks of concomitant endometrial cancer and progression
to endometrial cancer, the importance of endometrial surveillance and to delay
conception until disease regression.
The first-line fertility-sparing treatment is LNG-IUS, and the second-line
treatment is oral continuous progestogens.
Underlying endometrial cancer should be excluded by hysteroscopy with
targeted biopsy or dilatation and curettage.
 Investigations such as transvaginal ultrasound scan help to exclude ovarian
lesions.

12. Summary of EH
Endometrial hyperplasia is a precancerous lesion that is not
uncommon.
The diagnosis can be confirmed by endometrial sampling, or more
accurately, by hysteroscopy with targeted biopsy or dilatation and
curettage.
The first line treatment of hyperplasia without atypia is insertion of
LNG-IUS, and that of atypical hyperplasia is hysterectomy with or
without bilateral salpingo-oophorectomy if no fertility wish.

13. Endometrial Cancer-EC

14. EC-predominantly a disease of women in their sixth and
seventh decades
85-90% of EC occur in women over 50 years of age
Less than 5 % occurs in women less than 40 years of age
It Is increasingly aggressive in advancing age.
Introduction

15. Staging

16. After staging procedure- categorised in to different risk groups
• G1 ,G2 ,no myoinvasion
• no cervix or isthmic invasion
• Negative peritoneal cytology
• No LVSI
• No evidence of metastasis
low risk
(no further treatment)
• G1,G2 with ≤ 50% MI, G3 no MI
• No cervix or isthmic invasion
• Negative peritoneal cytology
• No LVSI
• No evidence of ………… met
Intermediate risk
(Vault Brachytherapy)
• Myoinvasion>50% ,G-3 any MI
• Adenexal spread
• Lymphnode Met
• Cervical invasion
• UPSC, CC
• Intraabd.met/ distant met
High risk
(EBRT/ Brachytherapy
Extended field RT/CT
If common iliac and PA node
+ve)

17. • grade 1-II
• < 50% myoinvasion
• no evidence of extrauterine disease
• absence of cervical involvement,
• tumour size less than 2 cm
Lymphadenectomy
omitted
• in Grade-I – II disease with tumor size >2cm,
PA LND if Pelvic node(S) +ve
Only Bilateral pelvic
lymphadenectomy
• FIGO Grade 3 tumour ,
• Evidence of extrauterine disease
• Nonendometrioid endometrial cancer,
• Depth of myoinvasion >50%
• Cervical extension
• When pelvic node(s) positive
Pelvic and para
aortic
lymphadenectomy
Lymphadenectomy?

18. Candidates for fertility preservation
women with the following characteristics:
Well-differentiated (grade 1) endometrial adenocarcinoma with
histology and grade confirmed on dilation and curettage.
Tumor confined to the endometrium, stage IA .
Reproductive age and desirous of future childbearing.
No contraindications to hormonal therapy
Understanding of the nonstandard nature of treatment, including
risk of occult cancer and risk of recurrent and/or persistent cancer.

19. Patient should be seen every 3-4 months in first 3 years, every 6
months in the third to fifth year and annually thereafter.
At each visit -complete physical and pelvic examination, a pap-
smear
Ultrasonography and CA-125 measurement, CT scan, MRI may be
done when considered appropriate
Post treatment Surveillance

20. ECs are essentially a disease of elderly women
Common -Endometrioid endometrial adenocarcinoma (EEA), and the uncommon
UPSC and CCC.
Surgery remains the mainstay management with lymphadenectomy and
laparoscopy/robotic being increasingly integrated.
Surgical staging defines extent of the disease and risk of recurrence.
Role of adjuvant radiotherapy is not very clear. It is mostly advocated in high-risk
cases without evidence of survival benefit, though there is decrease in local
recurrence.
Combination therapy with radiation and chemotherapy is under evaluation.
Patient should be seen every 3-4 months in first 3 years, every 6 months in the
third to fifth year and annually thereafter.
Summary of EC

21. Questions

22. Dr. Laxmi Shrikhande
Shrikhande Fertility Clinic
Ph-8805577600 / 8805677600
shrikhandedrlaxmi@gmail.com