I- DEFINITION :

TheThe term endometrial cancer refers to all malignant tumors that develop at the level of the uterus.
uterine cavity and whose starting point is located on the endometrium.

II- EPIDEMIOLOGY:
Incidence:
It is, after breast cancer, the most common cancer among women.
CFS is a disease of rich countries.
The incidence is 65% higher in white women than in black women.
It occurs 8 times out of 10 in menopausal women (peak prevalence: 59 years).
The diagnosis is most often made at an early stage before the occurrence of metrorrhagia.
postmenopausal.
In 5% of cases, it occurs in women under 40 years old (no racial differences in this group).
There is no effective screening test.
Risk factors:
Family history of endometrial cancer.
Personal or family history of breast, colon, or ovarian cancer (genetic factor: syndrome)
of Lynch: predisposition to cancers of the colon, rectum and uterus;
Hormonal origin factors:
Estrogen exposure in the absence of progestin.
Early puberty and/or late menopause.
Nulliparity.
Obesity (increase in plasma estrone levels due to aromatization of androstenedione and
androgens in adipose tissue). After menopause, the deficiency in progesterone could explain the peak
of occurrence due to hormonal imbalance.
Hormone therapy with tamoxifen.
Hypertension, diabetes.
Precancerous lesions: atypical endometrial hyperplasia.
History of pelvic irradiation.

III- ANATOMOPATHOLOGY:
TheThe CE represents about 90% of malignant tumors of the uterus.
TheCEs are often considered as lesions of good prognosis, however this notion is partly false.

since the 5-year survival rate does not exceed 55% in certain forms.
Omacroscopy:
Cancer usually presents as a very friable vegetative mass, with a polypoid appearance, which
invades the uterine cavity.
Less frequently, it can sit at the level of hyperplastic endometrium and it cannot be confirmed by examination.
histological.
OMicroscopy:
In 80% of cases, it is an adenocarcinoma (endometrioid carcinoma).
They are classified according to their degree of cellular differentiation into 3 grades:
Grade I = well differentiated,
grade II = moderately differentiated
grade III = undifferentiated.
More rarely, it concerns:
Adenoacanthomas (10%): association of a malignant glandular component and Malpighian areas.
benign
Adenosquamous carcinomas (2.5%): association of malignant glandular and squamous areas.
Squamous carcinomas (2.5%).
Clear cell cancers (2.5%).
Serous papillary cancers (2.5 %).
Sarcomas (malignant tumors originating from connective tissue).
The Extension :
Endometrial cancer has a slow local progression.
It develops more often (85%) byhyperplastic endometrium showing cellular atypia.
In 15% of cases, it can occur on an atrophic endometrium. Its prognosis is then more serious because
The invasion of the myometrium is constant and the diagnosis is later.
Extension locale :
On the surface:
The cancer is spreading in the uterine cavity and towards the uterine isthmus, whose involvement is poor.
forecast.
In depth:
Cancer spreads to the myometrium, whose involvement is an important negative factor because the risk of
Lymphatic metastases are proportional to the degree of infiltration into the uterine muscle.
Regional extension:
The extension occurs progressively and is only seen in advanced cancers: involvement of the parameters,
bladder, rectum.
The vaginal infection is of metastatic type.
Lymphatic extension:
Lymphatic spread of endometrial cancers is less common than that of cervical cancers, except
in case of failure of the isthmus.
Uterine body cancers are not very lymphophilic.
Visceral metastases:
Visceral metastases are mainly represented by low vaginal involvement: 10% of cases.
More rarely, hepatic or pulmonary metastases may occur.
Classification :

FIGO classification of cancer

of the endometrium
Stage I: Cancer confined to the body of the uterus
AI : limited to the endometrium (superficial)
IB : invasion ≤ 50% of the myometrium
IC : invasion ≥ 50% of the myometrium
Stage II : Cervical stenosis
IIA : superficial epithelial atrophy of the endocervix
IIB : twelve from the endocervical stroma
Stage III : Extension outside the uterus in the pelvis
III A : the serosa, appendages, positive peritoneal cytology
 III B : vaginal metastasis
IIIC : metastasis in the pelvic and/or lumbar aortic lymph nodes
Stage IV Invasion of nearby organs (bladder, intestine) or distant metastases
VAT : bladder or digestive invasion
IVB : distant metastasis including intra-abdominal lymphadenopathy
and/or inguinal

IV- DIAGNOSTIC :
A- Circumstances of discovery:
Ode to metrorrhagesspontaneous, painless, irregular, in women in peri- or postmenopause (> 95% of the
diagnostic circumstances). Such a symptom must systematically suggest endometrial cancer and
bring to an exploration.
Leucorrhea odysseypurulent and fetid (pyometra) or watery (hydorrhea).
Pelvic pain:late sign, revealing an evolved form.

B- Clinical examination:
He bringsfew elements for the diagnosis:
The Interrogation:
Risk factors.
Terrain (associated tasks).
Note on taking HRT (which can also often be responsible for metrorrhagia, in case of impregnation)
too important estrogenic.
Tamoxifen intake.
General examination :
Weight (obesity), blood pressure, cardiovascular and metabolic condition.
The research exam:
A genital prolapse.
Urinary incontinence.
Gynecological exam:
The gynecological examination is most often normal and sometimes made difficult by obesity and vaginal atresia.
frequent in menopausal patents.
In the speculum:
Research on abnormal estrogen impregnation signs for a menopausal woman, the cause
it can be an endocrine tumor of the ovary (classic association: 15% of cases):
Vulvovaginal trophism.
Flexibility, vaginal moisture.
Presence of cervical mucus.
The uterine cervix is not responsible for the metrorrhagia which, if present, comes from
the endocervical canal of the uterus.

Pelvic touchers (often hindered by obesity):

Assess the volume, consistency, mobility of the uterus and the condition of the annexes.
Globular, soft, sensitive uterus (most often normal).
Search for a vaginal lesion or a rectal involvement.
Systematic bilateral and comparative examination of the breasts.
Exploration of lymph node areas, the liver.
Cervicovaginal system
The positivity indicates an extensive lesion at the cervix (stage II).
 C- Additional examinations:
The diagnosishistological
Transvaginal ultrasound:
It shows the abnormal increase in the thickness of the endometrium (> 5 mm).
It specifies the location of the endocavitary lesions (irregular bud).
It allows to assess the degree of infiltration of the myometrium.
She is looking for ascitic fluid, lymphadenopathy, an ovarian involvement.
OL-diagnostic hysteroscopy:
She finds a budding, friable, hemorrhagic tumor on contact.
It assesses the seat, the extension to the collar, and allows for directed biopsies.
The staged biopsies, endocervical, then endometrial, during hysteroscopy:
It allows for a histological diagnosis with a histoprognostic grade.
When histology reports atypical endometrial hyperplasia, a hysterectomy is recommended.
(risk of developing cancer).
Others:
Endo-cavitare frosts:
It is possible to perform endocavitary frots using an endocavitary suction cannula (pipelle of
Cornier), through endometrial brushing or via the endocyte of J. Cohen.
The results are unfortunately inconsistent.
Hysterosalpingography:
Accused by some of being responsible for neoplastic dissemination and infectious pushes.
It is actually an essential examination, under the guise of precautions.
It allows to specify the extension of the cancer on the surface, to assess the size of the cavity, to recognize some
associated lesions (uterine fibroid, tubal lesions).
It is performed outside of any metrorrhagia and signs of infection, under low pressure in order to...
avoid a hysterosalpingography.
Results:
Images are generally characteristic, outlining an irregular gap with jagged edges.
She specifies the location of this gap.
Vascular passages translate to an ulceration of the endometrium.

V- EXTENSION REPORT:
It includes:
A gynecological clinical examination.
An abdominal-pelvic scanner or better a pelvic MRI (more reliable for the degree of involvement of the
myometrium) in order to specify the depth of myometrial invasion, any potential involvement of the bladder, rectum,
parametric, iliac lymphadenopathy.
A cystoscopy (performed during the biopsy curettage).
A rectoscopy in functiontended call signs.
A chest X-ray and a liver ultrasound that are systematic.
OEndometrial cancer most often originates in the uterine fundus or in a uterine horn.
We are evolvingit remains long limited to the endometrium, penetrates deep into
myometrium with a risk of extension towards the cervix.
OSon diagnosticmost often early (80% at stage I).
The extra-uterine dissemination to the lymph nodes (iliac nodes then lombo-aortic), the vagina,
the annexes, the peritoneum is delayed. The synchronous metastases are against (liver, lung, brain).
 VI- OPERATIONAL REPORT:
TheIt is essential, especially since it often concerns patents in poor overall condition and having
associated comorbidities (obesity, diabetes, hypertension).

VII- PROGNOSTIC FACTORS:

Where are they:

Old age, poor prognosis.

Visceral defects that may limit surgical indications (surgical operability assessment).
The FIGO stage: good prognosis for cancers treated at an early stage (stages I and IIa).
The histological type (adenocarcinomas and adenoacanthomas, of better prognosis; serous tumors and at
clear cells, poor prognosis.
The histoprognostic grade +++: severity of poorly or undifferentiated forms of grade III.
The degree of invasion of the myometrium +++, more than half of the thickness, conditioning survival, the
risk of pelvic and lymph node recurrence.
Peritoneal cytology (risk of extrapelvic recurrence tripled in the case of positive cytology).
Lymph node involvement of poor prognosis.
Surface extension.
Infected with the isthmus.
Uterine volume: hysterometry > 8 cm.
Survivors at 5 yearsare in the order of:
80% for the I stages,
60% for stage II,
30 and 10% for stages III and IV.

VIII- TREATMENT :
A- Methods
1- Primary surgery:
The surgerythe essential structure of the treatment.
She isalways considered as the first intention, except in case of:
inoperability
widespread disease making the gesture uncurable,
Cervical cancer can lead to 'neo-adjuvant' radiotherapy.
The laparotomy beginscomplete pelvic-abdominal exploration: peritoneal cytology, palpation of
peritoneum, biopsy of any abnormal area.
TheThe procedure consists of a total hysterectomy with bilateral salpingo-oophorectomy and iliac lymphadenectomy.

external and primitive bilateral.

TheThis intervention can be carried out by laparoscopy combined with a vaginal approach.

For locally evolved stages (stages III and IVA): interestof a maximum tumor reduction, if the condition
the patent general authorizes it:
extended colpohysterectomy
pelvic and lombo-aortic lymphadenectomy,
Even gestures of visceral respect.
The prevention of thromboembolic complications (compression stockings, low molecular weight heparin, early mobilization)it is important.
Adjuvant treatments to surgeryare carried out, if indicated, one month (4 to 6 weeks) after the
surgery.

2- External pelvic radiotherapy:

TheIt
is done in the case of poor prognosis factors:
lymph node invasion,
invasion of more than 50% of the thickness of the myometrium, histoprognostic grade III or histology
unfavorable (serous or clear cells, or sarcomatous component),
mail from the collar.
ButIt is to sterilize the microscopic pelvic disease (essentially ganglionic), which is all the more
frequently that there are the aforementioned prognostic factors.
The volume processedunderstand therefore the operative site (central-pelvic region) and the drainage territories
ganglionic (iliac chains, promontory nodes, presacral nodes, obturator nodes).
In the case of pelvic and/or lumbar-aortic lymph node involvement, lumbar-aortic irradiation is
recommended.
The dose of irradiationIn these volumes, it is 45 Gy in 25 fractions and 5 weeks.

3- Postoperative vaginal brachytherapy:

TheIt is almost systematic; only the AI stages are exempt.
For stage IIB (with cervical involvement),a preoperative uterovaginal brachytherapy can be performed
often in low dose rate.
I am butto prevent vaginal recurrences (the most common).
High-dose-rate brachytherapy preferred at low back pressure due to better tolerance and
its ambulatory nature.
OIt is carried out either as exclusive adjuvant treatment for early stages, or possibly, in
supplement to external radiotherapy.

4- Chemotherapy:
TheIt is indicated in metastatic stages and sometimes in locally advanced stages (III and IVA).

B- Indications :
The indicationsmust take into account:
Age, general condition (heart, blood pressure, obesity, diabetes).
The extent of the intrauterine lesion, its location, its spread.
Risk of lymphatic invasion, frequent in cases of low-located cancer (around the isthmus and the endocervix).
Relapsesare frequently in the form of metastases (vaginal) but the evolution is long and gives a
false impression of benignity.
The basis of treatmentremains surgical but it has become common to add a curative therapy
uterine and vaginal to sterilize the lesion and prevent local vaginal recurrences.
TheIn case of invasion of the myometrium, radiation therapy should be administered.tqué, becauselymph node invasion

is proportionally related to this injury.

Indications related to the terrain:
Patient in good overall condition:
In this case, we would prefer a brachytherapy combined with total hysterectomy with lymphadenectomy.
and external
In the case of lymph node invasion or penetration of cancer in more than half of the thickness of the
myometrium, cobalt therapy must be implementedkilled.
Obese, hypertensive, diabetic patient:
 Thanks to the advances in anesthesia-resuscitation, surgery is rarely contraindicated but limited to
a simple total hysterectomy.
In case of surgical contraindication, we inseither physiotherapy or hormone therapy
palliative.
Cancer on total prolapse:
We will settle for performing a minimally invasive vaginal hysterectomy.
Cancer-related indications:
Stage I:
Poor prognosis (myometrial infiltration of more than 2/3, grade 3 histoprognostic): radiotherapy
external (45 grays), followed by a total hysterectomy with annexectomy without lymphadenectomy.
Extemporaneous study of the operative piece.
If myometrial infiltration is greater than 2/3: adjuvant radiotherapy, vaginal brachytherapy
of barrage (20 grays) 2 months later.
Good prognosis: grade 1 or 2 histoprognostic.
No infiltration of the myometrium or invasion ≤ 1/3 internal: total hysterectomy with
appendectomy and frozen section study of the surgical specimen.
If the degree of infiltration is confirmed: lymph node verification for some.
If the invasion of the myometrium is more significant: external radiotherapy, vaginal brachytherapy of
barrage (20 grays) 2 months later.
Stage II :
External radiotherapy (50 grays), then total hysterectomy with adnexectomy without lymphadenectomy.
Secondary blockage curiotherapy (20 grays).
Stage III :
External radiotherapy (50 grays).
Total hysterectomy with appendectomy without lymphadenectomy.
Secondary blockade brachytherapy (20 grays).
Stage IV:
External radiotherapy, hormone therapy.

IX- RESULTS :
The superiority of surgeryseems to be demonstrated.
One observes at:
Stage I: 70 to 95% survival at 5 years.
Stage II: 70% survival at 5 years.
Stage III: 40% survival at 5 years.
Stage IV: 9% survival at 5 years.
The relapsesappear quite quickly (2 to 3 years after the initial treatment).
Recurrences of the vaginal vaultare the most frequent.

X- SURVEILLANCE :
TheIt
is based on a quarterly clinical examination for the first year, biannually for 3 years, then annually.
It searches for a local recurrence (vaginal vault ++, suburethral region), locoregional (lymph node) or to
distance.
There are no indications for performing systematic complementary examinations to search for recurrences and/or
of metastases in the absence of warning signs.
 A pelvic ultrasound and a dosage of ACE are, however, frequently performed once a year during ...
the early years.
OFinally, this is a contraindication subsequent to a substitute hormonal treatment.

XI- SCREENING:
A screeningit is possible because there are precursors, atypical adenomatous hyperplasias of the endometrium,
which can be diagnosed and whose treatment improves the prognosis.
The cancer in situThe most elaborate form, and its limits with severe atypical hyperplasia are not easy.
to specify.
What screening can we offer?
Biopsy curettage and endometrial sampling using a Novak cannula:
They are theoretically interesting due to the importance of the harvested endometrium, but unrealistic and
unachievable in consultation.
It is therefore necessary to resort to less invasive endometrial sampling methods, and
profitable.
The samples are taken by:
Abrasion of the mucosa (brush endocyte / endoscan / Mimar helix).
Endocavitary depression (Cornier pipette).
Intrauterine washing at positive or negative pressure (Gravlee jet washer).
However, their profitability and distribution remain limited.
The test for progestins:
It allows for improving the profitability of this screening.
It involves administering a mild progestin for 8 days in the woman who has been menopausal for 2 years.
The anti-ostrogenic effect and the luteomimetic action are important.
The occurrence of a withdrawal hemorrhage or even bleeding upon stopping the treatment should lead to
consider the test as positive requiring an exploration of the uterine cavity.
The high rate of false negatives (around 15 to 20%) limits the usefulness of this test.
It can, however, be associated, in case of positivity, with an endovaginal ultrasound or a hysteroscopy.
in order to specify the appearance of the endometrium.
Its profitability is significantly higher.
Who offers this screening?
If screening is targeted at the at-risk population, the economic viability is certain, but 1 patent per 5.
will not benefit.
It therefore seems legitimate to consider mass screening in the postmenopausal period.
If the patent does not benefit from hormone treatment, it seems quite possible to associate tests with it.
progestin, an endometrial evaluation in case of positive test (transvaginal ultrasound, hysteroscopy with
endometrial sampling, curettage.
If the patent is undergoing hormone replacement therapy for menopause, the progestin test may not be necessary.
to be proposed.
In the presence of a risk area, an annual intrauterine sampling must be carried out. This can be
associated with a transvaginal ultrasound to specify the appearance of the endometrium and with a hysteroscopy if
there is an endometrium measuring more than 4 mm in thickness.
In the absence of any risk factors, an endometrial sampling should be performed every 3 years.
Screening should continue until the age of 70 (and even longer, if allowed by the license).