The risk of endometrial carcinoma is highest with the following histological pattern of endometrial hyperplasia: March 2007

Ans. C: Complex hyperplasia with atypia Simple hyperplasia progresses to cancer in 10-20% whereas atypical hyperplasia is a precursor of cancer in 60-70% of cases. Classification Most endometrial cancers are carcinomas (usually adenocarcinomas Endometrial carcinomas can be classified into two pathogenetic groups: Type I: These cancers occur most commonly in pre- and peri-menopausal women, often with a history of unopposed estrogen exposure and/or endometrial hyperplasia. They are often minimally invasive into the underlying uterine wall, are of the low-grade endometrioid type, and carry a good prognosis. Type II: These cancers occur in older, post-menopausal women, and are not associated with increased exposure to estrogen. They are typically of the high-grade endometrioid, papillary serous or clear cell types, and carry a generally poor prognosis Risk factors High levels of estrogen Endometrial hyperplasia Polycystic ovary syndrome Nulliparity Infeility Early menarche Late menopause Endometrial polyps or other benign growths of the uterine lining Tamoxifen Hyperplasia Pelvic radiation therapy Breast cancer Ovarian cancer Clinical evaluation A Pap smear may be either normal or show abnormal cellular changes. Endometrial curettage is the traditional diagnostic method. If endometrial curettage does not yield sufficient diagnostic material, a dilation and curettage (D and C) is necessary for diagnosing the cancer. Endometrial biopsy or aspiration may assist the diagnosis. Transvaginal ultrasound to evaluate the endometrial thickness in women with postmenopausal Pathology The most common finding is a well-differentiated endometrioid adenocarcinoma, which is composed of numerous, small, crowded glands with varying degrees of nuclear atypia, mitotic activity, and stratification. Fuher evaluation Colonoscopy is recommended due to the etiologic factors common to both endometrial cancer and colon cancer. Staging Endometrial carcinoma is surgically staged using the FIGO cancer staging system. i a. Stage IA: tumor is limited to the endometrium i b. Stage IB: invasion of less than half the myometrium i c. Stage IC: invasion of more than half the myometrium ii a. Stage IIA: endocervical glandular involvement only ii b. Stage IIB: cervical stromal invasion iii a.Stage IIIA: tumor invades serosa or adnexa, or malignant peritoneal cytology iii b.Stage IIIB: vaginal metastasis iii c. Stage IIIC: metastasis to pelvic or para-aoic lymph nodes iv a. Stage IVA: invasion of the bladder or bowel iv b.Stage IVB: distant metastasis, including intraabdominal or inguinal lymph nodes Treatment Abdominal hysterectomy is recommended over vaginal hysterectomy because it affords the oppounity to examine and obtain washings of the abdominal cavity to detect any fuher evidence of cancer.