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Endometrial Carcinoma Surgery India

Cancer happens when cells in your body go through changes that make them grow out of control. Cancer cells differ from normal cells in the ability to grow into — invade — the surrounding tissues. Cancer cells also have the ability to spread elsewhere in the body. When this happens, the cancer is said to have metastasized.

Endometrial carcinoma is a kind of cancer that begins in your uterus. Only women have a uterus. So only women can get this kind of cancer.
Carcinoma refers to cancer that begins in tissues that form linings throughout the body. The endometrium is the lining of the inside of the uterus. Endometrial carcinoma is a cancer that forms from the inner lining of the uterus. Other kinds of cancer can form in the uterus as well. These are called uterine sarcomas. Endometrial cancer usually takes years to develop. It most often occurs in women who have already gone through menopause.


Who Are The Common Patients Of Endometrial Carcinoma?

Majority of the women suffering from Endometrial Carcinoma manifest vaginal spotting or heavy bleeding. Most of them are on the menopausal or post-menopausal stage. Only 5% of the sufferers will be asymptomatic. This manifestation is usually hard to detect since it looks just like a normal menstrual period. One the other hand, vaginal bleeding happens in between periods among women above 40 years of age. Frequency, heaviness of the flow, and length are the bleeding characteristics being closely monitored to help diagnose any pre-malignant changes.


Endometrial Cancer Types

Adenocarcinoma, which originates in surface cells of the endometrium, accounts for approximately 90% of cases of endometrial cancer. Adenocarcinomas are more common during perimenopause (i.e., transitional years proceeding and following actual menopause) and usually are associated with an early onset of symptoms.
Other types of endometrial cancer include papillary serous carcinoma and clear cell carcinoma. These types usually develop in postmenopausal women and are more likely to metastasize (spread) and recur.


Risk Factors

Prolonged periods of unopposed oestrogen are the main risk factor. Unopposed oestrogen means when oestrogen is not modified by the effects of progesterone. 
This may occur as a result of medication or in anovulatory cycles where the corpus luteum does not mature and secrete progesterone. The histological diagnosis can be difficult in that gross endometrial hyperplasia can look like a well-differentiated carcinoma. Risk factors for endometrial carcinoma include:

  • Being nulliparous increases the risk 2- or 3-fold. This may be by choice or as a result of infertility with anovulatory cycles.

  • Menopause past the age of 52.

  • Obesity raises oestrogen levels:

  • Diabetes mellitus and hypertension also increase the risk but this may simply be linked to obesity.

  • Polycystic ovarian syndrome and (insulin resistance) metabolic syndrome are also associated with obesity.

  • The greater the obesity, the greater the risk.

  • Women who have hereditary nonpolyposis colon cancer (HNPCC) have a 22 to 50% chance of developing endometrial carcinoma and are likely to get it about 15 years earlier than other women. There is a lack of evidence to suggest benefit but annual endometrial biopsy after the age of 35 is suggested.

  • Exogenous hormones can have markedly different effects. The antioestrogenic or pro-oestrogenic effect of a synthetic hormone varies between tissues. For example, tamoxifen is used to treat breast cancer because it has an antioestrogen effect on breast tissue but it has a pro-oestrogen effect on bone, reducing the risk of osteoporosis and a pro-oestrogen effect on the endometrium, increasing the risk of endometrial carcinoma. Tamoxifen is associated with an increased risk of endometrial cancer that tends to be at a more advanced stage and with a less favourable histology. In the treatment of breast cancer, benefits outweigh risks but its use in prevention of the disease has been questioned.

  • Tibolone doubles the risk of endometrial carcinoma compared with those not on hormone replacement therapy (HRT).

Taking combined oral contraceptives reduces the risk of developing endometrial cancer in later life. Prolonged use increases the benefit that lasts for at least 15 years after stopping.


Diagnosis

Physical Examination

  • On a gynecologic examination, the external genitalia is usually normal. The cervix may be involved with cancer (Stage II), and the vagina may also be involved (Stage III).

  • Occasionally the uterus will be enlarged or softened and masses may be detected in the pelvis (a rectal examination is an important aspect of the pelvic examination).

  • Enlarged lymph nodes in the neck and groin.

  • Enlarged liver, abdominal mass or excessive abdominal fluid (ascites).


Blood and Other Tests

  • Complete blood count.

  • Serum liver and kidney tests.

  • Serum CA-125 is produced by a small percentage of women with endometrial carcinoma, usually advanced, which can be useful in follow up to detect recurrences.


Imaging

  • A uterine sonogram with thickened endometrial cavity may be suggestive of a uterine cancer.

  • CT scan of the abdomen and MRI scan of the pelvis may be useful for determining the extent of the cancer in the pelvis, the presence of ovarian disease and the presence of involved pelvic and aortic lymph nodes and liver metastases. It is usually performed for advanced cancer.

  • Chest x-ray.


Endoscopy and Biopsy

  • The definitive diagnosis is made on an endometrial biopsy, which involves a small scraping of the uterus and is usually performed in the doctor's office. A dilation and curettage (D&C) is required for some women-those who have biopsy-proven endometrial hyperplasia (see below), those who have an insufficient specimen on an office biopsy or who can't have an endometrial biopsy done in the office because of a small cervical opening or discomfort.


Signs and Symptoms

Luckily, the early stages of endometrial cancer can cause symptoms. When a post-menopausal woman has vaginal bleeding (present in 90% of women at the time of diagnosis with endometrial cancer), the first thing that needs to be looked into is the possibility of endometrial cancer. However, some of the other symptoms are occasionally non-specific, and don't always point toward a diagnosis of endometrial cancer. As a tumor grows in size, it can produce a variety of problems including:

  • Vaginal bleeding (in a post-menopausal woman)

  • Abnormal bleeding (including bleeding in between periods, or heavier/longer lasting menstrual bleeding)

  • Abnormal vaginal discharge (may be foul smelling)

  • Pelvic or back pain

  • Pain on urination

  • Pain on sexual intercourse

  • Blood in the stool or urine

All of these symptoms are non-specific, and could represent a variety of different conditions; however, your doctor needs to see you if you develop any of these problems.


Staging

Staging is a system for classifying cancers based on the extent of the disease. In general, the lower the cancer stage, the better the outlook for remission and survival. (Remission is when no evidence of cancer is found in the body.) Health-care providers cannot make recommendations for the best treatment until they know the exact stage of cancer.

In endometrial cancer, staging is based on how far the primary tumor has spread, if at all. The staging system used for endometrial cancer was developed by the International Federation of Gynecology and Obstetrics (FIGO). The staging system for endometrial cancer is a surgical staging system, meaning that staging is based on the pathologist's findings on examining organs removed during surgery. The FIGO system uses four stages.

  • Stage I - The tumor is limited to the corpus (upper part) of the uterus and has not spread to the surrounding lymph nodes or other organs.

  • Stage IA - Tumor limited to the endometrium or less than one half the myometrium

  • Stage IB - Invasion equal to or more than one half the myometrium (middle layer of the uterine wall)

  • Stage II - Invasion of the cervical stroma but does not extend beyond the uterus (strong supportive connective tissue of the cervix)

  • Stage IIIA - Invasion of the serosa (outermost layer of the myometrium) and/or the adnexa (the ovaries or fallopian tubes)

  • Stage IIIB - Invasion of the vagina and/or parametrial involvement

  • Stage IIIC1 - Cancer has spread to the pelvic lymph nodes but not to distant organs

  • Stage IIIC2 - Cancer has spread to the paraaortic lymph nodes with or without positive pelvic lymph nodes but not to distant organs

  • Stage IV - The cancer has spread to the inside (mucosa) of the bladder or the rectum (lower part of the large intestine) and/or to the inguinal lymph nodes and/or to the bones or distant organs outside the pelvis, such as the lungs.

  • Stage IVA - Tumor invasion of the bladder, the bowel mucosa, or both

  • Stage IVB - Metastasis to distant organs, including intra-abdominal metastasis, and/or inguinal lymph nodes

The tumor grade is also defined during the staging process. Grade indicates the aggressiveness of the cancer. Generally, low-grade tumors are less likely to metastasize or recur after treatment.


Endometrial Carcinoma Treatment

The treatment is chosen according to the category of cancer and the stage of the disease - your age, your overall state of health, whether you plan to have children, and other personal considerations. There are four basic types of treatment for women with endometrial cancer - surgery, radiation therapy, hormonal therapy and chemotherapy.


1. Surgery

Surgery to remove the uterus is recommended for most women with endometrial cancer. Most women with endometrial cancer undergo a procedure to remove the uterus (hysterectomy), as well as to remove the fallopian tubes and ovaries (salpingo-oophorectomy). A hysterectomy makes it impossible for you to have children in the future. Also, once your ovaries are removed, you'll experience menopause, if you haven't already.

During surgery, your surgeon will also inspect the areas around your uterus to look for signs that cancer has spread. Your surgeon may also remove lymph nodes for testing. This helps determine your cancer's stage.


2. Radiation Therapy

Radiation therapy uses powerful energy beams, such as X-rays, to kill cancer cells. In some instances, your doctor may recommend radiation to reduce your risk of a cancer recurrence after surgery. If you aren't healthy enough to undergo surgery, you may opt for radiation therapy only. In women with advanced endometrial cancer, radiation therapy may help control cancer-related pain.
Radiation therapy can involve:

  • Radiation from a machine outside your body - Called external beam radiation, during this procedure you lie on a table while a machine directs radiation to specific points on your body.

  • Radiation placed inside your body - Internal radiation, or brachytherapy, involves placing a radiation-filled device, such as small seeds, wires or a cylinder, inside your vagina for a short period of time.


3. Hormone Therapy 

Hormone therapy involves taking medications that affect hormone levels in the body. Hormone therapy may be an option if you have advanced endometrial cancer that has spread beyond the uterus. Options include:

  • Medications to increase the amount of progesterone in your body -Synthetic progestin, a form of the hormone progesterone, may help stop endometrial cancer cells from growing.

  • Medications to reduce the amount of estrogen in your body - Hormone therapy drugs can help lower the levels of estrogen in your body or make it difficult for your body to use the available estrogen. Endometrial cancer cells that rely on estrogen to help them grow may die in response to these medications.


4. Chemotherapy

Chemotherapy uses chemicals to kill cancer cells. You may receive one chemotherapy drug, or two or more drugs can be used in combination. You may receive chemotherapy drugs by pill (orally) or through your veins (intravenously). Chemotherapy may be an option for women with advanced endometrial cancer that has spread beyond the uterus. These drugs enter your bloodstream and then travel through your body, killing cancer cells.


Follow Up

Most recurrences will occur within the first 3 years after treatment, and 3 - to 4-montly evaluations with history, physical and gynecological examination are usually recommended. Follow-up intervals of 6 months are recommended during the fourth and fifth years, and annually thereafter. No impact on survival of a routine follow-up strategy has been demonstrated. However, since a significant number of relapses occur isolated in the vagina or pelvis, early detection and possibly curative treatment of these should be the main focus of follow-up. Routine technical examinations such as PAP smears or imaging studies are of unproven benefit.


Endometrial Cancer Treatment Options For Women Who Want to Have Children

Premenopausal women with low-risk endometrial cancer (stage I grade I) are sometimes able to postpone hysterectomy until after having a child.
Before trying to get pregnant, you would be treated with a hormone, progestin, to suppress the endometrial cancer. Talk to your doctor to find out if postponing surgery is an option.

After you are finished having children, most experts recommend surgical removal of the uterus, cervix, fallopian tubes, and ovaries. Otherwise, there is a significant risk that the cancer will come back later.

Women with greater than stage I grade I endometrial cancer should not postpone surgery to remove the uterus, cervix, ovaries, and fallopian tubes. This is because not having surgery could potentially allow the cancer to grow and spread beyond the uterus.

Alternate options for having a child — Unfortunately, it is not possible to become pregnant after the uterus and ovaries are removed. However, advances in infertility treatments may offer a way for you to have a biologically related child after this type of treatment.

One such treatment is called embryo cryopreservation. With this treatment, you would take fertility medications and have a procedure to collect your oocytes (eggs). The oocyte is then combined with sperm to create an embryo. The embryo is then frozen for use at a later time.

If you are interested in this treatment, your endometrial cancer surgery would need to be delayed for several weeks. In addition, you would need a woman to carry the pregnancy for you (a friend, relative, or a gestational carrier/surrogate). More detailed information is available separately.


Recurrent Endometrial Cancer

Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or bone). Treatment depends on the amount and location of the cancer. If the recurrent cancer is only in the pelvis, radiation therapy may provide a cure. Women with more extensive recurrences are treated like those with stage IV endometrial cancer. Either hormone therapy or chemotherapy is recommended. Low-grade cancers containing progesterone receptors are more likely to respond well to hormone therapy. Higher-grade cancers and those without detectable receptors are unlikely to shrink during hormone therapy, but may respond to chemotherapy. Clinical trials of new treatments are another option.

If patients have other medical conditions that make them unable to have surgery, radiation therapy alone or combined with hormonal therapy is generally used. The outlook for these patients is not as good as those who are able to have surgery.


Why India?

India has tens of thousands of skilled physicians and nurse practitioners for the Endometrial Carcinoma treatment. Over the last two decades, the economic boom in India has led to the building of medical facilities & infrastructure that rival the very best that western medical care in the west has to offer. Many of the physicians that practice in these hospitals and clinics have returned (to India) from the U.S. and Europe, leaving behind successful practices. While some small countries may be viable as alternatives for minor surgical procedures, India is the only mainstream option that offers a comprehensive solution for any and all medical needs and does this with the highest levels of service, facilities and professional skills.

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