Endometrial Cancer. Part 6
These adenocarcinomas tend to me all lumped together, everything is graded on the adeno component, whether there is a benign squamous or a malignant squamous involved. Papillary serous adenocarcinoma is a variant and is not related to the garden variety adenocarcinoma, it’s not related to over estrogen production, and it can occur in skinny, young, thin patient’s, they have their first episode of postmenopausal bleeding, you open them up and they have a very typical spread pattern of ovarian cancer. It does not behave like the run of the mill adenocarcinoma, it has a much worse prognosis, fortunately, it is not as common as the run of the mill adenocarcinoma, and again, clear cell carcinoma is a variant of adenocarcinoma and again, carries a worse prognosis. If we look at the different cell types, this is the cell type of adenocarcinoma, the garden variety, it’s swollen glands back to back, papillary serous has a different type of pattern and has like a serous papillary growth pattern.
Survival based on your histiologic cell type, if you have one of the adenocarcinomas, your survival is very good, depending on the tumor differentiation, so if you have a well differentiated adenocarcinoma you are going to do very well, if you have a grade III adenocarcinoma you are going to do far better than if you have papillary serous or clear cell carcinoma. These are variants of endometrial cancer and really don’t follow the lymph node metastases and other problems that we see with advanced adenocarcinoma of the endometrium. They behave uniquely and they behave very similar to ovarian cancers. As I eluded to before, as the tumor loses differentiation, the survival rate directly goes down and there are several reasons for that. Here is a nice, well differentiated cancer, you can tell if you look at that, you would say it almost looks like normal endometrium, it’s a little crowded but it’s probably going to behave pretty much like a normal endometrium, it probably has estrogen and progesterone receptors and this is probably a cancer that you would ordinarily see in somebody who is morbidly obese, you’re uterine specimen is very small, has very superficial myometrial invasion., and this again is aggressive, ugly, it’s going to infiltrate, it’s going to have your uterus enlarge, it’s going to be infiltrating deeply into the myometrium and into the myometrium there are several lymphatics and once it’s in the lymphatics, it can spread to the pelvis, the periaorta and out toward the adnexa and into the peritoneal cavity.
So as the tumor loses differentiation, so does it gain access into the aortic lymph nodes, the higher the grade, the higher the incidence of lymph metastases and the reason for that is, if you have myometrial invasion, if it’s deep myometrial invasion that’s your highest risk for lymph node metastases because the lymphatics are in the myometrial wall, and if you have a tumor that’s deeply invasive into the myometrium, it’s going to gain access into your lymphatic system. If you have a tumor that is confined to the endometrium, your chance of having aortic and lymph node metastases is about zero, if you have deep myometrial invasion, this is going to be a tumor that most likely if you look hard enough and do a more thorough dissection, you are going to find metastases. The survival directly goes down with the amount of myometrial invasion.