Uterine Cancers
A. Alobaid, MBBS, FRCS(C), FACOGConsultant, Gynecologic OncologyAssistant professor, KSUMedical Director, Women’s Specialized HospitalKing Fahad Medical City
Introduction
It is the most common malignancy of the female genital tract
2-3% of women will develop endometrial cancer during their lifetime
Endometrial cancer is a disease that occurs primarily in postmenopausal women
Epidemiology
The median age of adenocarcinoma of the uterine corpus is 61 years
20-25% of the patients will be diagnosed before the menopause
Risk Factors Nulliparity Late menopause Obesity Anovulatory cycles, polycystic ovary
syndrome Unopposed estrogen exposure Tamoxifen Diabetes mellitus, hypertension
Risk Factors
Women who used oral contraceptives at some time, had a 0.5 relative-risk of developing endometrial cancer compared with women who had never used oral contraceptives
Cigarette smoking apparently decreases the risk for development of endometrial cancer
Tamoxifen The relative risk of endometrial cancer in
women taking tamoxifen in the adjuvant setting was 2.2
Tamoxifen causes subepithelial stromal hypertrophy which cause the endometrial stripe to be thickened on sonography
Current consensus opinion recommends annual pap smears for women taking tamoxifen, and endometrial biopsy only for women with abnormal vaginal bleeding
Endometrial Hyperplasia
It represents a spectrum of morphologic and biologic alterations of the endometrial glands and stroma, ranging from an exaggerated physiologic state to carcinoma in situ
It results from protracted estrogen stimulation in the absence of progestin influence
Endometrial Hyperplasia
Endometrial Hyperplasia
The risk of endometrial hyperplasia progressing to carcinoma is related to the presence and severity of cytologic atypia
Progestin therapy is very effective in reversing endometrial hyperplasia without atypia but is less effective for endometrial hyperplasia with atypia
Symptoms of Endometrial Cancer
90% of women have vaginal bleeding or discharge as their only presenting complaint
Less than 5% of women diagnosed with endometrial cancer are asymptomatic
Postmenopausal Bleeding
Postmenopausal Bleeding
60-80% of patients with postmenopausal bleeding have endometrial atrophy
Only about 10% of the patients have endometrial cancer
The older the patient is, the greater the risk of cancer
Diagnosis Office endometrial aspiration is the first
step in evaluating a patient with abnormal uterine bleeding
The diagnostic accuracy of office-based endometrial biopsy is 98%
A critical review of 33 reports of 13,598 D&Cs and 5851 office biopsies showed that D&C had a higher complication rate than office biopsy but that the adequacy of the specimens was comparable
Diagnosis If the initial biopsy result is negative,
further evaluation is recommended in patients with persistent symptoms, due to the high risk (11%) of an existing lesion having been overlooked
Feldman S, gynecol Oncol, 1994;55:56-9
Diagnosis
Endometrial thickness of less than 4mm as measured by ultrasonography is highly suggestive of endometrial atrophy (sensitivity 96-98%, specificity 36-68%, false negative rate 0.2%)
Pathology There appear to be two different
pathogenetic types of endometrial cancer The most common type occur in younger
perimenopausal women with a history of exposure to unopposed estrogen
These estrogen-dependent tumors tend to be better differentiated and have a more favorable prognosis
The other type occur in older, thin women with no source of estrogen stimulation
Pathology
Prognostic Factors
Treatment
Exploratory lapratomy, peritoneal washing (cytology), total abdominal hysterectomy and bilateral salpingo-oopherectomy are the primary operative procedures for carcinoma of the endometrium
Treatment
Treatment
Patients with stage I grade 1 and 2 tumors without myometrial invasion (stages IA, G1, G2) have an excellent prognosis and require no postoperative therapy
Patients with stages IC or IA/IB G3 are given postoperative vaginal cuff irradiation
Treatment Patients with stage II are treated similar
to patients with cervical cancer, the options are: Wertheim radical hysterectomy with BSO, bilateral pelvic lymphadenectomy and selective aortic node dissection,
extrafascial TAHBSO followed by adjuvant whole pelvis radiation therapy,or with whole-pelvis radiation therapy, followed by TAHBSO and selective para-aortic lymphadenectomy
Treatment
Patients with stage III after a thorough surgical staging are treated with postoperative adjuvant pelvic radiation therapy
Patients with stage IV are usually most suitable for systemic hormonal therapy or chemotherapy and possible local radiation
Follow-up
Patients are followed up in the first two years every 3-4 months, thereafter the patients are followed every 6 months for the following three years
After 5 years of remission, the follow-up will be annual
Recurrence In the early stage disease treated by
surgery only, recurrences are usually local/pelvic
Local recurrences are preferably managed by radiation, surgery, or a combination of the two
Patients with non-localized recurrences are treated with hormonal therapy or chemotherapy
Sarcomas Sarcomas of the uterus are rare, and
carry a poor prognosis 2-6% of uterine cancers. The incidence appears to be changing,
increasing recently, part of this may be due to better recognition by pathologists.
Some of this increase, also, can be attributable to the greater use of pelvic radiation therapy.
Classification
These tumors arise either from the endometrium: MMMT (carcinosarcoma) = 50% ESS = 8-10%
Or from the myometrium: LMS = 40%
Sarcomas
MMT (Mixed Mullerian tumors): also they are called carcinosarcomas
Currently they are classifiedand and treated as poorly differentiated adenocarcinomas
Outcome is generally poor
Leiomyosarcomas (LMS) They arise from either the myomertrium
itself or the smooth muscle of the myometrial veins.
Most cases are diagnosed incidentally while performing surgery to fibroids
There is scant evidence in the literature to support the common teaching that rapid uterine enlargement heralds the onset of LMS.
Leiomyosarcomas (LMS)
Treatment is surgical The spread of LMS is hematogenous,
so most recurrences are in distant sites
Chemotherapy is reserved for patients with advanced or recurrent disease
The 3-year progression-free survival for stage I and II patients is 21-31%
Endometrial Stromal Sarcomas LG ESS in premenopausal women. progress slowly with an indolent
clinical course. long term survival is the role. 5 years survival is 80-100%, but
about 37-60% will eventually recur after a very long time.
HG ESSHG ESS
In postmenopausal women. More aggressive behavior,
frequent and early recurrence. 5 year survival is 25-55%, median
time to recurrence was 7 months
Thank you
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