Download CARCINOMA OF THE ENDOMETRIUM

Gynaecologische Tumoren:
Internationale richtlijnen en Nieuwe
perspectieven in
diagnostiek en behandeling
SYMPOSIUM ONCOLOGIE – 7 JUNI 2008
• Philippe Van Trappen, MD PhD
• Gynaecologie/Oncologie
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Venous Spread
This pathway might account for the
occasional appearance of a low vaginal
metastasis; but venous spread is not a
common feature of uterine cancer.
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Lymphatic Spread
The incidence of this (it is much debated)
seems to be somewhere between 10 and
30%. All pelvic nodes, including the internal
iliacs, the parametrium, the ovaries, and
the vagina may be involved, probably with
equal frequency. Lymphatic spread is more
likely to occur when the tumour is
anaplastic and the uterine wall is deeply
invaded.
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Tubal Spread
Malignant cells can pass along the
tube in the same way that peritoneal
spill may occur during menstruation.
This may account for isolated ovarian
metastases.
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2003-10-27
Carcinoma of the Endometrium
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2003-10-27
Carcinoma of the Endometrium
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Cancers of the Uterine Corpus:
Histologic Types
• Carcinoma (94%)
Endometrioid (87%)
Adenosquamous (4%)
Papillary Serous* (3%)
Clear Cell* (2%)
Mucinous (1%)
Other (3%)
• Sarcoma (6%)
Carcinosarcoma* (60%)
Leiomyosarcoma* (30%)
Endometrial Stromal Sarcoma (10%)
Adenosarcoma (<1%)
*poor prognosis
histology
Endometrial Cancer:
Type I/II Concept
• Type I
Estrogen Related
Younger and heavier patients
Low grade
Background of Hyperplasia
Perimenopausal
Exogenous estrogen
• Type II (~10% of total cases)
Aggressive
High grade
Unfavorable Histology
Unrelated to estrogen stimulation
Occurs in older & thinner women
• Familial/genetic (~15% of total cases)
Lynch II syndrome/HNPCC
Familial trend
Endometrial Cancer –
diagnosis & assessment
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Endometrial biopsy
– outpatient sampling (pipelle aspirate)
– hysteroscopy and curettage
Ultrasound: thickened endometrium/abnormal areas within cavity
or wall of womb
Doppler demonstration of abnormal endometrial vascularity
MRI:
imaging of pelvic/paraaortic lymph nodes and myometrial
invasion
PET-CT
(high sensitivity in detecting distant metastases;
high NPV in predicting LN metastases)
Park et al, 2008, Gynecol Oncol
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• IA: Tumor limited to endometrium
• IB: Invasion to no more than half the myometrial
thickness.
• IC: Invasion to more than half the myometrial thickness
• IIA: Invasion to the mucosa of the cervix.
• IIB: Invasion to cervical stroma.
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IIIA: Tumor invades serosa and/or adnexa,and/or positive
peritoneal
cytology
IIIB: Vaginal metastases
IIIC: Metastases to pelvic and/or para-aortic lymph nodes.
IVA Tumor invasion of bladder and/or bowel mucosa.
IVB: Distant metastases including intra-abdominal metastases
and/or inguinal lymph nodes.
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Endometrial Cancer: Intra-operative
Surgical Principals
• Availability of frozen section to determine the
extent of staging procedure.
• Capability of complete surgical staging
• Capability of tumor reduction if indicated
Endometrial Cancer: Nodal Involvement
Situation
G1, inner 1/3 myometrial
invasion, no extrauterine
disease.
G2 or G3, inner 1/3 invasion,
no extrauterine disease
G3 with outer 1/3 invasion,
and/or extrauterine disease
% Positive Nodes
<1%
5-9% Pelvic
4% Aortic
20-60% Pelvic
10-30% Aortic
Endometrial Cancer 1.treatment
• Usually surgical
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Simple hysterectomy
(Laparoscopic)
and removal of tubes/ovaries only for
well differentiated stage Ia ~ 70%
Stage Ib/Ic, mod/poorly differentiated and poor prognostic
types also require
pelvic/paraaortic lymph node sampling
(FIGO, ACOG)
Uterine Serous Papillary Carcinoma (USPC):
staging like ovarian cancer
Stage II
- radical hysterectomy or simple hysterectomy + RT
Stage III/IV
- cytoreductive surgery (>palliative for bleeding, bladder and
bowel involvement)
Carcinoma of the Endometrium
Primary2003-10-27
radiotherapy is rarely used
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Uterine Cancer: Pre-op Evaluation
•Transvaginal U/S?
•CT Scan?
•MRI?
Endometrial Cancer: Surgical Approach
• TAH-BSO/washings only
– Endometrioid*
– Grades 1 and < 50% myometrial invasion*
– or Grade 2 and no or minimal invasion
and < 2 cm tumor diameter*
*Verified via frozen section
Endometrial Cancer: Surgical Approach
• Complete Surgical Staging*
– All Grade 3
– Any > 50% myometrial invasion
– Any >2 cm tumor diameter
– All Serous/clear cell subtype**
– Pre operative assessment of advanced
disease (gross cervical or vaginal dz, etc)
*TAH-BSO, washings, lymphadenectomy
**omental/peritoneal biopsy
Laparoscopic Staging:
Magrina JF, Weaver AL. Laparoscopic treatment of endometrial cancer:
five-year recurrence and survival rates. Eur J Gynaecol Oncol.
2004;25(4):439-41.
Holub Z, Jabor A, Bartos P, Eim J, Urbanek S, Pivovarnikova R.
Laparoscopic surgery for endometrial cancer: long-term results of a
multicentric study. Eur J Gynaecol Oncol. 2002;23(4):305-10.
GOG LAP2 Protocol: Randomized study of Total
Hysterectomy, BSO and Staging via Laparotomy vs.
Laparoscopy- study still open
• Previous studies show:
Similar blood loss
Same incidence of complications
Low incidence of conversion of laparoscopy to laparotomy
Longer operative times for laparoscopy (160 min vs. 115min)
Shorter hospital stay (4 vs 7 days) for laparoscopy
No difference in recurrence risk.
PROGNOSIS OF ENDOMETRIAL CARCINOMA
With the exception of stage 1 tumors
of histological grades I and II, the
prognosis is less favourable than
many gyaecologists believe，with an
overall 5 year survival of 70％
approximately．Fortunately over 80
％of cases are dagnosed at stage 1．
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Stage
I
II
III
IV
5 year survival
85%
68%
42%
22%
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