Download Malignant disease of the body of the uterus

MALIGNANT DISEASE OF THE BODY OF
THE UTERUS
Dr. Ahmed jasim
Ass.Prof.
MBChB-DOG-FICMS
COSULTANT OF GYN. & OBST.
UTERINE CANCER.
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Endometrial cancer may sometimes be referred
to as uterine cancer. However, different cancers
may develop not only from the endometrium
itself but also from other tissues of the uterus,
including cervical cancer, sarcoma of the
myometrium, and trophoblastic disease.
Corpus cancer accounts for 3% of cancer in
females.
 1.Endometrial carcinoma which arise from the
lining of the uterus.
 0r 2.Sarcoma arise from the stroma of
endometrium or from myometrium.
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ENDOMETRIAL CARCINOMA
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The incidence is at 60 years & more ,75% of
cases usually occur in the post menopausal
period
RISK FACTORS FOR ENDOMETRIAL CANCER
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high levels of estrogen
endometrial hyperplasia
obesity
hypertension
polycystic ovary syndrome[citation needed]
nulliparity (never having carried a pregnancy)
infertility (inability to become pregnant)
early menarche (onset of menstruation)
late menopause (cessation of menstruation)
endometrial polyps or other benign growths of the uterine lining
diabetes
Tamoxifen
high intake of animal fat[citation needed]
pelvic radiation therapy
breast cancer
ovarian cancer
heavy daily alcohol consumption (possibly a risk factor) [3]
FACTORS REDUCE RISK OF ENDOMETRIAL
CARCINOMA
oral contraception.
 progestogens.
 Smoking.
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PATHOLOGY
The histopathology of endometrial cancers is highly diverse. 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. This often appears on a background of endometrial
hyperplasia.
Lymphatic spread occurs later and is less frequent than in cases of cervical
carcinoma.
Remote metastases in lungs, bones or else-where are not common but occur more
often than with cervical carcinoma
CLINICAL PRESENTATION
Symptoms
1. The classic symptom is bleeding
 A. Post menopausal bleeding in 75-80 %.
 This symptom should be assumed to be caused by
carcinoma of endometrium until proved otherwise. Women
with post menopausal bleeding in women not taking
hormone replacement therapy has 10% risk of having a
genital tract cancer
 B. In premenopausal women may present as:
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* intermenstrual bleeding
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*menorrhagia.
 2. Watery or purulent vaginal discharge (blood stained).
 3. Pain is a late symptom and denotes extensive spread of
disease.
 4. Abnormal screening test.
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Signs
 A full general and systematic examination is
indicated.
 Enlarged lymph nodes in the groin or
supraclavicular fossa may be found.
 Breast should be palpated.
 Uterine enlargement can be palpated.
 Pelvic examination:
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Bleeding through cervix.
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Secondary metastasis in vagina, urethra.
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INVESTIGATIONS
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A Pap smear may be either normal or show abnormal cellular
changes.
Endometrial curettage is the traditional diagnostic method. Both
endometrial and endocervical material should be sampled.
If endometrial curettage does not yield sufficient diagnostic material,
a dilation and curettage (D&C) is necessary for diagnosing the
cancer.
Hysteroscopy allows the direct visualization of the uterine cavity and
can be used to detect the presence of lesions or tumours. It also
permits the doctor to obtain cell samples with minimal damage to the
endometrial lining (unlike blind D&C).
Endometrial biopsy or aspiration may assist the diagnosis.
Transvaginal ultrasound to evaluate the endometrial thickness in
women with postmenopausal bleeding is increasingly being used to
evaluate for endometrial cancer.
An endometrial thickness exceeding 4 to 5 mm
on ultrasound is suggestive of endometrial
pathology in such women.
 Sonohysterography:
 It may improve delineation of endometrial
polyps.
 both D&C and Pipelle biopsy curettage give 6570% positive predictive value. But most
important of these is hysteroscopy which gives
90-95% positive predictive value.
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Recently, a new method of testing has been
introduced called the TruTest, offered through
Gynecor. It uses the small flexible Tao Brush to
brush the entire lining of the uterus. This method
is less painful than a pipelle biopsy and has a
larger likelihood of procuring enough tissue for
testing. Since it is simpler and less invasive, the
TruTest can be performed as often, and at the
same time as, a routine Pap smear, thus allowing
for early detection and treatment
Magnetic resonance imaging (MRI):
 It is expensive and not practical to screen all
women.
 It used for evaluation of endometrial thickness
and to predict myometrial invasion.
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STAGING OF ENDOMETRIAL CANCER
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I: Confined to uterine corpus
 IA:
limited to endometrium
 IB: invades less than ½ of myometrium
 IC: invades more than ½ of myometrium
STAGING OF ENDOMETRIAL CANCER
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II: invades cervix but not beyond uterus
 IIA:
endocervical gland involvement only
 IIB: cervical stroma involvement
STAGING OF ENDOMETRIAL CANCER
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III: local and/or regional spread
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IIIA: invades serosa/adnexa, or positive cytology
IIIB: vaginal metastasis
IIIC: metastasis to pelvic or para-aortic lymph nodes
STAGING OF ENDOMETRIAL CANCER
IVA: invades bladder/bowel mucosa
 IVB: distant metastasis
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FIVE YEAR SURVIVAL
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Stage I: 81-91%
 72%
diagnosed at this stage
Stage II: 71-78%
 Stage III: 52-60%
 Stage IV: 14-17%
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 3%
diagnosed at this stage
SPREAD PATTERNS
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Direct extension
 most
common
Transtubal
 Lymphatic
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 Pelvic
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usually first, then para-aortic
Hematogenous
 Lung
most common
 Liver, brain, bone
TREATMENT
Stage IB or less: total hyst/BSO/PPALND,
cytology
 Stage IC to IIB: total hyst/BSO/PPALND,
cytology, adjuvant pelvic XRT
 Stage III: total hyst/BSO/PPALND, cytology,
adjuvant chemotherapy
 Stage IV: palliative XRT and chemotherapy
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METHODS OF ENDOMETRIAL CANCER
TREATMENT:
The treatment of endometrial carcinoma is
usually:
 * surgical.
 * Radiotherapy
 * Hormone therapy: Progestogens inhibit the
rate of growth and spread of endometrial
carcinoma.
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OTHER TYPES OF UTERINE CANCER
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Leiomyosarcoma
 Rapidly
growing fibroid should be evaluated
Stromal sarcoma
 Carcinosarcoma (MMMT)
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MMMT
leiomyosarcoma
UTERINE SARCOMAS
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Account for fewer than 10% of all corpus cancers.
Types:
( Carcinosarcoma, leiomyosarcoma, Endometrial stromal
sarcoma, adenosarcoma)
Exposure to radiation may enhance the development of pelvic
sarcomas
Abnormal vaginal bleeding most frequent presenting symptom
for all histologic types.
No specific staging system (commonly use staging of
endometrial carcinoma)
Management of Uterine Sarcomas:
Surgery is the hallmark of treatment with total abdominal
hysterectomy and bilateral salpingo-oopherectomy (TAH/BSO)
being the standard procedure.