Download Bengin Tumour of Uterus

Malignant disease of the body of
the uterus
The most common malignant diseas
affecting the uterus is endometrial
carcinoma, which arises from the lining
of the uterus.
sarcomas also arise from the stroma of
the endometriu'm or from the
myometrium.
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introduction
Incidence
The incidence about age 45 years to about
55 years and remains at the same high
rate thereafter.
Etiology
The cause of endometrial carcinoma is unknown Many
of the factors are related to an increase in oestrogen
levels. excess oestrogen as the prime factor in the development
of endometrial cancer. The interaction
between oestrogen, insulin and insulin-like growth factor-may be
more important.
In the postmenopausal period, the majority
of circulating oestrogen is derived from aromatization
of peripheral androgens. This conversion takes place
principally in adipose tissue. In addition, postmenopausal
women with diabetes have increased oestrogen levels.women
with polycystic disease increase oestrogen level.
Increasing evidence suggests that it is
simplistic to view excess oestrogen as
the prime factor in the development
of endometrial cancer. The interaction
between oestrogen, insulin and insulin-like
growth factor-1 may be more important.
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risk factor
number of factors that increase the risk of
endometrial cancer are :
 Obesity.
 Impaired carbohydrate tolerance.
 Nulliparity
 Late menopause.
 Unopposed oestrogen therapy.
 Functioning ovarian tumours.
 Previous pelvic irradiation.
 Family history of carcinoma of breast, ovary.
women who use oral contraception or
progestogens have up to a 50 per cent
reduction in the incidence of endometrial
cancer and the protection lasts for many
years after stopping these drugs.
Cigarette smoking has also been
associated with the reduced risk of
endometrial cancer.
Pathology
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The commonest subtype of endometrial
carcinoma is called endometrioid because it
resembles the normal proliferative
endometrium.
Squamous metaplasia can occur within
adenocarcinomas and this can result in an
adenoacanthoma or an adenosquamous
carcinoma.
Papillary serous and clear cell carcinomas .
primary squamous cell carcinoma of the
endometrium is extremely rare.
uterus with adenocarcinoma of
the endometrium.
Clinical presentation
1-Most women with endometrial carcinoma will
present with postmenopausal bleeding.
2- a postmenopausal discharge, particularly a
bloodstained discharge.
3-premenopausal period, many women with
endometrial carcinoma will present with
intermenstrual bleeding.
4-one-third will present with heavy periods only.
Diagnosis
Traditionally, postmenopausal bleeding was investigated
by a dilatation and curettage. More recently,
however, diagnosis has shifted to the outpatient setting,
with the ultrasound determination of endometrial
thickness and outpatient sampling of the
endometrium using instruments such as a Pipelle
sampler in cases where the ultrasound suggests that
the endometrium is more than 5 mm thick. If the
sampler has been fully introduced into the uterus
and no malignant tissue is identified, the test can be
regarded as negative. Outpatient hysteroscopy may be
Undertaken.
Diagnosis

Ultrasound also allows the ovaries to be
imaged, as a number of patients with
postmenopausal bleeding will have
ovarian pathology. It is important to
advise women to return if the bleeding
recurs.
Staging
The FIGO classification and staging are
│
The carcinoma is confined to the corpus
II
The carcinoma has involved the corpus
and the cervix but has not extended
outside the uterus
III
The carcinoma has extended outside the
uterus but not outside the true pelvis
IV
The carcinoma has extended outside the
true pelvis or has obviously involved
the mucosa of the bladder or rectum
Bullous oedema as such does not permit a
case to be allotted to Stage IV
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Staging is usually by histopathology
postoperative.
Treatment
Surgery
The treatment of choice in patients with endometrial
carcinoma is total abdominal hysterectomy and
bilateral
salpingo-oophorectomy.
Most women with Stage IIdisease are not diagnosed
until after the hysterectomyhas been performed. In
such women, the prognosis is much the same as
for Stage 1.
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Radical hysterectomy and bilateral pelvic
lymphadenectomy with paraaortic node sampling
is only performed if the cervical spread is clearly
recognized before surgery. Even then,it is often
wiser to treat the patient with radiotherapy like a
cervical cancer
 Lymphadenectomy
has not achieved
an establishedplace in the treatment
of endometrial cancer only
samplingThe age, the obesity and the
high rate of co-morbidity in these
women detract further from the
widespread adoption of lymph
adenectomy in women with
endometrial cancer
Radiotherapy
indication
1- postoperative radiotherapy deep myometrial
invasion was regarded as an indication for this
adjuvant treatment.
2-recurrent disease. In this group of women, salvage
radiotherapy offers a 50 per cent cure rate.
3-the patient with more advanced disease, but surgery is not
usually the first line of treatment. Pelvic radiotherapy is
performed and then occasionally residual disease may
be removed surgically.
4- radiation to para-aortic nodal disease if there is lymphatic
spread.
Hormonal therapy
Progestogens
1-The only value of progestogens is in the
palliation of recurrent disease. Good
results are obtained rarely and only with
well-differentiated tumors containing
oestrogen receptors.
2-Women unfit for surgery.
Five-year survival for women
with endometrial cancer
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5-year survival (%)
Stage I
 Stage II
 Stage III
 Stage IV
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83
71
39
27
Leiomyosarcoma
Leiomyosarcoma arise in the uterine
muscle.
 aris by transformation ofa previously
benign fibromyoma(0.2per cent of fibro
ids).
 Sarcoma also occasionally arises in the
stroma of the endometrium -endometrial
stromal sarcoma.
pathology
Tumours of this group grow more rapidly and are softer
than fibromyomata. They may increase in size after the
menopause.by naked-eye inspection, the tumour may
be seen to have invaded the uterine wall or the capsule
of the fibromyoma, and the cut surface often shows
small haemorrhages and areas of degenerative softening.
Microscopically, they consist of spindle-shaped or
rounded cells, many of them pleomorphic, with little
stroma and primitive blood vessels. Histological diagnosis
of malignancy depends on the number of mitoses
per high-power field (HPF).
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Metastasis
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Distant metastasis via the bloodstream
and direct spread to adjacent structures
often occur.
DIAGNOSIS&TREATMENT
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These tumours occur in adults, who
usually complain of uterine bleeding.
Rapid growth of the tumour,with
increasing pain, may give rise to
suspicion of itsnature, but in many cases
the diagnosis is made only after the
tumour has been removed. In rare
cases, asarcoma may be slow growing,
and its nature discovered only when it
recurs after operation.
Sarcoma and mixed
mesodermal tumours of
the uterus
Mixed mesodermal tumours
This includes tumours that contain
heterologous mesenchymal elements. In
adults they often present as a large
fleshy mass protruding from the uterine
wall into the uterine cavity.
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Histological examination
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shows that it contains some elements
resembling sarcoma and others
resembling carcinoma, together with
bizarre components such as cartilage
and striped muscle.
CLINICAL PRESENTATION
. The patient complains of bleeding from
the uterus, and sometimes of pain.
Tumours of this type occasionally follow
uterine irradiation.
 Metastasis via the bloodstream is
common,as is local recurrence after
removal
 The prognosis is poor.
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Sarcoma botryoides (embryonal
rhabdomyosarcoma)is a variety of the
same type of tumour that is seen in
infants and young children.
Clinical presentation
 There is a bloodstained,watery
discharge and the vagina is found to
contain grape-like masses of soft
growth, usually arisingfrom the cervix.
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Local recurrence often follows removal,
and distant metastases occur.
Treatment
total hysterectomy and bilateral
salpingo-oophorectomy is performed,
followed by external radiotherapy.
radiotherapy must then be taken,
depending on the extent and nature of
the disease.
 The prognosis is poor,except for
leiomyosarcoma arising in a
fibromyoma.
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Treatment ofSarcoma botryoides
(embryonal rhabdomyosarcoma)
In children, as with many other forms of
malignant disease, the prognosis with
conventional treatment has been very
poor. The modern use of a combination
of external irradiation and chemotherapy
hasaltered the outlook
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