Download 15-Uterine Cancers1

Uterine Cancers
A. Alobaid, MBBS, FRCS(C), FACOG
Consultant, Gynecologic Oncology
Assistant professor, KSU
Medical Director, Women’s Specialized
Hospital
King Fahad Medical City
Introduction
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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
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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
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Nulliparity
Late menopause
Obesity
Anovulatory cycles, polycystic ovary
syndrome
Unopposed estrogen exposure
Tamoxifen
Diabetes mellitus, hypertension
Risk Factors
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Exploratory lapratomy, peritoneal
washing (cytology), total abdominal
hysterectomy and bilateral salpingooopherectomy are the primary
operative procedures for carcinoma of
the endometrium
Treatment
Treatment
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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
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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
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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
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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
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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
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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
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These tumors arise either from the
endometrium:
MMMT (carcinosarcoma) = 50%
ESS = 8-10%
Or from the myometrium:
LMS = 40%
Sarcomas
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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)
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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)
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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
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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 ESS
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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