Download Cervical, uterine and ovarian cancer

Endometrial and ovarian cancer
Uterine anatomy and tumor origins
Uterine cancer:
• Endometrium:
endometrial carcinoma
(type I and II)
• Myometrium: uterine
sarcoma
Cervical cancer:
• Cervix: squamous cell
carcinoma and rarely
adenocarcinoma of the
cervix
Epidemiology of uterine cancer
Epidemiology of uterine cancer
Epidemiology of endometrial cancer
• The most common uterine cancer
• Approximately 75% of patients are
menopausal
2 main categories of endometrial
cancer
• Endometrial cancer is divided into type I and type II, characterized
by distinct biologic and clinical behavior, with different causes
• Type I carcinomas account for approximately 85% of all EC and are
associated with a hyperestrogenic state and generally are lowgrade; histology: endometrioid carcinoma. Patients are usually
younger (65).
• Type II tumors are estrogen-independent and arise in the setting of
uterine atrophy and generally consist of poorly differentiated
tumors; histology: papillary serous carcinoma, clear cell carcinoma
and malignant mixed müllerian tumor. They represent
approximately 15% of all ECs. Type II patients are more often
multiparous, older (70), and less likely to be obese. More frequent
in blacks than whites.
• Molecular genetic studies over the past decade have shown that
the two tumor types evolve via distinct pathogenetic pathways
Risk factors
• For endometrioid uterine cancer the most important
risk factor is unbalanced or high estrogen levels
• Obesity is an important contributing factor, since
fatty tissue produces estrone (E1). (These patients
usually have metabolic syndrome.)
• Estrone is unbalanced by progesterone, since the
ovaries don’t produce enough progesterone in
menopausal or premenopausal women=> the
endometrial mucosa is always in the proliferative
stage=>hyperplasia->atypical hyperplasia -> cancer
Risk factors
• Late menopause (>52 yrs)
• Hormone replacement therapy with estrogen
only
• Similarly, Tamoxifen, used in the treatment of
breast cancer can cause endometrioid uterine
cancer, since it is an agonist on the uterine
mucosa (and antagonist on breast tissue)
Genetic risk factors
• hereditary nonpolyposis colorectal cancer
syndrome (HNPCC) or Lynch syndrome II
Reminder: Metabolic Syndrome
The metabolic syndrome is characterized by a group of
metabolic risk factors in one person. They include:
• Abdominal obesity (excessive fat tissue in and around
the abdomen)
• Atherogenic dyslipidemia (high triglycerides, low HDL
cholesterol and high LDL cholesterol — that foster
plaque buildups in artery walls)
• HBP
• Insulin resistance or glucose intolerance
• Prothrombotic state (e.g., high fibrinogen or
plasminogen activator inhibitor–1 in the blood)
• Proinflammatory state (e.g., elevated C-reactive
protein in the blood)
Routes of extension-Local spread
• myometrium, cervix, vagina, parametria,
bladder, rectum, ovaries
Lymphatic
spread
• Lymphatic spread
(regional lymph nodes):
-tumors in the uterine
fundus->directly to
paraaortic lymph nodes
-tumors from the middle
and lower part of the
uterus->internal and
external iliac lymph
nodes->paraaortic lymph
nodes
or to inguinal lymph nodes
Routes of extension
• Peritoneal
• Distant Metastases:
-lung, liver, bone
Symptoms of endometrial cancer
• Uterine bleeding or discharge
Metrorrhagia in menopause is probably
endometrial cancer, unless proven otherwise.
(can be cervical cancer to)
-this symptom is early=> the majority of cases
(70%) will be diagnosed with stage I disease
confined to the corpus, and these patients have
excellent survival
• Other symptoms due to compression to adjacent
organs or invasion (invasion of the parametria:
ureteral obstruction)
Diagnosis of endometrial cancer
• Gynecologic examination:
-bimanual examination: uterus has increased
volume
-rectal examination: extension to the parametria
-speculum examination: the cervix is usually
normal; it can detect cervical or vaginal
invasion
Reminder-Pelvic exam
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Step One–External Genital Exam
Purpose: Check for irritation, unusual discharge, cysts or genital warts and to make sure the
glands around the opening of vagina or urethra are not swollen or inflamed.
How it's Done: The area is both visually and manually examined.
Step Two–Internal Bimanual Exam
Purpose: Evaluate the size, shape and position of pelvic organs (uterus, ovaries and fallopian
tubes) and help detect abnormalities such as adhesions, tears, enlargements, cysts, tumors
or tenderness.
How it's Done: One or two gloved, lubricated fingers are placed in the vagina while pressing
on the lower abdomen with the other hand.
Step Three–Internal Rectovaginal Exam
Purpose: Evaluate the tissue in between the uterus and vagina and the ligaments that hold
the uterus in place. Check for rectal bleeding.
How it's Done: A gloved, lubricated finger is placed in the vagina and another in the rectum
while pressing on the lower abdomen.
Step Four–Internal Speculum Exam
Purpose: Examine vaginal walls and cervix for damage, sores, growths, inflammation or
unusual discharge. A Pap smear might be taken during this phase of the exam.
How it's Done: A speculum is gently inserted and opened to hold the walls of the vagina
apart.
Diagnosis of endometrial cancer
• Endometrial biopsy (outpatient);
• If biopsy not diagnostic => Dilation and
curettage=D&C (inpatient)
The establishment of the extension and general
work-up
• For all patients: chest radiography, CBC,
platelets, renal function
1. Tumor limited to the uterus=> additional
tests needed for surgery
-then the patient is operated and the disease
surgically staged
2. Suspected or proven extrauterine disease
=> CT/MRI of the pelvis + abdomen, +/cystoscopy, +/- rectoscopy if suspicion of
mucosal invasion
Treatment of endometrial cancer
• Tumor limited to the uterus and no cervical
involvement
a) Medically operable=> total hysterectomy and
bilateral salpingo-oophorectomy (TH+BSHO)
plus pelvic and para-aortic lymphadenectomy
b) Medically inoperable=> radiotherapy
Treatment of endometrial cancer
• Extrauterine disease
a) Preoperative radiotherapy followed by
surgery
b) Radiotherapy alone
Treatment of endometrial cancer
• In the presence of risk factors adjuvant
radiotherapy might be used after surgery
Non-malignant tumors: fibroids
Questions
• What are the symptoms of endometrial
cancer and at which age group is the most
common?
• How is the diagnosis of endometrial cancer
made?
Ovarian cancer
• The most lethal cancer from the tumors of the
female genitalia, because diagnosis is usually
late and spread occurs easily to the
peritoneum
Risk factors
I. Genetic:
-BRCA1/2
-Lynch 2 syndrome etc.
II. Reproductive
-early menarche
-late menopause
-nulliparity
Protective: oral contraceptives
III. Environmental
-obesity
-”industrialized” living
Histology
1. Epithelial tumors (90%)
-most frequent subtype: serous adenocarcinoma
2. Stromal tumors
3. Germinal tumors
Routes of spread
• Peritoneal
• Greater omentum
Routes of spread
• Invasion of adjacent structures (uterine
corpus, salpinx)
• Lymphatic: iliac and para-aortic lymph nodes
• Hematogenous: liver
Symptoms
• Abdominal: abdominal pain, dyspepsia,
bloating, increase in the perimeter of the
abdomen
• Pelvic: metrorrhagia, pollakiuria
• Thoracic: dyspnea (due to ascites or pleurisy)
• General: fatigue, weight loss
Diagnosis
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Pelvic exam
US or CT of the pelvis and abdomen
CA-125 tumor marker
Chest radiography
additional tests needed for surgery
Treatment
• SURGERY +/- CHEMOTHERAPY
• In some stage I patient: unilateral salpingooophorectomy for fertility preservation
• All other patients: “optimal
debulking”=“optimal cytoreduction”
=resection of all tumor tissue, if possible, or
leaving behind tumor tissue with a diameter
of less than 1 cm
Surgery has to include:
• total hysterectomy and bilateral salpingooophorectomy (TH+BSHO) plus pelvic and
para-aortic lymphadenectomy
• Omentectomy
• Resection of the peritoneal metastases, if
present
• Resection of involved organs
Adjuvant chemotherapy
• Intraperitoneal + IV
• IV only
Questions?
• What is the special kind of surgery done in
locally advanced ovarian cancer?