Uterine Cancers

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Uterine Cancers

• A. Alobaid, MBBS, FRCS(C), FACOG
• Consultant, Gynecologic Oncology
• Assistant professor, KSU
• Medical Director, Womens Specialized Hospital
• King Fahad Medical City

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Introduction

• 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

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Epidemiology

• The median age of adenocarcinoma of the uterine
  corpus is 61 years
• 20-25 of the patients will be diagnosed before
  the menopause

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Risk Factors

• Nulliparity
• Late menopause
• Obesity
• Anovulatory cycles, polycystic ovary syndrome
• Unopposed estrogen exposure
• Tamoxifen
• Diabetes mellitus, hypertension

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Risk Factors

• 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

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Tamoxifen

• 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

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Endometrial Hyperplasia

• 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

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Endometrial Hyperplasia
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Endometrial Hyperplasia

• 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

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Symptoms of Endometrial Cancer

• 90 of women have vaginal bleeding or discharge
  as their only presenting complaint
• Less than 5 of women diagnosed with endometrial
  cancer are asymptomatic

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Postmenopausal Bleeding
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Postmenopausal Bleeding

• 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

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Diagnosis

• 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 DCs
  and 5851 office biopsies showed that DC had a
  higher complication rate than office biopsy but
  that the adequacy of the specimens was comparable

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Diagnosis

• 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, 19945556-9

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Diagnosis

• 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)

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Pathology

• 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

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Pathology
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Prognostic Factors
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Treatment

• Exploratory lapratomy, peritoneal washing
  (cytology), total abdominal hysterectomy and
  bilateral salpingo-oopherectomy are the primary
  operative procedures for carcinoma of the
  endometrium

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Treatment
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Treatment

• 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

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Treatment

• 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

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Treatment

• 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

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Follow-up

• 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

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Recurrence

• 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

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Sarcomas

• 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.

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Classification

• These tumors arise either from the
  endometrium MMMT (carcinosarcoma) 50
  ESS 8-10
• Or from the myometrium LMS
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Sarcomas

• MMT (Mixed Mullerian tumors) also they are
  called carcinosarcomas
• Currently they are classifiedand and treated as
  poorly differentiated adenocarcinomas
• Outcome is generally poor

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Leiomyosarcomas (LMS)

• 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.

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Leiomyosarcomas (LMS)

• 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

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Endometrial Stromal Sarcomas

• 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.

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HG ESS

• In postmenopausal women.
• More aggressive behavior, frequent and early
  recurrence.
• 5 year survival is 25-55, median time to
  recurrence was 7 months

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Thank you