Malignant Disease of the Body of the Uterus - PowerPoint Presentation

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Malignant Disease of the Body of the Uterus

Prof.

Dr.Esraa

AL-

Maini

5

th

year –

Gynecology

2019-2020

Endometrial canceris now the most common gynecological malignancy worldwide

Fourth most common female cancer

Account for approximately 30 %of all gynecological malignancies .

The mean age of diagnosis is 62 year

The incidence of endometrial cancer rises sharply in the mid 40s

25%occure before menopause

Classification

A-

Arising from

endometrium

1-

Adenocarcinoma

,

the most common type of cancer affecting the uterus is there are two distinct types:

A-

Endometrioid

adenocarcinoma

(type 1) account for 90 per cent ,

are

oestrogen

dependent,

occur in younger women and have a good prognosis

B- Papillary serous carcinoma

(type 2).

occur in elderly women, are non-

oestrogen

dependent and have a much poorer prognosis

2-

Clear cell carcinoma

can rarely arise from the

endometrium

.

B

-

Arise from the

stroma

or

myometrium

sarcoma

Factors Reducing Incidence of Endometrial Cancer:

-Use of the oral contraceptive pill

- progesterone only pill and progesterone injection

-Smoking

-pregnancy

-

Hystrectomy

for patients with lynch syndrome

-IUCD

Mirena

Risk factors for endometrial cancer

clear association with high circulating levels of

oestrogen

; many of the known risk factors relate to high

oestrogen

levels:

-Obesity

-Diabetes

-

Nulliparous

-Late menopause >52 years

-Unopposed

oestrogen

therapy

-

Tamoxifen

therapy

Tamoxifen

, a selective

oestrogen

receptor modulator (SERM) .

-Hormone replacement therapy

-Family history of colorectal or ovarian cancer . The most common genetic link is with hereditary

non­polyposis

colorectal cancer s.

Clinical features:

1-The most common symptom of endometrial cancer is

abnormal vaginal bleeding

90 %

post-menopausal bleeding (PMB -red flag )10% of women with PMB will have a gynecological malignancy.

Common symptoms in pre-menopausal women include

intermenstrual

bleeding (IMB), blood-stained vaginal discharge, heavy menstrual bleeding (HMB), lower abdominal pain or

dyspareunia

.

2- endometrial cancer can be diagnosed by the presence of

abnormal glandular cytology

at the time of a cervical smear.

3-In advanced cancer, patients may present with evidence

metastases

anc

endometrial carcinoma

Diagnosis

The mainstays of diagnosis are

-

Transvaginal

ultrasound scanning; endometrial thickness of less than 4 mm, cancer is very unlikely, any measurement more than this will require further assessment.

-Endometrial biopsy by the

Pipelle

or by Dilatation & curettage

-Hysteroscopy directed biopsy

-MRI is often performed: (for staging) and helps to decide on the type of surgical treatment

Vaginal ultrasound

FIGO staging of carcinoma of the uterus

Although this is a surgical classification, MRI may be offered

1

Confined to uterine body

1a Less than 50% invasion

1b More than 50% invasion

2

Tumour

invading cervical

stroma

3

Local and or regional spread of

3a Invades

serosa

of uterus

3b Invades vagina and/or

parametrium

3c Metastases to pelvic and/or

para

aortic LN

4

Tumour

invades bladder ± bowel

ManagementSurgery is the recommended treatment

1-Total hysterectomy, bilateral

salpingo-ophorectomy

.

Stage I (grades 1-2

) (3 Grade

the higher grade is more aggressive).

MRI staging suggests disease less than stage 1B

then this surgery is adequate.

This can be performed abdominally or

laparoscopically

(total, vaginally assisted or robotically).

2-Radiotherapy has been proven to be effective for patients that are not candidate for surgery whose disease limited to the uterus .

Gross involvement

of cervix or If MRI staging suggests cervical involvement

-Radical hysterectomy and

salpingo-ophorectomy

with

pelvic wash for cytology with

Pelvic and

para

-aortic node dissection

I

f the tumor is high grade (grade 3) or papillary serous

as the risk of nodal disease

can be as high as 30% many center performed nodal dissection

Dissection remains controversial as not improve survival

-Radiation for inoperable patients

Adjuvant treatment

Radiotherapy

:

Postoperative radiotherapy

will reduce the local recurrence rate but not improve survival .

1- local radiotherapy to the vaginal vault given over a short period of time (high-dose radiotherapy, HDR)

2-

External beam radiotherapy

given for locally advanced disease stage in combination with HDR.

Risk classification for patients with endometrial cancer

Low risk

endometroid

cancer that confined to

endometrium

Intermediate risk stage 1A stage 1B and patients with stage II(invade

myometrium

and occult cervical

stromal

invasion )

High risk gross cervical involvement (stage II

lll

and IV regardless of grade) and papillary and clear cell type

Low risk adjuvent therapy is not recommended neither radiation nor chemotherapy

Intermediate risk may benefit from post operative radiotherapy

High risk recommended for all patients included radiation and chemotherapy

PrognosisThe overall five-year survival rate for endometrial cancer is 80 % depending on tumor type, stage and grade of tumor.

Adverse prognostic features for survival include:

advanced age >70 years, high BMI, grade 3 tumors, papillary serous or clear cell

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