BENIGN DISEASES OF THE UTERUS - PowerPoint Presentation

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BENIGN DISEASES OF THE UTERUS ENDOMETRIAL CANCERPMB

Dr. A.M.ABDULMALEK MB.BCH,DGO,JBOG,FICS,FRCOG.Senior consultant OB&GYN /Head of Dept. Specialty hospital , Amman

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Postmenopausal BleedingDefinitionPMB is defined as

vaginal bleeding occurring after twelve months of amenorrhoea, in a woman of the age where the menopause can be expected.Unscheduled bleeding in women of menopausal age taking hormone replacement therapy (HRT) should be managed in the same way .Epidemiologyrepresents 5% of all gynaecology outpatient attendances.

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AetiologyVaginal atrophy. The most common cause of PMB.Use of HRT.Endometrial hyperplasia; simple, complex, and atypical.Endometrial cancer.

Endometrial polyps or cervical polyps.Cervical cancer; Uterine sarcoma (rare).Ovarian cancer, especially oestrogen-secreting Vaginal cancer (very uncommon).Vulval cancer may bleed, but the lesion should be obvious.Non-gynaecological causes including trauma or a bleeding disorder

.

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ManagementPMB should be treated as malignant, until proved otherwise.Investigations

Transvaginal ultrasound scan (TVUS)the thicker the endometrium, the higher the likelihood of important pathology.The threshold in the UK and the USA is 5 mm.

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Endometrial biopsyA definitive diagnosis in PMB is made by histology. Hysteroscopy

Hysteroscopy and biopsy (curettage) are the preferred diagnosticCautionMost women with PMB will not have significant pathology but the dictum remains that postmenopausal bleeding is cancer until proved otherwise.PMB in women on HRT still needs investigation.atrophic vaginitis does not exclude another lesion.Many women are unable to distinguish between vaginal and urinary bleeding and some are unable to distinguish rectal bleeding.Women with breast cancer who take

tamoxifen

on a long-term basis are at increased risk of endometrial cancer.

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Endometrial cancerRisk factors for endometrial

cancerOestrogen exposure.Unopposed oestrogen-only HRT.Tamoxifen use Low parity or infertility.Early menarche and late menopause.Increasing age.

Polycystic ovarian disease.

Hereditary non-polyposis colorectal carcinoma.

Obesity combined with diabetes.

Hypertension.

Protective factors for endometrial cancer

Use of combined oral contraceptives decreases risk.

Grand

multiparity

.

Cigarette smoking

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Endometrial cancer is the most common female genital cancer in the developed world, with adenocarcinoma of the endometrium the most common type. United States, 2.8%

Mortality is higher in black women (8.3 deaths per 100,000) than in white women (4.3 deaths per 100,000). Asian/Pacific Islander women have the lowest mortality (2.9% deaths per 100,000) among all races.Endometrial adenocarcinoma occurs during the reproductive and menopausal years. The median age of women with this malignancy is 62 years; most patients are aged 55-64 years. Signs and symptoms75% are postmenopausal. Thus, the most common symptom is

postmenopausal bleeding

.

the

25%

of endometrial cancers in patients who are

perimenopausal

or premenopausal,

Heavy

, frequent menstrual periods or

intermenstrual

bleeding.

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DiagnosisPelvic exam: Findings may be normal, with no gross evidence of cervical disease and with a normal-sized uterus, because bleeding usually occurs from the endometrium

Labs: Pregnancy must be excludedImaging: Pelvic ultrasoundEndometrial sampling39

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The following procedures are used to determine the status of the endometrium:Endometrial biopsy

Hysteroscopically directed biopsyDilatation and curettageExamination with the patient under anesthesia: May be necessary in patients who are bleeding and have a cervical os that is very

stenotic

; anesthesia may be required to perform adequate dilatation for endometrial sampling

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Treatment & ManagementStandard management of endometrial cancer at diagnosis involves surgery, followed by chemotherapy and/or

radiation therapy.Recurrent disease, secondary cytoreduction has been associated with progression-free (PFS) and overall (OS) survival. Lymph node metastasis is an important concern in patients with high-risk early or advanced endometrial cancer.

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Treatment of endometrial cancer is dependent on the stage of the disease and the patient’s surgical candidacy. Surgical interventionTotal hysterectomyBilateral

salpingo-oophorectomyPeritoneal cytologyPelvic and para-aortic lymphadenectomyPharmacotherapyChemotherapeutic medications

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StagingThe International Federation of Gynecology and Obstetrics (FIGO), 2008 staging system for carcinoma of corpus uteri is as follows :Stage IA* - No or less than half

myometrial invasionStage IB* - Invasion equal to or more than half of the myometriumStage II* - Tumor invades cervical stroma but does not extend beyond the uterus**

Stage III

- Local and/or regional spread of the tumor

Stage IIIA

* - Tumor invades the serosa of the corpus uteri and/or adnexa†

Stage IIIB

* - Vaginal metastasis and/or

parametrial

involvement†

Stage IIIC

* - Metastases to pelvic and/or

para

-aortic lymph nodes

Stage IIIC1

* - Positive pelvic nodes

Stage IIIC2

* - Positive

para

-aortic lymph nodes with or without positive pelvic nodes

Stage IV

* - Tumor invasion of bladder and/or bowel mucosa and/or distant metastases

Stage IVA

* - Tumor invasion of bladder and/or bowel mucosa

Stage IVB

* - Distant metastases, including intra-abdominal and/or inguinal lymph node

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StagingThe following two major staging systems are commonly used in endometrial cancer:The International Federation of Gynecology and Obstetrics (FIGO) system, developed in collaboration with the World Health Organization (WHO)

The TNM system, developed by the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC)44

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Primary tumor (T)

TNM

FIGO stages

Surgical-pathologic findings

TX

 

Primary tumor cannot be assessed

T0

 

No evidence of primary tumor

T1

I

Tumor confined to uterus

T1a

IA

Tumor ≤5 cm

T1b

IB

Tumor >5 cm

T2a

IIA

Tumor extends to the pelvis, adnexal involvement

T2b

IIB

Tumor extends to extra-uterine pelvic tissue

T3a

IIIA

Tumor invades abdominal tissues, one site

T3b

IIIB

Tumor invades more than one site

T4

IVA

Tumor invades bladder and/or rectum

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Regional lymph nodes (N)

TNM

FIGO stages

Surgical-pathologic findings

NX

 

Regional lymph nodes cannot be assessed

N0

 

No regional lymph node metastasis

N1

IIIC

Metastasis to pelvic and/or

para

-aortic lymph nodes

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Distant metastasis (M)

TNM

FIGO stages

Surgical-pathologic findings

M0

 

No distant metastasis

M1

IVB

Distant metastasis

Positive cytology is an adverse risk factor. Although peritoneal cytology results do not affect staging, FIGO and AJCC continue to recommend that peritoneal cytology be obtained and reported.

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Treatment of Advanced DiseaseCombination chemotherapy and radiation therapy should be considered before a single-modality treatment

For treatment of metastatic disease, hormonal therapy with progestational agents may be considered; tamoxifen and aromatase inhibitors are also acceptableNational Comprehensive Cancer Network (NCCN) guidelines for relapse or metastatic disease are as follows

:

Hormone therapy followed by chemotherapy on progression for low-grade

metastases

Chemotherapy and palliative radiation therapy for symptomatic, high-grade, or large-volume

metastases

Persistent progression should be treated with best supportive care and enrollment in a clinical trial

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Prognosis Prognostic factors :

Histopathologic subtypesHistologic differentiationMyometrial invasionPeritoneal cytologyLymph node metastasis

Again, a correlation among multiple prognostic factors has been shown to be present. Patients with poorly differentiated cancers, papillary serous and clear cell carcinomas, deep

myometrial

invasion, positive peritoneal cytology, or adnexal metastasis tend to have an increased risk of having lymph node metastasis

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ComplicationsComplications that may occur from therapy include complications that are normally expected from the surgical procedure itself. Because a lymphadenectomy is performed, increased bleeding could develop.

Postoperative complications can be expected, depending on the preoperative clinical condition of the patient. One postoperative complication that may be somewhat more common is thromboembolism because this is increased in patients who have cancer, are obese, and are older.

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SurveillanceFollowing surgical treatment, patients should receive a pelvic exam every 3-4 months for the first 2-3 years, then every 6 months until year 5 to monitor for recurrent disease. PET/CT is preferable over CT alone for assessment of suspected recurrence.

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