MALIGNANT DISEASES OF THE UTERUS

1. MALIGNANT DISEASES OF THE UTERUS DR. SAHAR ALTAI M . B. Ch .B , D. G. O , MSc (ART)

2. Adenocarcinoma is a common pelvic genital cancer in women In the US the life time risk of developing endometrial Ca is 2.4% in white women & 1.3% in black It is a disease of postmenopausal women with a peak incidence in the 6th & 7th decade of life Only 2-5% occur before 40 years Prognosis is better than other Gynecological Ca due to early Dx ---75% Dx Stage I Estrogen has been implicated as a causative factorbeen implicated as a causative factor

3. The most common type of cancer affecting the uterus is adenocarcinoma , this arise from the lining (endometrium) of the uterus. There are 2 distinct types of: 1. Endometrioidadenocarcinoma (type 1): 90% ,oestrogen dependent, occur in younger women than type 2and have a good prognosis. 2. Serous papillary carcinoma(type 2): 10% , non oestrogen dependent , occur in elderly women and have a much poorer prognosis)

4. Endometrioidadenocarcinoma Serous papillary adenocarcinoma

5. Risk Factors For Endometrial Cancer • 1. Age 65-75 Y , only 2-5% < 40 Y • 2.Excessive endogenous / exogenous estrogens -Early menarche < 12 Y - Late menopause > 52 Y  2 X risk 3. Nulliparity 2X > women with 1 child / 3X > women with ≥5 4. Chronic anovulation as in PCO 5. Obesity  aromatization of adrenal androgens in fat tissue risk is 3X for Pt 21-50 pounds overweight 10 X for Pt > 50 P overweight 6. Granulosa-thicka cell tumors of the ovary (a rare estrogen secreting ovarian tumor)  endometrial hyperplasia & Ca in 10% of Pt 7. Cirrhosis of the liver  degradation of estrogen 8. Endometrial hyperplasia

6. 9. Unopposed estrogen therapy in postmenopausal women  risk of E Ca 6-8 X • Tamoxifen  an anti-estrogen used in the Rx of breast Ca  has weak estrogenic activity on the genital tract 2 X  risk of E Ca when used ≥ 5 Y • 10.  risk in women with breast, ovarian (endometrial type) & colorectal Ca • 11. Diabetes  3X  risk • 12. Hypertension • 13. Previous pelvic radiation therapy • 14. Family Hx of endometrial Ca

7. PRESENTATION OF ENDOMETRIAL CA • Abnormal vaginal bleeding  most common 90% • Premenopausal Pt  usually heavy flow at the time of menses may present with  persistent intermenstrual bleeding  pre or post menstrual spotting  polymenorrhea that fails to respond to hormonal Rx • Postmenopausal bleeding is the most common type of abnormal bleeding  12-15% due to E Ca  5-8% due to other cancers like uterine sarcoma, ovarian Ca, Cx, tubal or vaginal Ca • Postmenopausal Pt  commonly c/o intermittent spotting • Postmenopausal vaginal discharge 10%

8. Asymptomatic women with glandular abnormalities on routine PAP smear/ abnormalities found in 50% of Pt with E Ca • Advanced disease  symptoms due to local or distant metastases • Sever cramps due to hematometra or pyometra  occur in postmenopausal Pt with Cxstenosis ----10%

9. INVESTIGATION • Any Pt with signs or symptoms suggestive of E Ca should be investigated • All Pt should have endometrial sampling in the clinic false -ve 10% • If continues to be symptomatic in spite of –ve biopsy or suspicious finding on biopsy  D&C • In the past the “gold standard” was D&C • The current “gold standard” is hystroscopy with targeted endometrial biopsy

10. As an alternative  endometrial sampling with a pipelle + transvaginal U/S to assess endometrial thickness, presence of endometrial polyp or ovarian masses • Endometrium < 5 mm in thickness  high –ve predictive value • U/S also helpful in assessing the depth of endometrial invasion • MRI  depth of E invasion, Cx, & LN involvement • Chest X-Ray  exclude pulmonary spread

11. Stages of the disease 88% 75% 55% 16%

13. DIFFERENTIAL DIAGNOSIS • Various causes of abnormal bleeding • 1. Premenopausal Pt  exclude pregnancy complications  abortion • 2. Endometrial hyperplasia • 3. Endometrial & Cx polyps • 4. Fibroid • 5. Ovarian, Cx or tubal neoplasms • 6. Postmenomausal Pt  atrophic vaginitis, endometrial atrophy, exogenous estrogens • 7. Urethral caruncles • 8. Trauma

14. COMPLICATIONS • 1. Severe anemia 2ry to chronic blood loss or acute hemorrhage  high dose bolus radiation therapy is effective in controlling the hemorrhage • 2. Hematometra Cx dilatation for adequate drainage • 3. Pyometra Cx dilatation for adequate drainage + antibiotics • 4. Perforation of the uterus at the time of D&C or endometrial sampling  laparoscopy or laparotomy to evaluate &repair the damage + antibiotics

15. TREATMENT 1-SURGERY • TAH & BSO  stage I & II  may require radiotherapy • Surgery alone ≤ stage Ib /grade 1or 2/adenocarcinoma • Stage III  radical surgery (TAH/BSO + max debulking) followed by radio therapy

16. 2-RADIOTHERAPY • Stage I or II  most Pt require surgery + radiotherapy if they have any adverse features • Radiotherapy regime: 1- high dose radiotherapy of intra-cavitarybrachytherapy (HDR)  risk of vault recurrence 2- low dose external beam radiotherapy in combination with HDR in stage 3 disease  risk of pelvic recurrence • 3-Advanced disease  as palliative Rx  bone pain & vaginal bleeding

17. 3-HORMONE THERAPY • Progestogens (medroxyprogestrone acetate 200-400mg/D) • *Will not prevent recurrence • *Used in the management of recurrent disease  response rate 30% • *Response is higher in estrogen progestrone receptor +ve tumors • Other hormonal agents  tamoxifen & GnRH limited response

18. 4-CHEMOTHERAPY • Not commonly used • Should be considered in fit Pt with systemic / advanced disease • Epirubicin, doxorubicin, cisplatin, carboplatin response rate 25-30% / short lived response

19. PROGNOSIS The 5 Y survival rate for endometrial Ca : • Stage I  88% • Stage II  75% • Stage III 55% • Stage IV 16% • Overall 5 Y survival  70%  most Pt present early due to abnormal vaginal bleeding

20. Other Malignant Uterine Tumors Sarcoma: 5% of all uterinecancers. Classified into : pure sarcoma, heterologous sarcoma and mixed epithelial sarcoma.