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Uterine Cancers

Uterine Cancers. A. Alobaid , MBBS, FRCS(C), FACOG Consultant, Gynecologic Oncology Assistant professor, KSU Medical Director, Women’s Specialized Hospital King Fahad Medical City. Introduction. It is the most common malignancy of the female genital tract

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Uterine Cancers

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  1. Uterine Cancers A. Alobaid, MBBS, FRCS(C), FACOG Consultant, Gynecologic Oncology Assistant professor, KSU Medical Director, Women’s Specialized Hospital King Fahad Medical City

  2. 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

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

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

  5. 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

  6. 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

  7. 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

  8. Endometrial Hyperplasia

  9. 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

  10. 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

  11. Postmenopausal Bleeding

  12. 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

  13. 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 D&Cs and 5851 office biopsies showed that D&C had a higher complication rate than office biopsy but that the adequacy of the specimens was comparable

  14. 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, 1994;55:56-9

  15. 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%)

  16. 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

  17. Pathology

  18. Prognostic Factors

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

  20. Treatment

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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.

  27. Classification • These tumors arise either from the endometrium: MMMT (carcinosarcoma) = 50% ESS = 8-10% • Or from the myometrium: LMS = 40%

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

  29. 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.

  30. 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%

  31. 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.

  32. 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

  33. Thank you

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