Malignant Disease of the Body of the Uterus

1. Prof. Dr.EsraaAL-Maini 5th year –Gynecology 2019-2020 Malignant Disease of the Body of the Uterus

2. Endometrial cancer is 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

3. Classification A-Arising from endometrium 1-Adenocarcinoma, the most common type of cancer affecting the uterus is there are two distinct types: A-Endometrioidadenocarcinoma(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 carcinomacan rarely arise from the endometrium. B-Arise from the stroma or myometrium sarcoma

4. 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

5. 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.

6. 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

7. anc • endometrial carcinoma

8. 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

9. Vaginal ultrasound

12. 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

13. ManagementSurgery is the recommended treatment 1-Total hysterectomy, bilateral salpingo-ophorectomy. Stage I (grades 1-2) (3 Gradethe 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 .

14. Gross involvementof 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 If 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

15. 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.

16. 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

17. 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

18. Prognosis The 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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