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Uterine Cancers

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Uterine Cancers A. Alobaid, MBBS, FRCS(C), FACOG Consultant, Gynecologic Oncology Assistant professor, KSU Medical Director, Women s Specialized Hospital – PowerPoint PPT presentation

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Title: Uterine Cancers


1
Uterine Cancers
  • A. Alobaid, MBBS, FRCS(C), FACOG
  • Consultant, Gynecologic Oncology
  • Assistant professor, KSU
  • Medical Director, Womens 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 DCs
    and 5851 office biopsies showed that DC 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, 19945556-9

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
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21
Prognostic Factors
22
Treatment
  • Exploratory lapratomy, peritoneal washing
    (cytology), total abdominal hysterectomy and
    bilateral salpingo-oopherectomy are the primary
    operative procedures for carcinoma of the
    endometrium

23
Treatment
24
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

25
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

26
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

27
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28
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

29
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

30
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.

31
Classification
  • These tumors arise either from the
    endometrium MMMT (carcinosarcoma) 50
    ESS 8-10
  • Or from the myometrium LMS
    40

32
Sarcomas
  • MMT (Mixed Mullerian tumors) also they are
    called carcinosarcomas
  • Currently they are classifiedand and treated as
    poorly differentiated adenocarcinomas
  • Outcome is generally poor

33
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34
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.

35
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

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37
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.

38
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

39
Thank you
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