Uterine CancerXi-Shi Liu

Obstetrics and Gynecology Hospital Fudan university

2013.08

General Description• Uterine cancer is one of the most common

malignancy of female genital tract.

• The incidence is increasing worldwide in recent years.

• Overall,2%-3% of women develop uterine cancer during their lifetime.

General Description• A malignant epithelial dise

ase that occurs in endometrial gland of uterus

• Also called endometrial cancer

Classification(pathogenetic,biologic behavior )

• Estrogen dependent type- have a history of exposure to unopposed estrogen (either endogeno

us or exogenous).

- Hyperplastic endometrium

- Better differentiafed

- ER(+),PR(+)

- Mere favorable prognesis

Estrogen independent type-- Have no source of estrogen stimulation of endometriu

m.

--Arising in background of atrophic endemetrium

--Less differentiated

--ER(-)PR(-)

--Poor prognosis

Risk Factors

1. Medical conditions

a. Diabetes mellitus, hypertension.

b. Overweight---obesity (excess estrogen as a result of peripheral conversion of adrenally derived androstenedione by aromatization in fat).

c. Late menopause.

Risk Factors2. Some gynecologic diseases

( Long-term endogenous estrogen exposure )

- polycystic ovary syndrome

- functioning ovarian tumors

- anovulating dysfunctional bleeding

- Infertility, Nulliparity.

Risk Factors

3. Prolonged Use of estrogen

a. Prolonged menopausal estrogen replacement therapy without progestogen.

b. Prolonged use of the antiestrogen tamoxifen for breast cancer.

Risk Factors

4. Genetic factors and other factors

a. Endometrial and ovarian cancer are the simultaneously occurring with other genital malignancy ,reported incidence (1.4~3.8%).

b. Family history of tumor is higher.(12-28%)

Five histological subtypes

• Endometrioid adenocarcinoma• Mucinous carcinoma• Serous adenocarcinoma• Clear cell carcinoma• Other rare subtypes

Five histological subtypes--Endometrioid Adenocarcinoma

• Account for about 80~90%.

• Well differentiated.

• Prognosis is better.

Five histological subtypes --Mucinous carcinoma

Rare (about 5%)

a. Most of them is a well differentiated.

b. Behavior is similar to that of common endometrial carcinoma.

Five histological subtypes --Serous adenocarcinoma

a. Architecture is identical with complex papillary.

b. More aggressively with deep myometrial and lymphatic invasion.

c. Simulating the behavior of ovarian carcinoma.

Five histological subtypes--Clear cell carcinoma

a. A rare subtype

b. Is high grade and aggressive

c. Prognosis is similar to or worse than that of papillary serous carcinoma

d. Survival rate is lower 33%~64%

Five histological subtypes--other rare subtypes

• Squamous adenocarcinoma

• Undifferentiated carcinoma

• Mixed adenocarcinoma

Clinical Features--Symptoms• Asymptomaic (about less than 5% )

• Abnormal vaginal bleeding (premenopausal or postmenopausal, mi

nimal or nonpersistant)

• Abnormal vaginal discharge(25% infection of uterine contents)

• Pelvic pressure or discomfort (uterine enlargement or extrauterine di

sease spread)

Clinical Features--Signs

• No evidence in early stage on physical ex

amination

• Slight enlargement of uterine size and soft

• Uterus fixed, immobile, adenexal mess in

advanced stage

Special ExaminationDilation and fractional curettage ( D. C)

– Most effective ,definitive procedure and commonl

y used

– Significance

-Established correct diagnosis, clinical stage

-differentiated from cervical cancer or cervical in

volvement

• Ultrasonography

– Useful adjuvant method

– Significances

• Size of lesion

• Invasion of endometrium or cervix

• Resistant index of new vessels

Endometrial carcinoma in a 58-year-old woman with substantial postmenopausal bleeding. (A) Sagittal transvaginal US scan shows the endometrium with a thickness of 44 mm and a large area of mixed echogenicity suggestive of a mass. (B) Transverse sonohysterogram shows a 50-mm-diameter polypoid mass protruding into the endometrial cavity (calipers indicate the stalk of the mass). Histopathologic findings indicated poorly differentiated endometrial carcinoma.

   

A B

Hysteroscopy

– Significance

-Direct observation

-Taking sample correctly

-Identifying polyps and submucous myoma

Pap test

-Unreliable diagnostic test

-30%-50% abnormal pap test results

Others

-MRI, CT, chest x-ray, IV urography, cystoscopy,

sigmoidoscopy,

Diagnosis

• History, and clinical sign , related risk factors symptoms

• Diagnostic methods

Differential Diagnosis

• Senile endometritis / vaginitis

• Dysfunctional uterine bleeding

• Submucous myoma / Endometrial polyps

• Cervix cancer / Sarcoma of uterus/ Primary carc

inoma of fallopian tube

Metastasis Route

• Direct extension

• Lymphatic metastasis: important route

• Hematogenous metastasis

Clinical Stage(FIGO 1971)

• Stage I

Ia The carcinoma is confined to the corpus and the length of the ut

erine cavity is ≤ 8 cm

Ib The carcinoma is confined to the corpus and the length of the u

terine cavity is > 8 cm

• Stage II The carcinoma has involved the corpus and the cervix, but has

not extended outside the uterus

Clinical Stage(FIGO 1971)

• Stage III The carcinoma has extended outside the uterus, but not out

side the true pelvis

• Stage IV

IVa The carcinoma has extended outside the uterus and involv

es the mucosa of the bladder or rectum (a bullous oedema as

such does not permit the case to be allotted to Stage IV)

IVb The carcinoma has extended outside the true pelvis and sp

read to distant organs

Surgical pathologic staging (FIGO 1988)

• Stage I

Ia* Tumour limited to the endometrium

Ib* Invasion to less than half of the myometrium

Ic* Invasion equal to or more than half of the myometrium

• Stage II

IIa* Endocervical glandular involvement only

IIb* Cervical stromal invasion

Surgical pathologic staging (FIGO 2000)

• Stage III

IIIa* Tumour invades the serosa of the corpus uteri and/or adnexae and/or positive cytological findings

IIIb* Vaginal metastases

IIIc* Metastases to pelvic and/or para-aortic lymph nodes

• Stage IV

IVa* Tumour invasion of bladder and/or bowel mucosa

IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodes

Stage Ia* Tumor limited to the endometrium Stage Ib* Invasion to less than half of the myometrium Stage Ic* Invasion equal to or more than half of the myometrium

Stage IIa* Endocervical glandular involvement only

Stage IIb* Cervical stromal invasion

Stage IIIa* Tumor invades the serosa of the corpus uteri and/or adnexae and/or positive cytological findingsStage IIIb* Vaginal metastases Stage IIIc* Metastases to pelvic and/or para-aortic lymph nodes

Stage IVa* Tumor invasion of bladder and/or bowel mucosaStage IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodes

Treatment• Surgery Radiation

• Chemotherapy Hormone therapy

Early stage

--- surge+ postoperative adjuvant therapy Advanced stage

--- radiation+ surge+ medicine

Principle of choice

• General condition (Age, complication)

• Clinical stage

• Tumour pathologic type

Surgery• Object

– Operative pathologic stage, finding prognosis risk factors

– Remove uterus and metastasis tumour

• Stage I :– Abdorminal hysterectomy + bilateral salpingoophorectomy + selec

tive lymphadenectomy

– clear cell or papillary carcinoma– omentectomy+appenditectomy

• Stage II

– Radical hysterectomy + pelvic lymphaden

ectomy + paraortic lymphadenectomy

• Stage III,IV

– Cytoreductive surgery

Indications of pelvic lymphadenectomy

• Special pathogenetic pattern

• Endometrial cancer, grade 3 or no differentiation

• Myo-invasion more than ½

• Size of lesion more than 50% of uterine cavity

• Involvement in isthmus of uterus

Radiation therapy

• Radiation alone

• Radiation with surgery

Radiation combined surgery--Radiation after surgery

• Adenexal / serosal / parametrial spread

• Vaginal metastasis

• Lymph node metastasis

• Intraperitoneal spread

• Bladder / rectal invasion

• Myoinvasion > 50%

• G3 < 50% myoinvasion

Indications for radiation alone

• Elderly or obesity

• Multiple chronic or acute medical illness

(hypertension, cardial disease, diabetes, pulm

onary, renal)

• Advanced stage unsuitable for surgery

Hormone Therapy• mechenism

– Most endometrial cancers have both ER & PR.(Estrogen dependent subtyp

e)

Indications:

– Advanced or recurrent stage

– Early stage and desire for fertility

• Used drugs– MPA

Chemotherapy• Advanced stage or recurrent carcinoma

• Postoperative adjunctive treatment for high risk factor

• Used drugs:

– DDP (cisplatin), CTX (cyclophosphamide),

ADM (doxorubicin ), 5-Fu,Taxal

MMC, VP16.

Prognostic Factors• Tumour bilologic bihavior

– Cell type – Histological grade – Depth of myometrium infiltration – lymph-node metastasis– Presence of lymph vascular space involvement – Positive peritoneal cytology

• General condition– Old age

– Acute or chronic medical illness

• Choice of treatment

5-Year Survival Rate

• Stage I b: 94%• Stage I c: 87%• Stage II : 84%• Stage III : 40-60%

Follow-up• 75-95% disease will recur within 2-3 years after operation.• Items

– Main complaints– Pelvic examination– Vaginal discharge smear– Chest X ray – Serum CA125– Blood routine test– Blood biochemistry examination– CT/MRI

Questions• How to make diagnosis of uterine cancer?

• What’s the principle of treatment on patients with uterine cancer?

• What’re associated with prognosis of uterine cancer?