slide for class presentation for UG and PG students.

1. Uterine Cancer
Dr Amar, MD
NMCTH

2. 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.

3. General Description
• A malignant epithelial
disease that occurs in
endometrial gland of
uterus
• Also called endometrial
cancer

4. Classification
(pathogenetic,biologic behavior )
• Estrogen dependent type
- have a history of exposure to unopposed estrogen
(either endogenous or exogenous).
- Hyperplastic endometrium
- Better differentiafed
- ER(+),PR(+)
- Mere favorable prognesis

5.  Estrogen independent type
-- Have no source of estrogen stimulation of
endometrium.
--Arising in background of atrophic
endemetrium
--Less differentiated
--ER(-)PR(-)
--Poor prognosis

6. 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.

7. Risk Factors
2. Some gynecologic diseases
( Long-term endogenous estrogen
exposure )
- polycystic ovary syndrome
- functioning ovarian tumors
- anovulating dysfunctional bleeding
- Infertility, Nulliparity.

8. 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.

9. 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%)

10. Hyperplacia

11. Endometrial Hyperplasia
• Simple
• Complex

12. How endometrial hyperplasia is associated
with endometrial cancer
Endometrial hyperplasia is a continuum…
Simple hyperplasiacomplex hyperplasia
without atypiacomplex hyperplasia w/
atypia endometrial cancer (well
differentiated adenocarcinoma)

13. How endometrial hyperplasia is associated
with endometrial cancer
Simple hyperplasia– 1% progress to
endometrial cancer
Complex hyperplasia– 3%
Simple hyperplasia with atypia—8%
Complex hyperplasia with atypia—28-30%
30-40% of endometrial cancers are found in
a background of atypical hyperplasia.
Overall, these tend to be lower grade

14. Hyperplasia: Progression to Cancer
• NO ATYPIA
Simple – 1.3%
Complex – 3%
• ATYPIA
Simple – 8%
Complex – 29%
Significant percentage (43%) of complex
hyperplasia with atypia will have
coexisting adenocarcinoma

15. Management: Hyperplasia
NO ATYPIA
–No Treatment (only for
simple)
–Continuous Progestins
–Re-examination if
bleeding
PROGESTIN OPTIONS
Medroxyprogesterone 10mg/d
(10-30mg/d) Norethindrone
2.5mg/d (2.5-10mg/d)
Megestrol 160mg/d*
Oral contraceptive pills

16. Management: Hyperplasia
ATYPIA
•Hysterectomy
•If poor surgical candidate/ desires
fertility sparing
– Continuous high dose progestin
• Megestrol acetate 160mg/day divided doses
– Levonorgestrel intrauterine device
– Re-exam every 3 months
– Response to hormones 50-75%

17. Five histological subtypes
• Endometrioid adenocarcinoma
• Mucinous carcinoma
• Serous adenocarcinoma
• Clear cell carcinoma
• Other rare subtypes

18. Five histological subtypes
--Endometrioid Adenocarcinoma
• Account for about
80~90%.
• Well differentiated.
• Prognosis is better.

19. 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.

20. 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.

21. 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%

22. Five histological subtypes
--other rare subtypes
• Squamous adenocarcinoma
• Undifferentiated carcinoma
• Mixed adenocarcinoma

23. Important Histology Points
• Papillary serous carcinomas are aggressive
– Even when mixed with other types, if there is >
25% serous they will retain aggressive behavior
• Clear cell carcinomas act similar to high
grade endometrioid type carcinoma
• Mucinous carcinomas act similar to well
differentiated endometrioid type carcinoma
• Squamous carcinomas have a poor
prognosis

24. Endometrial Cancer Grade
• The grade is based on the
percentage of the solid component.
– Well Differentiated (Grade 1): <5%
– Moderately Differentiated (Grade 2): 5-50%
– Poorly Differentiated (Grade 3): > 50%

25. Clinical Features--Symptoms
• Asymptomaic (about less than 5% )
• Abnormal vaginal bleeding (premenopausal or
postmenopausal, minimal or nonpersistant)
• Abnormal vaginal discharge(25% infection of uterine
contents)
• Pelvic pressure or discomfort (uterine enlargement or
extrauterine disease spread)

26. Clinical Features--Signs
• No evidence in early stage on
physical examination
• Slight enlargement of uterine size
and soft
• Uterus fixed, immobile, adenexal
mess in advanced stage

27. Special Examination
Dilation and fractional curettage ( D. C)
– Most effective ,definitive procedure and
commonly used
– Significance
-Established correct diagnosis, clinical
stage
-differentiated from cervical cancer or
cervical involvement

28. • Ultrasonography
– Useful adjuvant method
– Significances
• Size of lesion
• Invasion of endometrium or cervix
• Resistant index of new vessels

29. 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

30. Hysteroscopy
–Significance
-Direct observation
-Taking sample correctly
-Identifying polyps and submucous myoma

31. Pap test
-Unreliable diagnostic test
-30%-50% abnormal pap test results
Others
-MRI, CT, chest x-ray, IV urography,
cystoscopy, sigmoidoscopy,

32. Diagnosis
• History, and clinical sign ,
related risk factors symptoms
• Diagnostic methods

33. Differential Diagnosis
• Senile endometritis / vaginitis
• Dysfunctional uterine bleeding
• Submucous myoma / Endometrial
polyps
• Cervix cancer / Sarcoma of uterus/
Primary carcinoma of fallopian tube

34. Metastasis Route
• Direct extension
• Lymphatic metastasis: important route
• Hematogenous metastasis

35. Clinical Stage
(FIGO 1971)
• Stage I
Ia The carcinoma is confined to the corpus and
the length of the uterine cavity is ≤ 8 cm
Ib The carcinoma is confined to the corpus and
the length of the uterine cavity is > 8 cm
• Stage II The carcinoma has involved the corpus and the
cervix, but has not extended outside the uterus

36. Clinical Stage
(FIGO 1971)
• Stage III The carcinoma has extended outside the
uterus, but not outside the true pelvis
• Stage IV
IVa The carcinoma has extended outside the
uterus and involves 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 spread to distant organs

37. 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

38. 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

39. 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

40. Stage IIa*
Endocervical glandular involvement only
Stage IIb*
Cervical stromal invasion

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

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

43. Treatment
• Surgery Radiation
• Chemotherapy Hormone therapy
 Early stage
--- surge+ postoperative adjuvant therapy
 Advanced stage
--- radiation+ surge+ medicine

44. Principle of choice
• General condition (Age, complication)
• Clinical stage
• Tumour pathologic type

45. Surgery
• Object
– Operative pathologic stage, finding prognosis risk
factors
– Remove uterus and metastasis tumour
• Stage I :
– Abdorminal hysterectomy + bilateral salpingoophorectomy
+ selective lymphadenectomy
– clear cell or papillary carcinoma–
omentectomy+appenditectomy

46. • Stage II
–Radical hysterectomy + pelvic
lymphadenectomy + paraortic
lymphadenectomy
• Stage III,IV
–Cytoreductive surgery

47. 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

48. Radiation therapy
• Radiation alone
• Radiation with surgery

49. 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

50. Indications for radiation alone
• Elderly or obesity
• Multiple chronic or acute medical
illness
(hypertension, cardial disease, diabetes,
pulmonary, renal)
• Advanced stage unsuitable for
surgery

51. Hormone Therapy
• mechenism
– Most endometrial cancers have both ER &
PR.(Estrogen dependent subtype)
 Indications:
– Advanced or recurrent stage
– Early stage and desire for fertility
• Used drugs
– MPA

52. 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.

53. 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

54. 5-Year Survival Rate
• Stage I b: 94%
• Stage I c: 87%
• Stage II : 84%
• Stage III : 40-60%

55. 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

56. 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?