Download - 18. Carcinoma Uterus - Amita Maheshwari
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Uterine CancerUterine Cancer
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Amita MaheshwAmita MaheshwAssoc. Professor of GynAssoc. Professor of Gyn
OncologyOncology
Tata Memorial HospTata Memorial Hospmaheshwariamita@yahoomaheshwariamita@yahoo
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IntrodctionIntrodction
The most common gynecologic cancer The most common gynecologic cancer de!eloped contries.de!eloped contries.
In India" it ran#s third amongst gyneIn India" it ran#s third amongst gyne
cancer.cancer. $%& cases are diagnosed in stage'I.$%& cases are diagnosed in stage'I.
('year sr!i!al rate )*%&.('year sr!i!al rate )*%&.
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+is# factors+is# factorsFactors increasing riskFactors increasing risk IIncreasencreasedd exposure to unopposed estrogenexposure to unopposed estrogen
estrogen-replacement therapy, obesity, anovulatory cycestrogen-replacement therapy, obesity, anovulatory cycl
estrogen-secreting tumorsestrogen-secreting tumors
NulliparityNulliparity Years of menstruation Years of menstruation HNP family syndromeHNP family syndrome !amoxifen!amoxifen Increasing ageIncreasing age
FactorsFactors decr decr easing riskeasing risk "rand multiparity"rand multiparity ##ral contraceptivesral contraceptives $$mokingmoking Physical activityPhysical activity
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+ole of+ole of ,creening,creening
+otine screening -OT recommended.+otine screening -OT recommended.
.. Postmenopasal women on e/ogenos ePostmenopasal women on e/ogenos ewithotwithot progestins progestins
0.0. 1omen from families with hereditary1omen from families with hereditarynonpolyposis colorectal cancer syndromnonpolyposis colorectal cancer syndrom
2.2. Premenopasal women with ano!latoryPremenopasal women with ano!latorysch as those with polycystic o!arian sch as those with polycystic o!arian
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Patients in 1hom a 3iagnosis of 4ndoPatients in 1hom a 3iagnosis of 4ndoCancer ,hold 5e 4/cldedCancer ,hold 5e 4/clded
.. All patients with postmenopasal 6leedingAll patients with postmenopasal 6leeding
0.0. Postmenopasal women with a pyometraPostmenopasal women with a pyometra
2.2. Asymptomatic postmenopasal women with enAsymptomatic postmenopasal women with encells on a Pap smear" particlarly if they arcells on a Pap smear" particlarly if they are
7.7. Perimenopasal patients with inter'menstraPerimenopasal patients with inter'menstraor increasingly hea!y periodsor increasingly hea!y periods
(.(. Premenopasal patients with a6normal terinPremenopasal patients with a6normal terinparticlarly if there is a history of ano!latparticlarly if there is a history of ano!lat
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Cases of Postmenopasal 5leCases of Postmenopasal 5le Atrophic endometritis8!aginitisAtrophic endometritis8!aginitis
4ndometrial or cer!ical polyps4ndometrial or cer!ical polyps
4/ogenos estrogens4/ogenos estrogens
4ndometrial hyperplasia4ndometrial hyperplasia 4ndometrial cancer4ndometrial cancer
Miscellaneos 9e.g." cer!ical cancer" Miscellaneos 9e.g." cer!ical cancer"
sarcoma" rethral carncle" trama:sarcoma" rethral carncle" trama:
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Management of endometrial hyperplasiaManagement of endometrial hyperplasia
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3iagnosis ; Pre'op in!estigation3iagnosis ; Pre'op in!estigation Office endometrial 6iopsy
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1HO histological classificat1HO histological classificat
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• Type' 9low grade:< )%&Type' 9low grade:< )%&
4o related' Arise on a 6ac#grond of hyperplasia.4o related' Arise on a 6ac#grond of hyperplasia.
?ong dration of nopposed estrogenic stimlation.?ong dration of nopposed estrogenic stimlation.
1ell'moderately differentiated.1ell'moderately differentiated.
=a!ora6le prognosis.=a!ora6le prognosis.
• Type'0 9high grade:< )%&Type'0 9high grade:< )%&
4o non'related' Arise in atrophic endometrim.4o non'related' Arise in atrophic endometrim.
-on'estrogen dependent.-on'estrogen dependent.
Poorly differentiated or non'endometroid types.Poorly differentiated or non'endometroid types.
High ris# of relapse and metastasis.High ris# of relapse and metastasis.
Prognosis poor.Prognosis poor.
Clinico'pathologic TypesClinico'pathologic Types
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Ca'4ndometrim ; Ca'O!aryCa'4ndometrim ; Ca'O!ary
)*& Ca'endometrim associated with simlta)*& Ca'endometrim associated with simlta
presence of endometroid type Ca'o!ary.presence of endometroid type Ca'o!ary. ,ynchronos
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,pread Patterns,pread Patterns
3irect e/tension to adacent strctre3irect e/tension to adacent strctre T T ranst6al passage of e/foliated cellsranst6al passage of e/foliated cells
??ymphatic disseminationymphatic dissemination HHematogenos disseminationematogenos dissemination
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Management of 4ndometrialManagement of 4ndometrial
%%s%%s Primary srgeryPrimary srgery Mid 2%sMid 2%s Pre'operati!e +T Pre'operati!e +T
$%s$%s Primary srgery' clinical sPrimary srgery' clinical s
**** =IGO ,rgico'pathologica=IGO ,rgico'pathologica
0%%*0%%* +e!ised =IGO staging+e!ised =IGO staging
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=IGO ,rgico'pathologic stagin=IGO ,rgico'pathologic stagin9 9 @** !s 0%%*: @** !s 0%%*:
,t.'I,t.'I Tmor confined to the corps tTmor confined to the corps t
IAIA -o myometrial in!asion-o myometrial in!asion
I5I5 Myometrial in!asion B halfMyometrial in!asion B half
ICIC Myometrial in!asion halfMyometrial in!asion half
IAIA -o or B half myometrial -o or B half myometrial
I5I5 Myometrial in!asion halMyometrial in!asion hal
,t.'II,t.'II Cer!ical in!ol!ementCer!ical in!ol!ementIIAIIA Cer!ical glandlar in!ol!ementCer!ical glandlar in!ol!ement
II5II5 Cer!ical stromal in!ol!ementCer!ical stromal in!ol!ement
IIII Tmor in!ades cer!ical stTmor in!ades cer!ical st
+e!ised =IGO stagin+e!ised =IGO staging
=IGO ,rgico pathologic stagi=IGO ,rgico pathologic stagin
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=IGO ,rgico'pathologic stagi=IGO ,rgico'pathologic stagin9@** !s 0%%*: 9@** !s 0%%*:
,t.'III,t.'III ?ocal and8or regional spread?ocal and8or regional spreadIIIAIIIA Tmor in!ades the serosa of the tersTmor in!ades the serosa of the ters anan
and8or positi!e cytologyand8or positi!e cytologyIII5III5 Eaginal in!ol!ementEaginal in!ol!ement
parametrial in!ol!ementparametrial in!ol!ementIIICIIIC Pel!ic and or para'aotic ?- in!ol!ementPel!ic and or para'aotic ?- in!ol!ement
IIIC Positi!e pel!ic nodes
IIIC0 Positi!e para'aortic nodes F pe,t.'IE,t.'IE Tmor in!ades 6ladder and8or 6owTmor in!ades 6ladder and8or 6ow
mcosa or distant metastasesmcosa or distant metastases
IEAIEA In!asion of 6ladder and8or 6owel In!asion of 6ladder and8or 6owel
IE5IE5 3istant metastases3istant metastases
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=IGO'Grade=IGO'Grade
Applies to 4ndometroid type seros aApplies to 4ndometroid type seros a
cell carcinomas are considered to 6e hcell carcinomas are considered to 6e hgrade.grade.
Grade
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,teps of ,rgical ,taging,teps of ,rgical ,taging
Peritoneal washings for cytologyPeritoneal washings for cytology 4/ploration of the a6domen ; pel!i4/ploration of the a6domen ; pel!i
5iopsy of any sspicios lesion5iopsy of any sspicios lesion
Total hysterectomy K 5,OLTotal hysterectomy K 5,OL
Pel!ic ; para'aortic lymphadenectoPel!ic ; para'aortic lymphadenecto
LL O!arian preser!ationO!arian preser!ation
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Eale of ,rgical ,tagingEale of ,rgical ,tagingPrognosticPrognostic
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Prognostic Eale of ?ymph -ode Met
-odal ,tats ('year s
-egati!e ?- %&
Positi!e pel!ic ?- $(&
Positi!e para'aortic ?- 2*&
'Morrow et al. Gynecol Oncol"@'Morrow et al. Gynecol Oncol"@
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Mor6idity of ?ymphadenectoMor6idity of ?ymphadenectoIntra'operati!e
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Contro!ersies in the srgical staContro!ersies in the srgical sta
Complete srgical staging inclding pel!ic and parComplete srgical staging inclding pel!ic and par
lymphadenectomy for all patients.lymphadenectomy for all patients. Complete srgical staging -OT needed for any pComplete srgical staging -OT needed for any p
Uterine ris# factors are sfficient to identify hiUterine ris# factors are sfficient to identify hi
cases.cases.
An identifia6le grop of intermediate8high ris# pAn identifia6le grop of intermediate8high ris# p
will 6enefit from complete staging while those atwill 6enefit from complete staging while those at
will not.will not.
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Predictors of ?- MetastasPredictors of ?- Metastase
3epth of myometrial in!asion3epth of myometrial in!asion
Tmor gradeTmor grade
Tmor siNe J0cmTmor siNe J0cm
4/tra'terine disease4/tra'terine disease
?ymph !asclar space in!asion?ymph !asclar space in!asion
Histologic s6'types type IIHistologic s6'types type II
+i # ifi i
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+is# ,tratification+is# ,tratification ?ow ris#?ow ris#
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4/tent of ?ymphadenectom4/tent of ?ymphadenectom
Para?-
Common iliac ?-Common iliac ?-
4/ternal iliac ?-4/ternal iliac ?-
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=ifty percent of patients with pel!ic n=ifty percent of patients with pel!ic n
metastases will ha!e additional para'aometastases will ha!e additional para'aonodal metastases.nodal metastases.
In 0(& patients" para'aortic lymph nodIn 0(& patients" para'aortic lymph nod
metastases can occr with negati!e pelmetastases can occr with negati!e pel!
Para'aortic ?- in!ol!ement can occr aPara'aortic ?- in!ol!ement can occr a
IMA to the renal !essels directlyIMA to the renal !essels directly
4/tent of ?ymphadenectom4/tent of ?ymphadenectom
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+ole of Ad!ant Therapy+ole of Ad!ant Therapy
Ad!ant therapy decisions '' 5ased on prognostic fact
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Prognostic factorsPrognostic factors AgeAge
Histologic typeHistologic type Histologic gradeHistologic grade Myometrial in!asionMyometrial in!asion Easclar space in!asionEasclar space in!asion Tmor siNeTmor siNe Hormone receptor statsHormone receptor stats 3-A ploidy and other 6iological mar#er3-A ploidy and other 6iological mar#er
+ # f ; d+i # ifi i ; Ad
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+is# stratification ; Ad!an+is# stratification ; Ad!an
+is# Category+is# Category 4/tent of disease4/tent of disease Ad!ant treAd!ant tre
?ow +is# ,perficial in!asion 9B80:?ow grade 980:
-o frther +/
Intermediate +is# High Grade3eep In!asion
?E,I
-egati!e ?ymph -odes
Eaginal 5rachyt
High +is# Positi!e ?ymph -odes,tage II
UP,C" CCCa
Positi!e P'A ?-s
4/ternal pel!ic
!aginal 6rachyt
CT K 4/tended
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M/ of Ad!anced8recrrent dis
Mltimodality +/ ,/" +T" CT" HT.Mltimodality +/ ,/" +T" CT" HT. ,rgical cytoredction in appropriately,rgical cytoredction in appropriately
selected cases
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=ollow p protocol=ollow p protocol
4!ery 2 mthly for 0 years4!ery 2 mthly for 0 years
4!ery mthly for 2 years4!ery mthly for 2 years
Annally life longAnnally life long
History
Clinical e/
Eaginal cy
+adiologic
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+ole of Minimally In!asi!e ,+ole of Minimally In!asi!e ,
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?aparoscopy seems to 6e an appro?aparoscopy seems to 6e an approalternati!e to open srgeryalternati!e to open srgery
?aparoscopic pel!ic lymphadenecto?aparoscopic pel!ic lymphadenecto
+ 6
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+o6otic ,rgery
+o6otic srgery for 4ndometrial'Ca can 6e+o6otic srgery for 4ndometrial'Ca can 6e
accomplished in hea!ier patients and resltsaccomplished in hea!ier patients and reslts
shorter operating times and hospital stay" shorter operating times and hospital stay"
transfsion rate" and less freent con!erstransfsion rate" and less freent con!erslaparotomy compared to laparoscopy.laparotomy compared to laparoscopy.
' ,eamon et al. Gynecol Oncol"0%%@
+ 6 ti , = 4 d t i l+ 6 ti , = 4 d t i l
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+o6otic ,rgery =or 4ndometrial +o6otic ,rgery =or 4ndometrial
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Eaginal ,rgery for 4ndometrEaginal ,rgery for 4ndometr Eaginal hysterectomy with 5,O
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4ndometrial Ca in ong 1ome4ndometrial Ca in ong 1ome=ertility preser!ation=ertility preser!ation
4arly stage" grade and P+ positi!e.4arly stage" grade and P+ positi!e. M+I to e/clde significant myometrial in!asionM+I to e/clde significant myometrial in!asion
adeate imaging of the o!ariesadeate imaging of the o!aries High dose progestins< megestrol acetate oraHigh dose progestins< megestrol acetate ora
% to 20% mg8day or medro/yprogesteron% to 20% mg8day or medro/yprogesteron0%% to (%% mg8day 0%% to (%% mg8day
7%& of these patients will carry a sccessfl 7%& of these patients will carry a sccessfl Hysterectomy is recommended once child6eariHysterectomy is recommended once child6eari
6een completed6een completed
M/ of Incompletely ,taged PaM/ of Incompletely ,taged Pa
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M/ of Incompletely ,taged PaM/ of Incompletely ,taged Pa+e!iew HP+' Grade" In!asion" adne/+e!iew HP+' Grade" In!asion" adne/
CT8M+I8 P4T'scanCT8M+I8 P4T'scan
-o gross disease-o gross disease
IA"I5IA"I5G"0G"0
O6ser!eO6ser!e
IC" any gradeIC" any gradeIIA"II5IIA"II5
+estaging+estaging Pel!ic +T Pel!ic +T
GroGro
,rgic,rgic
+T+T
+
l
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ConclsionsConclsions 3isease of postmenopasal women.3isease of postmenopasal women.
,ymptoms occr early in the corse< most,ymptoms occr early in the corse< mostha!e early stage disease at presentation.ha!e early stage disease at presentation.
O!erall ('year sr!i!al )*%&.O!erall ('year sr!i!al )*%&. Type' 9low grade" hormone sensiti!e:< e/Type' 9low grade" hormone sensiti!e:< e/
prognosisprognosis Type'0 9high grade" hormone independentType'0 9high grade" hormone independent
otcome.otcome.
C l iC l i
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ConclsionsConclsions
,rgery is the primary modality srgical st,rgery is the primary modality srgical st
offers the opportnity for the most accratoffers the opportnity for the most accratassessment of occlt e/tra'terine disease assessment of occlt e/tra'terine disease
nodal metastases.nodal metastases.
-odal metastasis is the most important ris#-odal metastasis is the most important ris#
The li#elihood of nodal metastasis increasesThe li#elihood of nodal metastasis increases
e/tent of disease and tmor grade.e/tent of disease and tmor grade.
Ad!ant +/ is needed in high ris# cases.Ad!ant +/ is needed in high ris# cases.
Uterine ,arcomas
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Pathological s6typesPathological s6types IncidencIncidenc ?eiomyosarcoma?eiomyosarcoma 0('0(' 4ndometrial stromal tmors4ndometrial stromal tmors %'%'
4ndometrial stromal nodle4ndometrial stromal nodle
4ndometrial stromal sarcoma'low grade4ndometrial stromal sarcoma'low grade
Undifferentiated sarcomaUndifferentiated sarcoma
Mi/ed epithelial'mesenchymal tmorsMi/ed epithelial'mesenchymal tmors
AdenosarcomaAdenosarcoma (&(&Carcinosarcoma 9Mi/ed Mllerian Tmor:Carcinosarcoma 9Mi/ed Mllerian Tmor: 7('7('
HomologosHomologos
HeterologosHeterologos
UndifferentiatedUndifferentiated (&(&
Uterine ,arcomas
M t f t iM t f t i
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Management of terine sarcoManagement of terine sarco ,rgery is the cornerstone of the treatme,rgery is the cornerstone of the treatme
Total a6dominal hysterectomy K 58? ,O is Total a6dominal hysterectomy K 58? ,O is gold standard.gold standard.
3e6l#ing srgery in ad!anced cases.3e6l#ing srgery in ad!anced cases.
4,, is hormone dependent so ,O is indicat4,, is hormone dependent so ,O is indicat
High recrrence rates e!en in early stage dHigh recrrence rates e!en in early stage d
Ad!ant treatment has shown to significanAd!ant treatment has shown to significanimpro!ement in sr!i!al.impro!ement in sr!i!al.