Gynecology 5th year, 7th lecture/part two (Dr. Sindus)
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  • 1. Premalignant and malignant disorders of the uterine corpus
  • 2.
    • Most common malignant diseases affecting the uterus is endometrial carcinoma, which arises from the lining of the uterus. However, sarcoma also arise from the stroma of the endometrium or from the myometrium.
    • Epidemiology :
    • The median age of presentation is just over 60 years of age, however it can occur in their 20s, but the vast majority of cases occur in women over 45 years of age. with less than 5 % diagnosed under 40 years of age .
    • Highest incidence is in white north americans.
  • 3.
    • Aetiology :
    • The exact cause is unknown, however risk factors in postmenapausal and premenapausal women include the following :
    • 1 – Obesity. 2 – Impaired carbohydrate tolerance.
    • 3 – Nulliparity.
    • 4 – Late menopause.
    • 5 – Unopposed oestrogen therapy.
    • 6 – Functioning ovarian tumors.
    • 7 – Previous pelvic irradiation.
    • 8 – Sequential oral contraceptives with dimethisterone
    • 9 – Family history of carcinoma of breast, ovary or colon.
    • 10 – Polycystic ovary disease.
    • 11 – Tamoxifin therapy which has weak oestrogen effects on the endometrium
  • 4.
    • * Many of the factors are related to an increase in oestrogen levels.
    • * In post – menopausal period, the majority of circulating oestrogen is derived from aromatization of peripheral androgens. This conversion take place principally in adipose tissue. Also post – menopausal women with diabetes have increased oestrogen levels.
    • * Nulliparity and late menopause are both associated with increased risk of endometrial cancers, which may be explained by the prolonged oestrogenic effect on the endometrium.
    • * Women who use oral contraceptive or progesterone have up to a 50 % reduction in the incidence of endometrial cancer and protection lasts for many years after the discontinuation of these treatments. Cigarette smoking has also been associated with the reduced risk of endometrial cancer.
  • 5.
    • There is no effective screening programme , but occasionally cervical smears contain endometrial cancer cells or double thickness endometrial ultrasonic thickness of 4mm or more indicates a need for endometrial sampling .
  • 6.
    • Classification :
    • A Endometrialhypeplasia :
    • Glandular hyperplasia of the endometrium are benign conditions that may produce symptoms clinically indistinguishable from early endometrial carcinoma. Some of hyperplasias, even though reversible, are considered premalignant lesions. Divided into:
    • 1/ Hyperplasia without atypia
    • which is subdivided into either simple ( cystic ) hyperplasia and complex ( adenomatous ) hyperplasia.
    • 2/ Hyperplasia with atypia, these hyperplasia are generally considered premalignant.
    • 3/ Carcinoma insitu
  • 7.
    • B Endometrial carcinoma :
    • Characterized by obvious hyperplasia and anaplasia of glandular element, with invasion of underlying stroma, myometrium or vascular spaces.
    • * Endometrial cancer can spread by 4 possible routs :
    • 1 – Direct extension.
    • 2 – Lymphatic metastasis.
    • 3 – peritoneal implants after transtubal spread.
    • 4 – haematogenous spread.
    • * Pathologist recognized 3 major histological types of endometrial carcinoma:
    • 1 – Adenocarcinoma.
    • 2 – Adenocarcinoma with squamous differentiation.
    • 3 – Adenosquamous carcinoma.
  • 8. 2003-10-27 Carcinoma of the Endometrium
  • 9.
    • All 3 types have identical presenting symptoms and signs, patterns of spread, and general clinical behavior.
    • * Papillary serous and clear cell carcinoma of the endometrium are other unusual histological subtypes that carry a poor prognosis even when apparently confined to the superficial myometrium.
  • 10.
    • Clinical presentation :
    • 1 – About 75 – 80 % of women with endometrial carcinoma will present with postmenopausal bleeding . Sometimes bloody stain postmenopausal vaginal discharge may be associated with endometrial carcinoma.
    • 2 – In premenopausal period, most women with endometrial carcinoma present with intermenstrual bleeding . Although 1/3 may present with heavy periods only.
  • 11.
    • 3 - Postmenopausal discharge from pyometra carries a 50 % risk of associated malignancy.
    • 4 – Pain may occur with pyometra or metastatic spread .
  • 12.
    • Diagnosis :
    • Traditionally, post menopausal bleeding was investigated by a dilatation and curettage.
    • Fractional curettage : dilatation and fractional curettage is the definitive procedure for diagnosis of endometrial carcinoma. It should be performed with the patient under anesthesia and by first curetting the endocervical canal followed by dilatation of the canal and circumferential curettage of the endometrial cavity.
  • 13.
    • More recently diagnosis has shifted to outpatient setting with :
    • a – Pap smear.
    • b – Ultrasound determination of endometrial thickness, also any ovarian pathology may be detected.
    • In post menopausal woman 5 mm is the cutoff for a normal unilateral endometrial strip. Color flow imaging may increase specificity.
    • c – Out – patient endometrial sampling using instruments such as a pipelle Sampler.
    • d – Out – patient hysteroscopy.
  • 14. 2003-10-27 Carcinoma of the Endometrium
  • 15. 2003-10-27 Carcinoma of the Endometrium
  • 16.
    • Staging :
    • The FIGO classification and staging of endometrial carcinoma are ( it is surgical staging ) :
    • Stage I : The carcinoma is confined to the corpus.
    • Ia : Tumor limited to the endometrium.
    • Ib : Invasion to less than ½ of the myometrium.
    • Ic : Invasion more than ½ of the myometrium.
    • Stage II : The carcinoma has involved the corpus and the cervix but has not extended outside the uterus.
    • IIa : Endocervical glandular involvement only.
    • IIb : Cervical stromal invasion.
    • Stage III : The carcinoma has extended outside the uterus but not outside the true pelvis.
    • Stage IV : The carcinoma has extended outside the true pelvis or has obviously involved the mucosa of the bladder or rectum.
  • 17. 2003-10-27 Carcinoma of the Endometrium
  • 18. 2003-10-27 Carcinoma of the Endometrium
  • 19. 2003-10-27 Carcinoma of the Endometrium
  • 20.
    • * Surgical stage I tumor account for 75 % of all endometrial carcinoma which explain the relative good overall prognosis.
  • 21.
    • Prognosis :
    • Prognosis of the disease is related to stage, which now include grade of disease, myometrial invation and LN involvement. Other factors such as age and body morphology are also important.
    • It is believed that the presence of malignant squamous component ( adeno squamous carcinoma ) is thought to be associated with a poorer outcome.
  • 22.
    • Stage 5 year survival
    • I 85%
    • II 68%
    • III 42%
    • IV 22%
    2003-10-27 Carcinoma of the Endometrium
  • 23.
    • Differential diagnosis :
    • Clinically the differential diagnosis of endometrial carcinoma include all the causes of abnormal uterine bleeding.
    • * In premeopausal patient the following should be excluded :
    • 1 – Complication of early pregnancy.
    • 2 – Liomyoma.
    • 3 – Endometrial hyperplasia and polyps.
    • 4 – Cervical polyps.
    • 5 – Various genital or metastatic cancers.
    • * In the postmenopausal age group, the following should be considered :
    • 1 – Atrophic vaginitis.
    • 2 – Exogenous oestrogen ( HRT )
    • 3 – Endometrial hyperplasia and polyps.
    • 4 – Various genital neoplasma.
  • 24.
    • Treatment :
    • Stage I : - The treatment of choice is total abdominal hysterectomy and bilateral salpingoopherectomy.
    • - Radiotherapy is also necessary if invasion of the myometrium has occurred to more than the inner half of the myometrium.
    • Stage II : - If patient is surgically fit, do radical hysterectomy and bilateral lymphadenectomy with para-aortic node sampling should be performed.
    • - If patient unfit surgically then radiotherapy may be used.
    • Stage III : If node suggest spread of disease then surgery with adjuvant radiotherapy.
    • Stage III & IV : Treatment needs to be individualized to the patient, but surgery is not usually the first line of treatment.
  • 25. Treatments
  • 26.
    • Radiotherapy is performed and then occasionally residual disease may be involved by surgical intervention.
    • Progesterone :
    • Some believe that progesterone may be helpful in preventing recurrence after treatment of early stage disease.