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![Classification
Type 1 neoplasms
low-grade [FIGO] grades 1 and 2
endometrioid histology 80
percent of ECs
Type 2 neoplasms
(FIGO grade 3 endometroid ,
serous, clear cell, mixed cell,
undifferentiated,
carcinosarcoma)
are less common and typically
not estrogen-sensitive.
HIGH RISK UTERINE CANCER
LOW RISK
UTERINE CANCER](https://image.slidesharecdn.com/uteriancancer1-250319163540-4a9b1d81/75/uterine-cancer-in-publish-in-saudi-arabia-14-2048.jpg)
uterine cancer in publish in saudi arabia
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- 2. OBJECTIVES ❖Epidemiology ❖Risk factors ❖screening ❖Diagnosis ❖Classification ❖FIGO staging ❖MangmentOf Endometrial Cancer ❖overall survival
- 3. Uterine cancer isthe most common gynecologic malignancy in high-income countries and the second most common in low- and middle-income countries The incidence peaks between ages 55 and 70 years 2 to 5 percent of cases occur before age 40 years Adenocarcinoma of the endometrium is the most common histologic site and type of uterine cancer Epidemiology
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- 7. Lynch syndrome. • Isautosomal dominant • high risk of uterine cancer (40%-60%) • The American Cancer Society recommends annual endometrial biopsy (EMB) starting at age 35 years • Risk-reducing hysterectomy with bilateral salpingo-oophorectomy (BSO) is recommended once childbearing is completed
- 8. DIAGNOSIS Complete history, assessingfor hereditary cancer syndromes. Abnormal uterine bleeding (70-90%) Upward of 90% of uterine cancer cases present with abnormal uterine bleeding (AUB) or postmenopausal bleeding. Abnormal cervical cytology • Endometrial cells in a woman greater than 40 years old • Atypical glandular cells of undetermined significance • Adenocarcinoma Incidental finding after hysterectomy or during abdominopelvic surgery A recent study revealed that 43% of hysterectomies performed for hyperplasia with atypia will have uterine cancer on final pathology . To avoid this scenario of occult malignancy, it is recommended that all women with AUB have endometrial sampling prior to their hysterectomy.
- 9. Physical examination Complete physicalexam, including comprehensive pelvic exam assessing the size and mobility of the uterus and assessment for metastasis (ie,supraclavicular lymphadenopathy) Laboratory Consider cancer antigen 125 (CA-125) in patients with uterine serous carcinoma .Elevated CA-125 levels are associated with metastatic disease and can be used to follow the patient if it was elevated at diagnosis. Ultrasound On pelvic ultrasound, an endometrial stripe less than 5 mm portends a low risk for cancer, with a negative predictive value of 99%. Those with persistent bleeding should be evaluated with endometrial sampling regardless of stripe measurement.
- 10. • Endometrial sampling AnEMB should be performed in women at high risk for uterine cancer with postmenopausal or Abnormal uterine bleeding . The accuracy of detecting cancer on an EMB is between 91% and 99%. The false-negative rate for EMB is between 5% and 15%.
- 11. D&C allows for morecomplete sampling of the endometrium and has a false- negative rate between 2% and 6%. A D&C is advised when 1. an EMB result is read as “insufficient sample” 2. cervical stenosis prevents office EMB 3. patient is unable to tolerate ambulatory EMB 4. patient has continued bleeding despite prior negative biopsy 5. endometrial polyp or endometrial mass is suspected (D&C with hysteroscopy)
- 12. Role of otherinvestigations in Endometrial Cancer ❖MRI i. Determing the thickness of myometrum involved ii. Give information about lower uterine segment and cervical involvement ❖CT Scan I. Metastasis II. Pelvic involvement III. Lymph node involvement ❖Chest radiograph should be performed as part of the initial assessment to exclude lung metastases.
- 14. Classification Type 1 neoplasms low-grade[FIGO] grades 1 and 2 endometrioid histology 80 percent of ECs Type 2 neoplasms (FIGO grade 3 endometroid , serous, clear cell, mixed cell, undifferentiated, carcinosarcoma) are less common and typically not estrogen-sensitive. HIGH RISK UTERINE CANCER LOW RISK UTERINE CANCER
- 15. • STAGING FORENDOMETRIAL CANCER IS DONE SURGECALLY A fully staged procedure includes total extra fascial hysterectomy, BSO, a pelvic and para-aortic lymph node assessment/dissection In cases of advanced disease, cytoreduction of all visible disease. Omentectomy should be performed if serous or clear cell histology is suspected. Surgical management of cervical involvement — (1) radical hysterectomy with postoperative radiation therapy based on pathologic factors (2) extrafascial hysterectomy with postoperative radiation (3) primary radiation therapy followed by extrafascial hysterectomy
- 17. MANAGEMENT OF UTERINECANCER • Appropriate treatment is determined by stage, grade, histologic type, and the patient’s ability to tolerate therapies • Patients with early-stage, low-risk endometrial cancer of endometrioid type require no further therapy beyond surgery, particularly patients with grade 1, stage 1 endometrial cancer and no risk factors.
- 18. Management of High-RiskUterine Cancer For women with high-risk, early-stage (stage I or II) disease • Women with clear cell or serous-histology cancers that are stage IA without myometrial invasion may be observed. However, alternatively, adjuvant vaginal brachytherapy (VBT) may be offered, depending on patient and provider preferences • Women with clear cell or serous-histology cancers that are stage IA with myometrial invasion, stage IB, or stage II; or with grade 3 endometrioid cancers that are stage IB or II and may be treated with pelvic radiation therapy (RT) alone or with chemotherapy, with or without VBT.
- 19. For women withlocally advanced or advanced disease (stage III or IV) • Women with stage III or IV disease who have undergone resection (surgical cytoreduction) are treated with adjuvant chemotherapy, often with the addition of VBT for high-risk features for local recurrence. • Women with unresectable stage III or IV disease are treated with chemotherapy. The role of pelvic RT in these women must be individualized based on burden of disease
- 20. • Timing ofpelvic radiation with chemotherapy — For those in whom RT is indicated, acceptable approaches include giving RT after completion of six cycles of chemotherapy, "sandwiched" in between three cycles of chemotherapy before and after RT Adjuvant RT should be initiated as soon as the vaginal cuff is healed and no later than 12 weeks after surgery.
- 21. Chemotherapy and Immunotherapy •Based on the results of Gynecologic Oncology Group (GOG)-209 suggest carboplatin and paclitaxel. • Hormonal therapies (progestins like Megace, selective estrogen receptor modulators like tamoxifen, and aromatase inhibitors) are largely more useful in the palliative setting and are not used with an intention to cure. • The combination of Megace sequenced with tamoxifen as studied in a phase II GOG trial demonstrated a response rate of more than 40% in the setting of recurrence. • Pembrolizumab is an immunotherapy drug treat unresectable or metastatic microsatellite instability . The pembrolizumab response rate was an impressive 52%, and overall disease control was 73% in a recent study.
- 22. POST-TREATMENT SURVEILLANCE • Themajority of recurrences occur within three years of treatment. Approximately 70 percent of patients develop symptoms at the time of recurrence (eg, vaginal bleeding, abdominal pain, cough, weight loss). • clinical examination at three-month intervals for two years, then every six months or annually. (including symptom review, symptom-directed physical examination, and pelvic examination)
- 23. • Previously, yearlyvaginal cytology was recommended; however NCCN, SGO, and American College of Obstetricians and Gynecologists no longer support this practice because it did not improve survival or outcomes. • If serum CA-125 is elevated at the time of diagnosis, it can be followed at each visit.
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