Transcript malignant disorder of the cervi̇x,the vulva, the vagina

MALIGNANT DISORDER OF
THE UTERINE CORPUS
Assoc. Prof. Gazi YILDIRIM, M.D.
Yeditepe University, Medical Faculty
Dept of Ob&Gyn
Objectives
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To define
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Uterine cancer
To learn
Risk factors for endometrial cancer
 Prognostic factor for endometrial cancer
 Diagnosis of endometrial cancer
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To manage
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A woman with endometrial cancer
Endometrial Carcinoma
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The most common pelvic genital cancer in women.
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White woman have 2.4% risk of endometrial carcinoma
(Black woman 1.3%)
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The peak incidence in the 7th decade
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characterised by hyperplasia and anaplasia of the
glanduler elements, with invasion of underlying stroma,
myometrium and vascular spaces
Risk Factors
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Long term exposure to unopposed estrogens
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polycystic ovarian syndrom
chronic anovulation
obesity
late menopause
exogenous estrogens)
Metabolic syndrome including diabetes, hypertension
Nulliparity
Increasing age
History of breast cancer
genetic predisposition
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(hereditary nonpolyposis colon cancer syndrom) (HNPCC
syndrom)  MSH2, MLH1, Ha-, K-, N-ras, c-myc, Her-2/neu,
alterations in p53
ETIOLOGY
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Type I Endometrial carcinoma
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Associated with either endogenous
unopposed estrogen exposure
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low grade or well differentiated tumor with favourable
prognosis.
Type II Endometrial carcinoma
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Independent of estrogen
Associated with endometrial atrophy
High risk of relapse with poor prognosis.
or
exogenous
CLINICAL FINDINGS
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Abnormal bleeding
80% of patients
Most important and early symptom
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Menorrhagia
Metrorrhagia
Postmenopausal bleeding
Lower abdominal cramps and pain
10% of patients
It is secondary to uterine contractions caused by blood
trapped behind a stenotic cervical os
LABORATORY FINDINGS
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Rutin laboratory are usually normal
Anemia may be present
Pap smear
CA 125
SPECIAL EXAMINATIONS
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main examination: endometrial sampling
Fractional curretage
Endometrial biopsy
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Pelvic ultrasonography
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Pipelle, novac curet, vabra aspirator
In postmenopausal woman endometrial thickness of more
than 5 mm is considered to be suspicious for hyperplasia or
malignancy
Estrogen and progesteron receptor assays
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In general patiens with tumors positive for one or two
receptors have longer survival than patients with receptornegative tumors
CLASSIFICATIONS-1
1.
Adenocarcinoma
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The most common type (80%)
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Adenocarcinoma with squamous differantitation
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Serous carcinoma
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identical to the serous carcinoma of ovary
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1-10%
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Woman with serous carcinoma are more likely to be older
and less likely to have hyperestrogenic states
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spread early and involve peritoneal surfaces of the pelvis
CLASSIFICATIONS-2
4.
Clear cell carcinoma
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1% of all endometrial carcinomas
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Microscopic significance: clear cells or hobnail cells
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Solid, papillary, tubular and cystic patterns
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Commonly high grade and aggresive with deep invasion
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older woman (average age: 67 years)
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not associated with hyperestrogenic state.
Route of Metastasis
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Direct extension
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Lymphatic metastasis
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Peritoneal implants after transtubal spread
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Hematogenous spread.
Prognostic factors
Stage
 Histologic grade
 Cell type
 Depth of myometrial invasion
 Presence of lymphovascular space
involvement
 Lymph node status
 Involvement of the lower uterine segment
 Size of tumor
 Tumor ploidy and the proportion of cells in S
phase as determined by DNA flow cytometry
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Endometrium Kanseri Cerrahi Evrelemesi (FIGO2009)
Evre1 : tm uterus korpusuna sınırlı G1 2 3
1a: myometrial invazyon yok veya <1/2’den az
1b: myometriumun =>1/2’si invaze
Evre2: uterus korpusunu ve servikal stromayı tutar,uterusu aşmaz
Evre3: pelvise rejyonel tm yayılımı
3a:seroza ve/veya adnekslere invazyon
3b: vajinal ve/veya parametrial metastaz
3c: pelvik ve/veya para-aortik lenf nodu metastazı
3c1: pelvik lenf nodu metastazı
3c2: para-aortik lenf nodu metastazı var, pelvik lenf nodu metastazı var veya yok
Evre4: ilerlemiş pelvik hastalık veya uzak metastaz
4a:mesane ve/veya barsak mukozasında tümöral tutulum
4b: intraabdominal ve/veya inguinal lenf nodlarını içeren uzak metastazlar
TREATMENT
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Surgery
Radiation therapy
Hormone therapy
Chemotherapy
SURGERY
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The most important treatment modality
total simple or radical hysterectomy,
bilateral salpingooopherectomy
staging, including pelvic and periaortic
lymphadectomy
Surgical Staging
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who requires surgical staging?
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Patients with stage I disease with grade 3 lesions
Tumor greater than 2 cm in maximum dimension
Tumors with greater than 50% myometrial invasion
Cervical extention
Evidence of extrauterine spread
Clear cell and papillary serous carcinomas because
of high incidence of lymphatic spread
RADIATION THERAPY
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primary therapy in patients considered to be medically
unstable for laparotomy
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Adjuvant preoperative radiation is no longer used
unless the patient presents with gross cervical
involvement
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Relative contraindications
presense of pelvic mass,
a pelvic kidney,
pyometra,
history of a pelvic abscess,
prior pelvic radiation
previous multiple laparotomies
HORMONE THERAPY
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Progesteron has shown some efficacy
in the treatment of recurrent endometrial
carcinoma not amenable to irradiation or
surgery.
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In patients with well differentiated
estrogen receptor-positive tumors
tamoxifen has been used either alone
or in combination with progesterons.
CHEMOTHERAPHY
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Doxorubicin, cisplatin, taxol.
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Doxorubicin  single agent response rate
38%
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Doxorubicin + cysplatin  longer survival
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Taxol + doxorubicin+ cisplatin  response
rate 57%
Uterine Sarcomas
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Four categories;
leiomyosarcomas(LMSS)
 endometrial stromal sarcomas (ESSS),
 malignant mixed mesodermal tumors
(MMMTS)
 adenosarcoma
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