1. Xi-Shi Liu Obstetrics and Gynecology Hospital Fudan university 2012.08
Uterine Cancer
Xi-Shi Liu
Obstetrics and Gynecology Hospital
Fudan university

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 Also called endometrial cancer
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. Five histological subtypes
Endometrioid adenocarcinoma
Mucinous carcinoma
Serous adenocarcinoma
Clear cell carcinoma
Other rare subtypes

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

12. 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.

13. 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.

14. 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%

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

16. 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)

17. 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

18. 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

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

20. 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. B A

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

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

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

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

25. Metastasis Route Direct extension
Lymphatic metastasis: important route
Hematogenous metastasis

26. 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

27. 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

28. 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

29. 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

30. Stage Ia. Tumor limited to the endometrium Stage Ib
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

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

32. 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

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

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

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

36. Surgery Object Stage I :
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

37. Stage II
Radical hysterectomy + pelvic lymphadenectomy + paraortic lymphadenectomy
Stage III,IV
Cytoreductive surgery

38. 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

39. Radiation therapy
Radiation alone
Radiation with surgery

40. 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

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

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

43. 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.

44. Prognostic Factors Tumour bilologic bihavior Choice of treatment
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

45. 5-Year Survival Rate Stage I b: 94% Stage I c: 87% Stage II : 84%
Stage III : 40-60%

46. 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

47. 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? ?

48. THANKS
THE END