1. MALIGNANT DISORDER OF THE UTERINE CORPUS
Assoc. Prof. Gazi YILDIRIM, M.D.
Yeditepe University, Medical Faculty
Dept of Ob&Gyn

2. Objectives To define To learn To manage Uterine cancer
Risk factors for endometrial cancer
Prognostic factor for endometrial cancer
Diagnosis of endometrial cancer
To manage
A woman with endometrial cancer

3. Endometrial Carcinoma
The most common pelvic genital cancer in women.
White woman have 2.4% risk of endometrial carcinoma (Black woman 1.3%)
The peak incidence in the 7th decade
characterised by hyperplasia and anaplasia of the glanduler elements, with invasion of underlying stroma, myometrium and vascular spaces

4. Risk Factors Long term exposure to unopposed estrogens
polycystic ovarian syndrom
chronic anovulation
obesity
late menopause
exogenous estrogens)
Metabolic syndrome including diabetes, hypertension
Nulliparity
Increasing age
History of breast cancer
genetic predisposition
(hereditary nonpolyposis colon cancer syndrom) (HNPCC syndrom)  MSH2, MLH1, Ha-, K-, N-ras, c-myc, Her-2/neu, alterations in p53

5. ETIOLOGY Type I Endometrial carcinoma Type II Endometrial carcinoma
Associated with either endogenous or exogenous unopposed estrogen exposure
low grade or well differentiated tumor with favourable prognosis.
Type II Endometrial carcinoma
Independent of estrogen
Associated with endometrial atrophy
High risk of relapse with poor prognosis.

6. CLINICAL FINDINGS Abnormal bleeding Lower abdominal cramps and pain
80% of patients
Most important and early symptom
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

7. LABORATORY FINDINGS Rutin laboratory are usually normal
Anemia may be present
Pap smear
CA 125

8. SPECIAL EXAMINATIONS main examination: endometrial sampling
Fractional curretage
Endometrial biopsy
Pipelle, novac curet, vabra aspirator
Pelvic ultrasonography
In postmenopausal woman endometrial thickness of more than 5 mm is considered to be suspicious for hyperplasia or malignancy
Estrogen and progesteron receptor assays
In general patiens with tumors positive for one or two receptors have longer survival than patients with receptor-negative tumors

9. CLASSIFICATIONS-1 Adenocarcinoma
The most common type (80%)
Adenocarcinoma with squamous differantitation
Serous carcinoma
identical to the serous carcinoma of ovary
1-10%
Woman with serous carcinoma are more likely to be older and less likely to have hyperestrogenic states
spread early and involve peritoneal surfaces of the pelvis

10. CLASSIFICATIONS-2 Clear cell carcinoma
1% of all endometrial carcinomas
Microscopic significance: clear cells or hobnail cells
Solid, papillary, tubular and cystic patterns
Commonly high grade and aggresive with deep invasion
older woman (average age: 67 years)
not associated with hyperestrogenic state.

11. Route of Metastasis Direct extension Lymphatic metastasis
Peritoneal implants after transtubal spread
Hematogenous spread.

12. 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

13. 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

14. TREATMENT
Surgery
Radiation therapy
Hormone therapy
Chemotherapy

15. SURGERY The most important treatment modality
total simple or radical hysterectomy,
bilateral salpingooopherectomy
staging, including pelvic and periaortic lymphadectomy

16. Surgical Staging who requires surgical staging?
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

17. RADIATION THERAPY
primary therapy in patients considered to be medically unstable for laparotomy
Adjuvant preoperative radiation is no longer used unless the patient presents with gross cervical involvement
Relative contraindications
presense of pelvic mass,
a pelvic kidney,
pyometra,
history of a pelvic abscess,
prior pelvic radiation
previous multiple laparotomies

18. HORMONE THERAPY
Progesteron has shown some efficacy in the treatment of recurrent endometrial carcinoma not amenable to irradiation or surgery.
In patients with well differentiated estrogen receptor-positive tumors tamoxifen has been used either alone or in combination with progesterons.

19. CHEMOTHERAPHY Doxorubicin, cisplatin, taxol.
Doxorubicin  single agent response rate 38%
Doxorubicin + cysplatin  longer survival
Taxol + doxorubicin+ cisplatin  response rate 57%

20. Uterine Sarcomas Four categories; leiomyosarcomas(LMSS)
endometrial stromal sarcomas (ESSS),
malignant mixed mesodermal tumors (MMMTS)
adenosarcoma