Uterine Cancer

Xi-Shi Liu

Obstetrics and Gynecology Hospital

Fudan university
2012.08
 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.
 General Description
• A malignant epithelial
disease that occurs in
endometrial gland of
uterus

• Also called endometrial

cancer
 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

 Estrogen independent type
-- Have no source of estrogen stimulation of
endometrium.

--Arising in background of atrophic

endemetrium

--Less differentiated

--ER(-)PR(-)

--Poor prognosis
 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.
 Risk Factors
2. Some gynecologic diseases
( Long-term endogenous estrogen
exposure )
- polycystic ovary syndrome
- functioning ovarian tumors
- anovulating dysfunctional bleeding
- Infertility, Nulliparity.
 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.
 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%)
 Five histological subtypes

• Endometrioid adenocarcinoma
• Mucinous carcinoma
• Serous adenocarcinoma
• Clear cell carcinoma
• Other rare subtypes
 Five histological subtypes
--Endometrioid Adenocarcinoma

• Account for about

80~90%.

• Well differentiated.

• Prognosis is better.
 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.
 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.
 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%
Five histological subtypes
--other rare subtypes

• Squamous adenocarcinoma

• Undifferentiated carcinoma

• Mixed adenocarcinoma
 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)
 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
 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
• Ultrasonography

– Useful adjuvant method

– Significances

• Size of lesion

• Invasion of endometrium or cervix

• Resistant index of new vessels

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.

A B
Hysteroscopy
– Significance
-Direct observation

-Taking sample correctly

-Identifying polyps and submucous myoma

Pap test
-Unreliable diagnostic test
-30%-50% abnormal pap test results

Others
-MRI, CT, chest x-ray, IV urography,

cystoscopy, sigmoidoscopy,
 Diagnosis

• History, and clinical sign ,

related risk factors symptoms

• Diagnostic methods
 Differential Diagnosis

• Senile endometritis / vaginitis

• Dysfunctional uterine bleeding
• Submucous myoma / Endometrial
polyps
• Cervix cancer / Sarcoma of uterus/
Primary carcinoma of fallopian tube
 Metastasis Route

• Direct extension

• Lymphatic metastasis: important route

• Hematogenous metastasis
 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
 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
 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
 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
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
Stage IIa*
Endocervical glandular involvement only

Stage IIb*
Cervical stromal invasion
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
Stage IVa*
Tumor invasion of bladder and/or bowel mucosa
Stage IVb*
Distant metastases, including intra-abdominal metastasis
and/or inguinal lymph nodes
 Treatment
• Surgery Radiation

• Chemotherapy Hormone therapy

 Early stage
--- surge+ postoperative adjuvant therapy
 Advanced stage
--- radiation+ surge+ medicine
 Principle of choice
• General condition (Age, complication)

• Clinical stage

• Tumour pathologic type

 Surgery
• Object
– 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
• Stage II
– Radical hysterectomy + pelvic
lymphadenectomy + paraortic
lymphadenectomy
• Stage III,IV
– Cytoreductive surgery
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
 Radiation therapy

• Radiation alone

• Radiation with surgery

 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
Indications for radiation alone
• Elderly or obesity
• Multiple chronic or acute medical
illness
(hypertension, cardial disease, diabetes,
pulmonary, renal)
• Advanced stage unsuitable for
surgery
 Hormone Therapy
• mechenism
– Most endometrial cancers have both ER &
PR.(Estrogen dependent subtype)

 Indications:
– Advanced or recurrent stage
– Early stage and desire for fertility
• Used drugs
– MPA
 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.
 Prognostic Factors
• Tumour bilologic bihavior
– 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
 5-Year Survival Rate
• Stage I b: 94%
• Stage I c: 87%
• Stage II : 84%
• Stage III : 40-60%
 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
 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?