Malignant disease of the body of the uterus

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Malignant disease of the body ofthe uterus

• The most common malignant diseas affecting the
  uterus is endometrial carcinoma, which arises
  from the lining of the uterus.
• sarcomas also arise from the stroma of the
  endometriu'm or from the myometrium.

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introduction
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Incidence

• The incidence about age 45 years to about 55
  years and remains at the same high rate
  thereafter.

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Etiology

• The cause of endometrial carcinoma is unknown
  Many
• of the factors are related to an increase in
  oestrogen
• levels. excess oestrogen as the prime factor in
  the development of endometrial cancer. The
  interaction
• between oestrogen, insulin and insulin-like
  growth factor-may be more important.
• In the postmenopausal period, the majority
• of circulating oestrogen is derived from
  aromatization
• of peripheral androgens. This conversion takes
  place
• principally in adipose tissue. In addition,
  postmenopausal
• women with diabetes have increased oestrogen
  levels.women with polycystic disease increase
  oestrogen level.

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• Increasing evidence suggests that it is
  simplistic to view excess oestrogen as the prime
  factor in the development
• of endometrial cancer. The interaction
• between oestrogen, insulin and insulin-like
  growth factor-1 may be more important.

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risk factor

• number of factors that increase the risk of
  endometrial cancer are
• Obesity.
• Impaired carbohydrate tolerance.
• Nulliparity
• Late menopause.
• Unopposed oestrogen therapy.
• Functioning ovarian tumours.
• Previous pelvic irradiation.
• Family history of carcinoma of breast, ovary.

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• women who use oral contraception or progestogens
  have up to a 50 per cent reduction in the
  incidence of endometrial cancer and the
  protection lasts for many years after stopping
  these drugs.
• Cigarette smoking has also been associated with
  the reduced risk of endometrial cancer.

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Pathology

• The commonest subtype of endometrial carcinoma is
  called endometrioid because it resembles the
  normal proliferative endometrium.
• Squamous metaplasia can occur within
  adenocarcinomas and this can result in an
  adenoacanthoma or an adenosquamous carcinoma.
• Papillary serous and clear cell carcinomas .
• primary squamous cell carcinoma of the
  endometrium is extremely rare.

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uterus with adenocarcinoma ofthe endometrium.
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Clinical presentation

• 1-Most women with endometrial carcinoma will
  present with postmenopausal bleeding.
• 2- a postmenopausal discharge, particularly a
  bloodstained discharge.
• 3-premenopausal period, many women with
  endometrial carcinoma will present with
  intermenstrual bleeding.
• 4-one-third will present with heavy periods only.

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Diagnosis

• Traditionally, postmenopausal bleeding was
  investigated
• by a dilatation and curettage. More recently,
• however, diagnosis has shifted to the outpatient
  setting,
• with the ultrasound determination of endometrial
• thickness and outpatient sampling of the
• endometrium using instruments such as a Pipelle
• sampler in cases where the ultrasound suggests
  that
• the endometrium is more than 5 mm thick. If the
• sampler has been fully introduced into the uterus
• and no malignant tissue is identified, the test
  can be regarded as negative. Outpatient
  hysteroscopy may be
• Undertaken.

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Diagnosis

• Ultrasound also allows the ovaries to be imaged,
  as a number of patients with postmenopausal
  bleeding will have ovarian pathology. It is
  important to advise women to return if the
  bleeding recurs.

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StagingThe FIGO classification and staging are

• The carcinoma is confined to the corpus
• II The carcinoma has involved the corpus
• and the cervix but has not extended
• outside the uterus
• III The carcinoma has extended outside
  the
• uterus but not outside the true
  pelvis
• IV The carcinoma has extended outside the
• true pelvis or has obviously involved
• the mucosa of the bladder or rectum
• Bullous oedema as such does not permit a
• case to be allotted to Stage IV

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• Staging is usually by histopathology
  postoperative.

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Treatment

• Surgery
• The treatment of choice in patients with
  endometrial
• carcinoma is total abdominal hysterectomy and
  bilateral
• salpingo-oophorectomy.
• Most women with Stage IIdisease are not
  diagnosed until after the hysterectomyhas been
  performed. In such women, the prognosis is much
  the same as for Stage 1.
• Radical hysterectomy and bilateral pelvic
  lymphadenectomy with paraaortic node sampling is
  only performed if the cervical spread is clearly
  recognized before surgery. Even then,it is often
  wiser to treat the patient with radiotherapy like
  a cervical cancer

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• Lymphadenectomy has not achieved an
  establishedplace in the treatment of endometrial
  cancer only samplingThe age, the obesity and the
  high rate of co-morbidity in these women detract
  further from the widespread adoption of lymph
  adenectomy in women with endometrial cancer

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Radiotherapyindication

• 1- postoperative radiotherapy deep myometrial
• invasion was regarded as an indication for this
• adjuvant treatment.
• 2-recurrent disease. In this group of women,
  salvage
• radiotherapy offers a 50 per cent cure rate.
• 3-the patient with more advanced disease, but
  surgery is not usually the first line of
  treatment. Pelvic radiotherapy is
• performed and then occasionally residual disease
  may
• be removed surgically.
• 4- radiation to para-aortic nodal disease if
  there is lymphatic spread.

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Hormonal therapy

• Progestogens
• 1-The only value of progestogens is in the
  palliation of recurrent disease. Good results are
  obtained rarely and only with well-differentiated
  tumors containing oestrogen receptors.
• 2-Women unfit for surgery.

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Five-year survival for women with endometrial
cancer

• 5-year survival ()
• Stage I 83
• Stage II 71
• Stage III 39
• Stage IV 27

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Leiomyosarcoma

• Leiomyosarcoma arise in the uterine muscle.
• aris by transformation ofa previously benign
  fibromyoma(0.2per cent of fibro ids).
• Sarcoma also occasionally arises in the stroma of
  the endometrium -endometrial stromal sarcoma.

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pathology

• Tumours of this group grow more rapidly and are
  softer than fibromyomata. They may increase in
  size after the menopause.by naked-eye inspection,
  the tumour may
• be seen to have invaded the uterine wall or the
  capsule
• of the fibromyoma, and the cut surface often
  shows
• small haemorrhages and areas of degenerative
  softening.
• Microscopically, they consist of spindle-shaped
  or
• rounded cells, many of them pleomorphic, with
  little
• stroma and primitive blood vessels. Histological
  diagnosis
• of malignancy depends on the number of mitoses
• per high-power field (HPF).

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Metastasis

• Distant metastasis via the bloodstream and direct
  spread to adjacent structures often occur.

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DIAGNOSISTREATMENT

• These tumours occur in adults, who usually
  complain of uterine bleeding. Rapid growth of the
  tumour,with increasing pain, may give rise to
  suspicion of itsnature, but in many cases the
  diagnosis is made only after the tumour has been
  removed. In rare cases, asarcoma may be slow
  growing, and its nature discovered only when it
  recurs after operation.

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• Sarcoma and mixed mesodermal tumours of the uterus

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Mixed mesodermal tumours

• This includes tumours that contain heterologous
  mesenchymal elements. In adults they often
  present as a large fleshy mass protruding from
  the uterine
• wall into the uterine cavity.

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Histological examination

• shows that it contains some elements resembling
  sarcoma and others resembling carcinoma, together
  with bizarre components such as cartilage and
  striped muscle.

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CLINICAL PRESENTATION

• . The patient complains of bleeding from the
  uterus, and sometimes of pain. Tumours of this
  type occasionally follow uterine irradiation.
• Metastasis via the bloodstream is common,as is
  local recurrence after removal
• The prognosis is poor.

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• Sarcoma botryoides (embryonal rhabdomyosarcoma)is
  a variety of the same type of tumour that is seen
  in infants and young children.
• Clinical presentation
• There is a bloodstained,watery discharge and the
  vagina is found to contain grape-like masses of
  soft growth, usually arisingfrom the cervix.
• Local recurrence often follows removal, and
  distant metastases occur.

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Treatment

• total hysterectomy and bilateral
  salpingo-oophorectomy is performed, followed by
  external radiotherapy. radiotherapy must then be
  taken, depending on the extent and nature of the
  disease.
• The prognosis is poor,except for leiomyosarcoma
  arising in a fibromyoma.

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Treatment ofSarcoma botryoides (embryonal
rhabdomyosarcoma)

• In children, as with many other forms of
  malignant disease, the prognosis with
  conventional treatment has been very poor. The
  modern use of a combination
• of external irradiation and chemotherapy
  hasaltered the outlook

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T H A N K Y O u