18. Carcinoma Uterus - Amita Maheshwari

8/21/2019 18. Carcinoma Uterus - Amita Maheshwari

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Uterine CancerUterine Cancer


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Amita MaheshwAmita MaheshwAssoc. Professor of GynAssoc. Professor of Gyn

OncologyOncology

Tata Memorial HospTata Memorial Hospmaheshwariamita@yahoomaheshwariamita@yahoo


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IntrodctionIntrodction

The most common gynecologic cancer The most common gynecologic cancer de!eloped contries.de!eloped contries.

In India" it ran#s third amongst gyneIn India" it ran#s third amongst gyne

cancer.cancer. $%& cases are diagnosed in stage'I.$%& cases are diagnosed in stage'I.

('year sr!i!al rate )*%&.('year sr!i!al rate )*%&.


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+is# factors+is# factorsFactors increasing riskFactors increasing risk IIncreasencreasedd exposure to unopposed estrogenexposure to unopposed estrogen

estrogen-replacement therapy, obesity, anovulatory cycestrogen-replacement therapy, obesity, anovulatory cycl

estrogen-secreting tumorsestrogen-secreting tumors

NulliparityNulliparity Years of menstruation Years of menstruation HNP family syndromeHNP family syndrome !amoxifen!amoxifen Increasing ageIncreasing age

FactorsFactors decr decr easing riskeasing risk "rand multiparity"rand multiparity ##ral contraceptivesral contraceptives $$mokingmoking Physical activityPhysical activity


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+ole of+ole of ,creening,creening

+otine screening -OT recommended.+otine screening -OT recommended.

.. Postmenopasal women on e/ogenos ePostmenopasal women on e/ogenos ewithotwithot progestins progestins

0.0. 1omen from families with hereditary1omen from families with hereditarynonpolyposis colorectal cancer syndromnonpolyposis colorectal cancer syndrom

2.2. Premenopasal women with ano!latoryPremenopasal women with ano!latorysch as those with polycystic o!arian sch as those with polycystic o!arian


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Patients in 1hom a 3iagnosis of 4ndoPatients in 1hom a 3iagnosis of 4ndoCancer ,hold 5e 4/cldedCancer ,hold 5e 4/clded

.. All patients with postmenopasal 6leedingAll patients with postmenopasal 6leeding

0.0. Postmenopasal women with a pyometraPostmenopasal women with a pyometra

2.2. Asymptomatic postmenopasal women with enAsymptomatic postmenopasal women with encells on a Pap smear" particlarly if they arcells on a Pap smear" particlarly if they are

7.7. Perimenopasal patients with inter'menstraPerimenopasal patients with inter'menstraor increasingly hea!y periodsor increasingly hea!y periods

(.(. Premenopasal patients with a6normal terinPremenopasal patients with a6normal terinparticlarly if there is a history of ano!latparticlarly if there is a history of ano!lat


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Cases of Postmenopasal 5leCases of Postmenopasal 5le Atrophic endometritis8!aginitisAtrophic endometritis8!aginitis

4ndometrial or cer!ical polyps4ndometrial or cer!ical polyps

4/ogenos estrogens4/ogenos estrogens

4ndometrial hyperplasia4ndometrial hyperplasia 4ndometrial cancer4ndometrial cancer

Miscellaneos 9e.g." cer!ical cancer" Miscellaneos 9e.g." cer!ical cancer"

sarcoma" rethral carncle" trama:sarcoma" rethral carncle" trama:


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Management of endometrial hyperplasiaManagement of endometrial hyperplasia


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3iagnosis ; Pre'op in!estigation3iagnosis ; Pre'op in!estigation Office endometrial 6iopsy


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1HO histological classificat1HO histological classificat


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• Type' 9low grade:< )%&Type' 9low grade:< )%&

4o related' Arise on a 6ac#grond of hyperplasia.4o related' Arise on a 6ac#grond of hyperplasia.

?ong dration of nopposed estrogenic stimlation.?ong dration of nopposed estrogenic stimlation.

1ell'moderately differentiated.1ell'moderately differentiated.

=a!ora6le prognosis.=a!ora6le prognosis.

• Type'0 9high grade:< )%&Type'0 9high grade:< )%&

4o non'related' Arise in atrophic endometrim.4o non'related' Arise in atrophic endometrim.

-on'estrogen dependent.-on'estrogen dependent.

Poorly differentiated or non'endometroid types.Poorly differentiated or non'endometroid types.

High ris# of relapse and metastasis.High ris# of relapse and metastasis.

Prognosis poor.Prognosis poor.

Clinico'pathologic TypesClinico'pathologic Types


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Ca'4ndometrim ; Ca'O!aryCa'4ndometrim ; Ca'O!ary

)*& Ca'endometrim associated with simlta)*& Ca'endometrim associated with simlta

presence of endometroid type Ca'o!ary.presence of endometroid type Ca'o!ary. ,ynchronos


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,pread Patterns,pread Patterns

3irect e/tension to adacent strctre3irect e/tension to adacent strctre T T ranst6al passage of e/foliated cellsranst6al passage of e/foliated cells

??ymphatic disseminationymphatic dissemination HHematogenos disseminationematogenos dissemination


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Management of 4ndometrialManagement of 4ndometrial

%%s%%s Primary srgeryPrimary srgery Mid 2%sMid 2%s Pre'operati!e +T Pre'operati!e +T

$%s$%s Primary srgery' clinical sPrimary srgery' clinical s

**** =IGO ,rgico'pathologica=IGO ,rgico'pathologica

0%%*0%%* +e!ised =IGO staging+e!ised =IGO staging


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=IGO ,rgico'pathologic stagin=IGO ,rgico'pathologic stagin9 9 @** !s 0%%*: @** !s 0%%*:

,t.'I,t.'I Tmor confined to the corps tTmor confined to the corps t

IAIA -o myometrial in!asion-o myometrial in!asion

I5I5 Myometrial in!asion B halfMyometrial in!asion B half

ICIC Myometrial in!asion halfMyometrial in!asion half

IAIA -o or B half myometrial -o or B half myometrial

I5I5 Myometrial in!asion halMyometrial in!asion hal

,t.'II,t.'II Cer!ical in!ol!ementCer!ical in!ol!ementIIAIIA Cer!ical glandlar in!ol!ementCer!ical glandlar in!ol!ement

II5II5 Cer!ical stromal in!ol!ementCer!ical stromal in!ol!ement

IIII Tmor in!ades cer!ical stTmor in!ades cer!ical st

+e!ised =IGO stagin+e!ised =IGO staging

=IGO ,rgico pathologic stagi=IGO ,rgico pathologic stagin


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=IGO ,rgico'pathologic stagi=IGO ,rgico'pathologic stagin9@** !s 0%%*: 9@** !s 0%%*:

,t.'III,t.'III ?ocal and8or regional spread?ocal and8or regional spreadIIIAIIIA Tmor in!ades the serosa of the tersTmor in!ades the serosa of the ters anan

and8or positi!e cytologyand8or positi!e cytologyIII5III5 Eaginal in!ol!ementEaginal in!ol!ement

parametrial in!ol!ementparametrial in!ol!ementIIICIIIC Pel!ic and or para'aotic ?- in!ol!ementPel!ic and or para'aotic ?- in!ol!ement

IIIC Positi!e pel!ic nodes

IIIC0 Positi!e para'aortic nodes F pe,t.'IE,t.'IE Tmor in!ades 6ladder and8or 6owTmor in!ades 6ladder and8or 6ow

mcosa or distant metastasesmcosa or distant metastases

IEAIEA In!asion of 6ladder and8or 6owel In!asion of 6ladder and8or 6owel

IE5IE5 3istant metastases3istant metastases


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=IGO'Grade=IGO'Grade

Applies to 4ndometroid type seros aApplies to 4ndometroid type seros a

cell carcinomas are considered to 6e hcell carcinomas are considered to 6e hgrade.grade.

Grade


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,teps of ,rgical ,taging,teps of ,rgical ,taging

Peritoneal washings for cytologyPeritoneal washings for cytology 4/ploration of the a6domen ; pel!i4/ploration of the a6domen ; pel!i

5iopsy of any sspicios lesion5iopsy of any sspicios lesion

Total hysterectomy K 5,OLTotal hysterectomy K 5,OL

Pel!ic ; para'aortic lymphadenectoPel!ic ; para'aortic lymphadenecto

LL O!arian preser!ationO!arian preser!ation


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Eale of ,rgical ,tagingEale of ,rgical ,tagingPrognosticPrognostic


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Prognostic Eale of ?ymph -ode Met

-odal ,tats ('year s

-egati!e ?- %&

Positi!e pel!ic ?- $(&

Positi!e para'aortic ?- 2*&

'Morrow et al. Gynecol Oncol"@'Morrow et al. Gynecol Oncol"@


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Mor6idity of ?ymphadenectoMor6idity of ?ymphadenectoIntra'operati!e


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Contro!ersies in the srgical staContro!ersies in the srgical sta

Complete srgical staging inclding pel!ic and parComplete srgical staging inclding pel!ic and par

lymphadenectomy for all patients.lymphadenectomy for all patients. Complete srgical staging -OT needed for any pComplete srgical staging -OT needed for any p

Uterine ris# factors are sfficient to identify hiUterine ris# factors are sfficient to identify hi

cases.cases.

An identifia6le grop of intermediate8high ris# pAn identifia6le grop of intermediate8high ris# p

will 6enefit from complete staging while those atwill 6enefit from complete staging while those at

will not.will not.


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Predictors of ?- MetastasPredictors of ?- Metastase

3epth of myometrial in!asion3epth of myometrial in!asion

Tmor gradeTmor grade

Tmor siNe J0cmTmor siNe J0cm

4/tra'terine disease4/tra'terine disease

?ymph !asclar space in!asion?ymph !asclar space in!asion

Histologic s6'types type IIHistologic s6'types type II

+i # ifi i


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+is# ,tratification+is# ,tratification ?ow ris#?ow ris#


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4/tent of ?ymphadenectom4/tent of ?ymphadenectom

Para?-

Common iliac ?-Common iliac ?-

4/ternal iliac ?-4/ternal iliac ?-


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=ifty percent of patients with pel!ic n=ifty percent of patients with pel!ic n

metastases will ha!e additional para'aometastases will ha!e additional para'aonodal metastases.nodal metastases.

In 0(& patients" para'aortic lymph nodIn 0(& patients" para'aortic lymph nod

metastases can occr with negati!e pelmetastases can occr with negati!e pel!

Para'aortic ?- in!ol!ement can occr aPara'aortic ?- in!ol!ement can occr a

IMA to the renal !essels directlyIMA to the renal !essels directly

4/tent of ?ymphadenectom4/tent of ?ymphadenectom


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+ole of Ad!ant Therapy+ole of Ad!ant Therapy

Ad!ant therapy decisions '' 5ased on prognostic fact


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Prognostic factorsPrognostic factors AgeAge

Histologic typeHistologic type Histologic gradeHistologic grade Myometrial in!asionMyometrial in!asion Easclar space in!asionEasclar space in!asion Tmor siNeTmor siNe Hormone receptor statsHormone receptor stats 3-A ploidy and other 6iological mar#er3-A ploidy and other 6iological mar#er

+ # f ; d+i # ifi i ; Ad


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+is# stratification ; Ad!an+is# stratification ; Ad!an

+is# Category+is# Category 4/tent of disease4/tent of disease Ad!ant treAd!ant tre

?ow +is# ,perficial in!asion 9B80:?ow grade 980:

-o frther +/

Intermediate +is# High Grade3eep In!asion

?E,I

-egati!e ?ymph -odes

Eaginal 5rachyt

High +is# Positi!e ?ymph -odes,tage II

UP,C" CCCa

Positi!e P'A ?-s

4/ternal pel!ic

!aginal 6rachyt

CT K 4/tended


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M/ of Ad!anced8recrrent dis

Mltimodality +/ ,/" +T" CT" HT.Mltimodality +/ ,/" +T" CT" HT. ,rgical cytoredction in appropriately,rgical cytoredction in appropriately

selected cases


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=ollow p protocol=ollow p protocol

4!ery 2 mthly for 0 years4!ery 2 mthly for 0 years

4!ery mthly for 2 years4!ery mthly for 2 years

Annally life longAnnally life long

History

Clinical e/

Eaginal cy

+adiologic


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+ole of Minimally In!asi!e ,+ole of Minimally In!asi!e ,


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?aparoscopy seems to 6e an appro?aparoscopy seems to 6e an approalternati!e to open srgeryalternati!e to open srgery

?aparoscopic pel!ic lymphadenecto?aparoscopic pel!ic lymphadenecto

+ 6


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+o6otic ,rgery

+o6otic srgery for 4ndometrial'Ca can 6e+o6otic srgery for 4ndometrial'Ca can 6e

accomplished in hea!ier patients and resltsaccomplished in hea!ier patients and reslts

shorter operating times and hospital stay" shorter operating times and hospital stay"

transfsion rate" and less freent con!erstransfsion rate" and less freent con!erslaparotomy compared to laparoscopy.laparotomy compared to laparoscopy.

' ,eamon et al. Gynecol Oncol"0%%@

+ 6 ti , = 4 d t i l+ 6 ti , = 4 d t i l


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+o6otic ,rgery =or 4ndometrial +o6otic ,rgery =or 4ndometrial


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Eaginal ,rgery for 4ndometrEaginal ,rgery for 4ndometr Eaginal hysterectomy with 5,O


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4ndometrial Ca in ong 1ome4ndometrial Ca in ong 1ome=ertility preser!ation=ertility preser!ation

4arly stage" grade and P+ positi!e.4arly stage" grade and P+ positi!e. M+I to e/clde significant myometrial in!asionM+I to e/clde significant myometrial in!asion

adeate imaging of the o!ariesadeate imaging of the o!aries High dose progestins< megestrol acetate oraHigh dose progestins< megestrol acetate ora

% to 20% mg8day or medro/yprogesteron% to 20% mg8day or medro/yprogesteron0%% to (%% mg8day 0%% to (%% mg8day

7%& of these patients will carry a sccessfl 7%& of these patients will carry a sccessfl Hysterectomy is recommended once child6eariHysterectomy is recommended once child6eari

6een completed6een completed

M/ of Incompletely ,taged PaM/ of Incompletely ,taged Pa


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M/ of Incompletely ,taged PaM/ of Incompletely ,taged Pa+e!iew HP+' Grade" In!asion" adne/+e!iew HP+' Grade" In!asion" adne/

CT8M+I8 P4T'scanCT8M+I8 P4T'scan

-o gross disease-o gross disease

IA"I5IA"I5G"0G"0

O6ser!eO6ser!e

IC" any gradeIC" any gradeIIA"II5IIA"II5

+estaging+estaging Pel!ic +T Pel!ic +T

GroGro

,rgic,rgic

+T+T

+

l


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ConclsionsConclsions 3isease of postmenopasal women.3isease of postmenopasal women.

,ymptoms occr early in the corse< most,ymptoms occr early in the corse< mostha!e early stage disease at presentation.ha!e early stage disease at presentation.

O!erall ('year sr!i!al )*%&.O!erall ('year sr!i!al )*%&. Type' 9low grade" hormone sensiti!e:< e/Type' 9low grade" hormone sensiti!e:< e/

prognosisprognosis Type'0 9high grade" hormone independentType'0 9high grade" hormone independent

otcome.otcome.

C l iC l i


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ConclsionsConclsions

,rgery is the primary modality srgical st,rgery is the primary modality srgical st

offers the opportnity for the most accratoffers the opportnity for the most accratassessment of occlt e/tra'terine disease assessment of occlt e/tra'terine disease

nodal metastases.nodal metastases.

-odal metastasis is the most important ris#-odal metastasis is the most important ris#

The li#elihood of nodal metastasis increasesThe li#elihood of nodal metastasis increases

e/tent of disease and tmor grade.e/tent of disease and tmor grade.

Ad!ant +/ is needed in high ris# cases.Ad!ant +/ is needed in high ris# cases.

Uterine ,arcomas


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Pathological s6typesPathological s6types IncidencIncidenc ?eiomyosarcoma?eiomyosarcoma 0('0(' 4ndometrial stromal tmors4ndometrial stromal tmors %'%'

4ndometrial stromal nodle4ndometrial stromal nodle

4ndometrial stromal sarcoma'low grade4ndometrial stromal sarcoma'low grade

Undifferentiated sarcomaUndifferentiated sarcoma

Mi/ed epithelial'mesenchymal tmorsMi/ed epithelial'mesenchymal tmors

AdenosarcomaAdenosarcoma (&(&Carcinosarcoma 9Mi/ed Mllerian Tmor:Carcinosarcoma 9Mi/ed Mllerian Tmor: 7('7('

HomologosHomologos

HeterologosHeterologos

UndifferentiatedUndifferentiated (&(&

Uterine ,arcomas

M t f t iM t f t i


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Management of terine sarcoManagement of terine sarco ,rgery is the cornerstone of the treatme,rgery is the cornerstone of the treatme

Total a6dominal hysterectomy K 58? ,O is Total a6dominal hysterectomy K 58? ,O is gold standard.gold standard.

3e6l#ing srgery in ad!anced cases.3e6l#ing srgery in ad!anced cases.

4,, is hormone dependent so ,O is indicat4,, is hormone dependent so ,O is indicat

High recrrence rates e!en in early stage dHigh recrrence rates e!en in early stage d

Ad!ant treatment has shown to significanAd!ant treatment has shown to significanimpro!ement in sr!i!al.impro!ement in sr!i!al.

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18. Carcinoma Uterus - Amita Maheshwari