Uterine CancerXi-Shi LiuObstetrics and Gynecology HospitalFudan university 2007.04General 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 cancerClassification (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 prognesisl Estrogen independent type- Have no source of estrogen stimulation of endometrium.-Arising in background of atrophic endemetrium-Less differentiated-ER(-)PR(-)-Poor prognosisRisk Factors1. 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 Factors2. Some gynecologic diseases ( Long-term endogenous estrogen exposure )- polycystic ovary syndrome- functioning ovarian tumors - anovulating dysfunctional bleeding- Infertility, Nulliparity.Risk Factors3. Prolonged Use of estrogen a. Prolonged menopausal estrogen replacement therapy without progestogen.b. Prolonged use of the antiestrogen tamoxifen for breast cancer.Risk Factors4. Genetic factors and other factors a. Endometrial and ovarian cancer are the simultaneously occurring with other genital malignancy ,reported incidence (1.43.8%).b. Family history of tumor is higher.(12- 28%) Five histological subtypes Endometrioid adenocarcinoma Mucinous carcinoma Serous adenocarcinoma Clear cell carcinoma Other rare subtypesFive histological subtypes -Endometrioid Adenocarcinoma Account for about 8090%. Well differentiated. Prognosis is better.Five histological subtypes-Mucinous carcinomaRare (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 carcinomaa. 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 adenocarcinomaClinical 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 stageSpecial ExaminationDilation 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 vesselsEndometrial 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.ABHysteroscopySignificance-Direct observation-Taking sample correctly-Identifying polyps and submucous myomaPap test-Unreliable diagnostic test-30%-50% abnormal pap test resultsOthers-MRI, CT, chest x-ray, IV urography, cystoscopy, sigmoidoscopy, Diagnosis History, and clinical sign , related risk factors symptoms Diagnostic methodsDifferential Diagnosis Senile endometritis / vaginitis Dysfunctional uterine bleeding Submucous myoma / Endometrial polyps Cervix cancer / Sarcoma of uterus/ Primary carcinoma of fallopian tubeMetastasis Route Direct extension Lymphatic metastasis: important route Hematogenous metastasis Clinical Stage (FIGO 1971) Stage IIa The carcinoma is confined to the corpus and the length of the uterine cavity is 8 cmIb 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 uterusClinic