UTERINE MALIGNANT AND BENIGN TUMOURS PPT

Uterine Cancers

1. UTERINE CANCER CHN

2. OUTLINE Introduction Aetiology Risk factors Staging Approach Treatment Other uterine malignancies Summary

3. INTRODUCTION Endometrial carcinoma is the most common gynaecological malignancy worldwide (30%) and fourth most common female cancer after Breast, colon and lung. Adenocarcinoma of the endometrium (lining of the uterus) is the most common histologic site and type of uterine cancer (75-85%). Others: mucinous , papillary serous , clear cell , squamous carcinoma Age related incidence 95/ 100 000 women with lifetime risk 1 in 90 with mean age of 54 years with incidence rising in mid 40s.

4. AETIOLOGY Associated with high levels of oestrogen. Menstrual cycle: endometrial proliferation due to oestrogen and secretory changes due to progesterone. Unopposed oestrogen leads to continual stimulation and proliferation with eventual carcinoma from increasing mitotic figures and cellular atypia (seen histologically)

5. RISK FACTORS Obesity- peripheral fat conversion of androgens to oestrogen Parity –infertility due to anovulation with nulliparity Family History- found in 15 % of cases Delayed menopause- menstruation beyond 52 years x4 risk Exogenous oestrogen- hormone replacement therapy, oppose with 11 days progesterone. Tamoxifen also risk. Endogenous oestrogen- PCOS anovulatory state and ovarian tumours Medical disorders- hypertensive, diabetic or previous pelvic irradiation

6. HISTOLOGY Adenocarcinoma most common cell type (60-80%) Graded according to degree of differentiation (% of solid growth patterns) Two distinct types Endometroid adenocarcinoma (type 1) 90% Serous papillary carcinoma (Type 2)

7. PATTERNS OF SPREAD Direct Depth of myometrial invasion correlates with degree of differentiation Lymphatic Primary site of tumour determines drainage site Involves pelvic nodes( obturator , common and external illiac ), para -aortic nodes or inguinal nodes Hematogenous Late process Metastises to liver, lungs, skeletal bones and rarely brain

8. FIGO STAGING

9. APPROACH TO PATIENT History Post menopausal (90%) or irregular bleeding Vaginal discharge – purulent due to secondary infection of tumour Lower abdominal pain or generalised- late presentation and sign of metastatic spread. dyspareunia Examination Systemic can reveal risk factors like obesity, HTN, DM Gynae exam- usually no abnormality seen but can find blood on speculum and bulky uterus. Pelvirectal exam- rule out parametrial involvement. Barrel shaped cervix

10. INVESTIGATION Cytology- poorly predictive Transvaginal USS - <5mm probably atrophy, greater than 5mm will require sample for histology Endometrial sampling- can use vacuum aspiration Hysteroscopy and dilatation and curettage

11. TREATMENT Surgical Mainstay treatment. Staging, adequate debulking and palliative role Involves TAH, bilateral salpingo -oophorectomy and peritoneal lavage as minimal in all cases. In advanced involves radicle hysterectomy and pelvic lymph node resection Radiation therapy- post operative Chemotherapy Hormonal- high dose progesterone Chemotherapeutic agents – Adriamycin and Epiadriamycin

12. Figure showing treatment according to stage

13. Cont …. Follow up Disease re occurrence or therapy related complications eg diarrhoea, dysuria or long term bladder and bowel complications (6%) Survival Average 80% 5 year survival rate but highly dependent on stage

14. Cont …. Survival rates Stage I  72% -Stage II  56% -Stage III  32% -Stage IV  11%

15. OTHER UTERINE MALIGNANCY Uterine Sarcomas Less than 1% of gynae malignancy Aetiology associated with previous pelvic radiotherapy Classification- according to histology Pure –single soft tissue element eg leiomyosarcomas Mixed Homologous- tissue native to uterine corpus Heterologus - tissue foreign to uterine corpus Most common are leiomyosarcomas , MMMT and Endometrial Stromal Sarcomas

16. Cont …. Malignant Mixed Mullerian Tumours (MMMT) Malignant soft tissue component and malignant epithelial component. HISTORY Lower abdominal mass, post menopausal bleeding or abnormal menstruation. DIAGNOSIS Histology and usually made post hysterectomy for clinically fibroid uterus or through curettage specimen Poor 5 year survival

17. SUMMARY Endometrial cancers are now the most common gynaecological malignancy worldwide. Increasing incidence due to increasing risk factors like obesity, HTN and DM, increasing age of population and hormonal therapy Mainstay treatment is surgical

18. REFFERENCES Monger A. Gynaecology by Ten Teachers. 19th ed. Dobs S, editor. London: Hodder Arnold; 2011 Spuy ZMvd . Handbook of Obstetrics and Gynaecology. 4th ed. Attwell A, editor. Capetown : Oxford University Press Southern africa ; 2009 . Up to Date. Greentop Guidelines