Uterine Cancer

Epidemiology

It is important that the endometrium neoplasm is detected early in the course of evolution with at least 75% of new cases limited to the uterus in the clinical evaluation.

In the US for 2009 it was estimated 42,160 new cases and 7780 deaths. Endometrial cancer is the most common gynecologic malignancy and justifies 6% of all cancers in women. To detect endometrial cancer, a technique is required that can remove endometrial tissue. Pap smear is not a test Babes safety endometrial cancer, though a retrospective study found a strong correlation between positive cervical cytology and high risk disease (high-grade tumor, deep myometrium invasion) as well as an increased risk of lymph node disease.

In Romania in 1996 Crude incidence was 7.2 per 100,000 women and 4.9 deaths per 100,000 women.

In Romania the estimated incidence for 2000 was 13.6 to 100,000 inhabitants and the mortality rate of 3.7 per 100,000 inhabitants.

Risk Factors

1. Obesity

2. Hypertension

3. Infertility, nulliparous women

4. Obesity

5. Diabetes

6. Polycystic ovarian disease

7. Family history of cancer

Histopathological types

I. epithelial tumors: 90%

1). Adenocarcinomas -67%

2). Adenoacantoma- 10.3% – favorable development

3). Adenoscuamos carcinoma 12.6% – aggressive development

4). Clear cell carcinoma <1% – aggressive development

5). Squamous cell carcinoma – aggressive development

6). Papillary serous carcinoma – 10% – aggressive development

7). Endometrioid carcinoma papillary

II. Mesenchymal tumors leiomiosarcomas 5% –

III. Mixed tumors adenosarcoamas 3% –

IV. 2% Secondary tumors – metastasis

– Direct extension of the cervix, ovary, colon

Signs and symptoms: abnormal vaginal discharge, vaginal discharge in postmenopausal women or heavy menstrual periods, prolonged, increasing the uterus.

Diagnosis and staging

The diagnosis is confirmed by histopathological examination.

Stage I – 75% tumor limited to the uterus

Stage I (T1a) – Tumor limited to the endometrium

Stage I b (T1b) – Tumor invades <1/2 of myometrium

Stage I c (T1c) – Tumor invades> 1/2 of myometrium

G1: well-differentiated

G2: moderately differentiated

G3: undifferentiated

Stage II – 11% – Tumor invades the body and cervix but not the uterus exceeds

Stage II (T2a) – Invasion of endocervical gland only

Stage II b (T2b) – Invasion of cervical stroma

Stage III – 11%: Tumor extends beyond the uterus but not outside the pelvis

Stage III (T3a) – Tumor invades serous and / or positive peritoneal cytology Annex or

Stage III b (T3b) – The tumor invades the vagina

Stage III c (T1-3 N1) – Pelvic lymph node and / or para-aortic metastases

Stage IV – 3% – cancer extends beyond the pelvis or invades bladder or

to the rectal mucosa.

Stage IVa (T4) – The tumor invades the lining of the bladder and / or bowel.

Stage IVB (M1) – abdominal distant metastases including lymph and / or groin.

For staging is recommended:

• Historically, complete clinical examination,

• blood count,

• brief examination urine, urea, creatinine, glucose, liver tests

• EKG, chest X-ray, ultrasound,

• urography, barium enema,

• pelvic and abdominal CT, MRI

• exploratory laparotomy with all data obtained from histopathology.

TREATMENT

Therapeutic Indication

Atypical adenomatous hyperplasia (premalignant disease)

In postmenopausal women with hysterectomy and perimenopause is recommended.

In premenopausal women progestational cyclic therapy is recommended. If after 3 months of therapy practiced progestational premalignant lesions persist- hysterectomy.

H.T. with SOB – total hysterectomy with bilateral salpingo-oophorectomy

Stage I

Total abdominal hysterectomy is recommended salpingo-oophorectomy with

In patients with risk factors for occult disseminated disease is practiced surgical staging.

Risk factors for occult disease:

– Histological grade G2, G3

– Variations histological types: serous papillary carcinoma, endometrial papillary carcinoma, clear cell carcinoma

– G1 myometrium invasion> 50% and neck

Surgical Staging focuses on two areas: the abdominal cavity and retroperitoneal lymph nodes. It consists of visual and careful inspection probe with biopsy abnormal areas of the peritoneum or serous. In the absence of obvious macroscopic releases is performed multiple biopsies (randomly) peritoneal. Cytological and histological samples were taken from the diaphragm. Remove a portion of the diaphragm. Carry out a selective and systematic lymphadenectomy pelvic lymph nodes and para-aortic. The primary purpose of surgical staging is to provide an accurate assessment of disease extension at treatment initiation.

For patients with stage I disease confined to the uterus without risk factors for occult disease (G1 invasion superficial myometrium) recommended treatment is total hysterectomy with bilateral salpingo-oophorectomy.

Patients with risk factors have an incidence of recurrent disease by 25% -40% and require adjuvant therapy, postoperative.

Postoperative pelvic radiotherapy is indicated in patients with risk factors for local recurrence:

a) mucinous carcinoma, papillary serous papillary endometrial

b) the invasion of the myometrium more than 50% or the invasion of the cervical stroma

c) lymphovascular invasion

d) lymph node invasion

e) the invasion of the whole uterine cavity

The total dose of radiation is 40-50 Gy to the whole pelvis.

Primary Radiotherapy

Although surgery is the primary treatment of endometrial carcinoma, radiotherapy is also an effective treatment for patients with inoperable medical conditions or unresectable disease.

For patients with stage I uterine cancer and stage II treated with radiotherapy alone were reported survival rates of 75% – 85% and local recurrence rates of 10% -20%. In patients with serous papillary tumors survival rate was 43% and was not different from that obtained only by hysterectomy.

In patients with tumors G1, G2, tumors that do not increase the uterus intracavitary irradiation treatment is indicated only.

In patients with tumors that increase uterine cavity, cervix invasion or pelvic radiotherapy is recommended G3 and intracavitary irradiation then.

Stage II

a) .For patients with stage IIa where there is contraindication for surgery is radical hysterectomy with bilateral salpingo-practice oophorectomy and pelvic lymphadenectomy.

If pelvic lymph node metastases or occult parametrial invasion practiced the whole pelvis irradiation with 50 Gy associated with brachytherapy 4-6 weeks after surgery.

If there is no nodal invasion or intracavitary irradiation parameters are carried out only because of the risk of local recurrence.

b) .For patients stage IIb (with extended cervical extension) which are not candidates for hysterectomy is performed extensive radiotherapy with 50 Gy whole pelvis. If there are large invasion of the cervix is ​​added and intracavitary irradiation. At 4-6 weeks after irradiation practice simple hysterectomy.

Stage III.

Stage IIIa and IIIc ovarian there nodal metastases recommended total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy periaortitis. Omentectomy is added when there is intraperitoneal or adnexal metastasis. 4-6 weeks after surgery is performed whole pelvis radiation.

Vaginal metastases in stage IIIb recommended by external irradiation of the whole pelvis and intracavitary radiation to a total dose of 7000-8000 cGy and 5000-6000 cGy to point A to point B.

Stage IV – Treatment at this stage is palliative role although some patients with stage IVa (invasion of bladder and rectum) can be cured.

Stage IVa. It is recommended that whole pelvis radiation therapy with a total dose of 4500-5000 cGy intracavitary irradiation and where technically possible.

After completing radiation where it is technically possible bleeding and infection persist practice total hysterectomy with bilateral salpingoophorectomy.

Stage IVB. It is recommended that the whole pelvis external irradiation with a total dose of 4500- 5000 cGy.

Chemotherapy is associated with hormonal agents or cytotoxic agents. Where technically possible bleeding or infection persists in total abdominal hysterectomy is recommended pelvis with bilateral salpingoophorectomy.

Endometrial Cancer Treatment Radiotherapy only

The results are worse than radiation recall after surgery or radiotherapy combined treatment associated with surgical treatment.

Radiation therapy should be reserved for isolated patients with increased medical risk and those with extensive pelvic tumors that cannot be operated.

Survival at 5 years was 69% for stage I to stage II 47% and 18% for stage III.

Chemotherapy and hormonal therapy

It is indicated in recurrent or metastatic disease.

a) In patients with G1 and progesterone receptor positive (+) is recommended hormonal therapy (response rate 40%)

b) In patients with G2, G3 and progesterone receptor negative (-) is recommended chemotherapy.

Megace (megestrol acetate) 80-160mg / day produced objective responses between 15-40% in patients with well-differentiated tumors (G1) with lung metastases only and with a long disease-free interval after completion of initial treatment.

Most patients with advanced disease and anaplastic tumors have recidivating absence RE and RP and not responding to hormone therapy.

Chemotherapy

The most active drugs are cisplatin, paclitaxel, doxorubicin and carboplatin.

see table no. 26 chemotherapy regimens:

1. Taxol 175 mg / m2 IV on Day 1 3:00

Carboplatin AUC 6 IV in 1 hour day 1

Was repeated 21 days

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2. Cisplatin 50 mg / m2 day 1

Doxorubicin 60 mg / m2 day 1

Repeat for 21 days.

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3. Docetaxcel 75mg / m2 iv in 250ml NS

Carboplatin AUC 5 iv in 250ml NS

Repeat 3 weeks

Prognostic

1. Disease stage is the most important prognostic factor. The more advanced the stage of survival is lower: stg. I – 87% std. II – 71% std. III – 50% std. IV – 9%

2. The histological degree and myometrial invasion. As the risk histologic increases, there is increase in myometrial invasion, lymph node invasion and metastasis of marrow.

3. Histological type. The prognosis is increasingly unfavorable according to the histology in the following order: adenoacantoma, adenosquamous carcinoma, clear cell carcinoma and small cell carcinoma.

4. Vascular space invasion is a negative prognostic factor.

5. The presence of hormonal receptors, estrogen and progesterone is associated with a favorable prognosis

6. Aneuploidy is associated with an increased risk of relapse.

Survival at 5 years is:

90% for stage I,

75% for stage II,

50% for stage III

10% for stage IV.

Tracking. Clinical examination is recommended abdominal and pelvic Papanicolaou cytology at 3 months in the first 2 years and 6 months for the next 3 years. We recommend chest X-ray, abdominal CT or annual depending on the symptoms.

UTERINE Sarcomas

2-5% of uterine tumors arise from endometrial stroma and myometrium.

see table no. 28

Histological Classification

Homologous: Leiomiosarcomas – unfavorable

Stromal sarcomas – favorable development

Endolymphatic stromal miosis

Angiosarcoma

Fibrosarcoma

Heterologous: rhabdomyosarcoma – unfavorable

Chondrosarcoma – unfavorable

Osteosarcoma

Liposarcoma

Staging

Similar to cervical carcinoma

TREATMENT

Therapeutic Indication

Stage I and II

We recommend total hysterectomy with bilateral salpingo-oophorectomy. Associate postoperative radiotherapy and systemic chemotherapy because of the increased number of lymph node metastases and distant.

Stage III

Surgical treatment of cytoreduction of tumor bleeding and central pain relieving, without making an aggressive cytoreduction due to the risk of bleeding.

Associating radiotherapy associated with systemic chemotherapy.

Chemotherapy

Most active cytostatics are cisplatin, ifosfamide and doxorubicin.

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Cisplatin 100 mg / m2 / day, i.v. on day 1

Ifosfamide 1.5 g / m2 / day, days 1-5 i.v.

Repeat 21 days.

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Docetaxel 75 mg / m2 IV day 1

Gemcitabine 800mg / m2 IV day 1

Repeat 21 days.

Survival is:

<50% for stage I,

10% for stage II

0% in stage III

0% in stage IV