St George's Gynaecological Oncology Website
St George's Gynaecological Oncology Website
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Uterine Cancers
by
Thomas Ind
Consultant Gynaecological Surgeon
St George's & Royal Marsden Hospitals
UTERINE CANCER and SARCOMA
Uterine cancer
Incidence
There are about 3500 new case in the UK every year.
Age of presentation
The incidence increases with age
Geographic distribution
The incidence is higher in the the developed countries. In the USA it is the most common gynaecological cancer. In the UK it is the second most common gynaecological cancer.
Predisposing factors
Endometrial cancer is more common in women who are nulliparous and who have had an early menarche and late menopause. There is an association with polycystic ovarian syndrome due to an excess of unapposed oestrogens in anovulatory cycles. There is also an association with obesity due to peripheral aromatisation of androstenedione. Women who take unopposed HRT have a much higher risk of endometrial cancer as do women receiving tamoxifen therapy. There is also an association with diabetes and hypertension.
Pathology
There are four main histological types of endometrial cancer;
· Endometrioid
· Clear cell
· Serous papillary
· Mixed Mullerian
Mixed Mullerian cancers are not true cancers but carcinosarcomas (there is a sarcoma element as well). They have a poor prognosis. The most common type are endometrioid cancers. Clear cell and Serous papillary are also glandular cancers and carry a worse prognosis.
Staging
Stage I Confined to uterus
Ia confined to endometrium
Ib <50% myometrial invasion
Ic >50% myometrial invasion
Stage II Spread to cervix
IIa endocervical gland involvement only
IIb cervical stromal involvement
Stage III Further spread
IIIa serosa, adnexae, +/- +ve peritoneal washings
IIIb vaginal metastases
IIIc pelvic or para-aortic lymph nodes
Stage IV Outside pelvis
IVa adjacent organs (bladder or rectum)
IVb distant spread
Each stage also takes into account grade (1, 2 or 3)
Clear cell and serous papillary tumors are all grade 3
Clinical features
Usually presents with postmenopausal bleeding. Risk factors include;
Nulliparity
Diabetes
Obesity
Hypertension
Unopposed HRT usage
Tamoxifen usage
Treatment
It is recommended that all women with endometrial cancer have a TAH BSO. There is little argument for a radical hysterectomy in stage 2 disease if a patient will receive pelvic radiotherapy irrespective. Therefore a standard hysterectomy is usually performed.
Recent studies have suggested that a laparoscopic approach to treatment may be associated with less complications. It is generally agreed that women with peritoneal and serosal involvement of cancer should have an open operation to reduce the risk of port site disease.
The role of Lymphadenectomy is controversial. It may be of benefit but lymph node sampling is utilised by many instead of a full resection. Lymph node status is required for staging.
The role of radiotherapy is also controversial. However, most agree that women with high risk tumors (serous papillary, clear cell, mixed mullerian, grade three), or in those with deep myometrial invasion (1c and above) should have both external beam radiotherapy and vagina radiotherapy.
Chemotherapy is now often given for stage 3 disease. High dose progesterones and GnRH analogues are often used for advanced disease.
Recurrent endometrial cancer carries a poor prognosis. If it is a single site of recurrence at the top of the vagina it may be possible to excise it surgically (Exenteration) or to use radiotherapy if a woman has not had it already. Other treatments include chemotherapy and hormone treatment.
Prognosis
The overall prognosis is about a 70% five year survival. Most stage 1 cancers are cured. The prognosis in the UK is less good than in other countries.
Pure uterine sarcomas are rare and occur in less than 1 in 1000 women.
Late 50s.
Occur in all countries. Leiomyosarcoma is more common in African countries. Mixed Mullerian cancer is commonest in the USA and western countries but has an increasing incidence in Asian.
Leiomyosarcoma is a sarcoma of a leiomyoma (fibroid).
Stromal sarcoma is a tumour of soft tissue fibres of the womb.
A 'Mixed Mullerian' tumour of the uterus is a mixed cancer consisting of a sarcoma and an endometrial cancer. These 'Mixed Mullerian' tumours are also called 'Carcinosarcomas' and behave more like aggressive endometrial cancer.
Sometimes it is difficult to distinguish histologically whether a lesion is a fibroid or a leiomyosarcoma. These tumours are sometimes called STUMPs which stands for Soft Tissue Tumours of Uncertain Malignant Potential.
Treatment is initially by surgery with removal of the womb and ovaries.
Most women also require radiotherapy. There are two types of radiotherapy commonly used.
Chemotherapy is used for mixed mullerian cancers when they have spread. The role of chemotherapy in stromal sarcomas and leiomyosarcomas is limited.
Hormone treatment in the form of antioestrogens called GnRH analogues is sometimes advised for some types of leiomyosarcoma and stromal sarcoma. Some forms of advanced Mixed Mullerian tumours are treated with hormones called GnRH analogues and progesterones.
Recurrent sarcoma carries a poor prognosis. If a woman has a single site of recurrence at the top of the vagina it may be possible to excise it surgically or to use radiotherapy if a woman has not had it already. Other treatments include chemotherapy and hormone treatment.
This is dependant on the type of sarcoma and stage. Low grade stromal sarcomas general have a good prognosis where as Mixed Mullerian and high grade sarcomas so less well.