1. MALIGNANT DISEASE OF THE
UTERUS
Lectures on Gynecology
Dr Magda Helmi

2.  Endometrioid adenocarcinoma:
type 1 cancers account for 90 per cent of endometrial
adenocarcinomas, are oestrogen dependent, occur in younger
women and have a good prognosis.
 Serous papillary carcinoma:
type 2 cancers occur in elderly women, are non-oestrogen
dependent and have much poorer prognosis.
Clear cell carcinoma can rarely arise from the endometrium.
Endometrioid endometrial adenocarcinoma Uterine papillary serous carcinoma

3. Epidemiology
Worldwide, approximately 320,000 women
are diagnosed with endometrial cancer
each year, making it the fifth most
prevalent cancer in women. It is more
common in developed countries; the risk of
endometrial cancer is 1.6% compared to
0.6% in developing countries. Unlike most
cancers, the incidence rate has risen
dramatically in recent years, including an
increase of over 40% in the United
Kingdom between 1993 and 2013.

4. Risk factors for endometrial cancer
Obesity
Diabetes
Nulliparous
Late menopause >52 years
Unopposed oestrogen therapy
Tamoxifen therapy
Hormone replacement therapy Y N
Family history of colorectal or ovarian cancer

5. Signs and symptoms
Vaginal bleeding and/or spotting in postmenopausal
women are a common early sign of endometrial
cancer, especially in its adenocarcinoma form; it is
seen in approximately 2/3 of cases.
Abnormal menstrual periods or extremely long,
heavy, or frequent episodes of bleeding in
premenopausal women may also signify endometrial
cancer.
Thin white or clear vaginal discharge is a symptom in
postmenopausal women.
More advanced disease shows more obvious
symptoms or signs.

6. physical examination :
Pelvic examinations are frequently normal ,
The uterus may become enlarged or the cancer may
spread, causing lower abdominal pain or pelvic
cramping.
Pyometra may occur in advanced cases of the
disease.
These symptoms, not including bleeding, are often
not indicative of endometrial cancer; it is the cause of
these symptoms in 10-15% of women.

7. Diagnosis
Transvaginal
ultrasound
CT scans
MRI is also useful
for examining the
nearby lymph
nodes.
Dilation and
curettage or an
endometrial biopsy

8. Diagnosis
There is a continuing
debate about the value
of hysteroscopy in
diagnosis of serious
endometrial diseases,
such as cancer,
hyperplasia, or both.
This is because
individual studies on
histopathologic
validation of endoscopic
visual interpretation are
small, leading to
imprecise and
heterogeneous
estimates of accuracy.

9. Endometrial carcinoma is surgically staged using the FIGO cancer
staging system.
• IA: Tumor is confined to the uterus with less than half
myometrial invasion
• IB: Tumor is confined to the uterus with more than half
myometrial invasion
• II: Tumor involves the uterus and the cervical stroma
• IIIA: Tumor invades serosa or adnexa
• IIIB: Vaginal and/or parametrial involvement
• IIIC1: Pelvic lymph node involvement
• IIIC2: Para-aortic lymph node involvement, with or without
pelvic node involvement
• IVA: Tumor invades bladder mucosa and/or bowel mucosa
• IVB: Distant metastases including abdominal metastases
and/or inguinal lymph nodes
Myometrial invasion and involvement of the pelvic and para-aortic
lymph nodes are the most commonly seen patterns of spread.

10. Histopathological Classification
The two subtypes are genetically distinct.
Type I endometrial carcinomas occur most commonly in pre- menopausal women,
are more common in white women, often with a history of endometrial
hyperplasia. Type I endometrial cancers are often low-grade, minimally invasive
into the underlying uterine wall (myometrium), estrogen-dependent, and carry a
good prognosis. Type I carcinomas represent 75%-90% of endometrial cancer.
Type II endometrial carcinomas usually occur in older, post-menopausal women,
are more common in Black women, and are not associated with increased
exposure to estrogen or a history of endometrial hyperplasia. Type II endometrial
cancers are often high-grade, with deep invasion into the underlying uterine wall
(myometrium), and are of the serous or clear cell type, and carry a poorer
prognosis.
Type II Type I

11. Metastasis
ovaries and
Fallopian
uterus, and the
cervix
When the
lymphatic system is
involved, the pelvic
and para-aortal
nodes are usually
first to become
involved

12. Surgery
As the majority of patients present
with stage 1 disease, surgery is the
most common treatment for
endometrial cancer. The extent of
surgery will depend on a number of
factors including; grade of disease, MRI
stage and the patient’s co morbidities.

13. Adjuvant treatments
Postoperative radiotherapy will reduce the
local recurrence rate but does not influence
survival.
local radiotherapy to the vaginal vault given
over a short period of time (high-dose
radiotherapy, HDR), external beam
radiotherapy given for locally advanced disease
(stage 3) in combination with HDR.
Chemotherapy may also be given for
metastatic disease to combat the risk of distant
spread of the cancer.
.

14. Treatment of recurrences
Chemotherapy is often used to
treat recurrent endometrial
cancer, particularly capecitabine
and gemcitabine.

15. Survival rates
5-year relative survival rates by FIGO stage:
Stage 5 year survival rate
I-A 88%
I-B 75%
II 69%
III-A 58%
III-B 50%
III-C 47%
IV-A 17%
IV-B 15%

16. Recurrence rates
Recurrence of early stage endometrial
cancer ranges from 3 to 17%,
depending on primary and adjuvant
treatment. Most recurrences (70%)
occur in the first three years.
Higher-staged cancers are more
likely to recur

17. Adenosarcoma
Epidemiology
These are rare tumours accounting for
approximately 5 per cent of all uterine
cancers. They are classified into pure
sarcomas, heterogonous sarcomas or
mixed epithelial sarcomas depending on
tissue type present in the histological
specimen.

18. Classification
Pure sarcomas
This group includes endometrial stromal
sarcomas (ESS) and leiomyosarcoma. ESS
typically occur in perimenopausal women
between 45 and 50 years,
Mixed epithelial sarcomas (carcinosarcoma)
This group of tumours, formerly known as
mixed mesenchymal tumours contains both
carcinoma and sarcoma.
Heterologous sarcomas
This rare group of tumours consists of
sarcomatous tissue not usually found in the
uterus, such as striated muscle, bone or
cartilage.
Pure sarcomas
carcinosarcoma
Heterologous sarcomas

19. Etiology
Adenosarcomas have been reported in
women treated with tamoxifen and after
prior pelvic radiation. No association of
adenosarcoma with obesity or
hypertension has been reported.
No known racial or other epidemiologic
features associated with endometrial
carcinoma have been linked to
adenosarcomas.

20. Location
Approximately 90%
of adenosarcomas
arise in the uterine
corpus, but
cervical, vaginal,
tubal, ovarian, and
primary peritoneal
adenosarcomas
have also been
reported.

21. Clinical Features
The most common clinical
feature of adenosarcoma
is abnormal vaginal
bleeding, many times
associated with an
enlarged uterus, pelvic
pain,
and tissue protruding from
the cervical os

22. Prognosis and Predictive Factors
Most patients are considered cured of
adenosarcoma after simple hysterectomy;
however, they require long-term follow-up,
as recurrences generally occur more than 5
years later. Recurrences tend to occur in the
pelvis, with distant metastases (eg, to the
lung) following local recurrence.