Uterine Cancer

Uterine Cancer 2nd commonest gynae malignany (after ovary) Incidence lower in women < 40 yrs (2/100,000), rises rapidly 40-55yrs & levels off after menopause (44/100,000) Linked to high oestrogen levels Obesity - peripheral androgens à oestrogens (DM, HT, endometrial Ca linked by obesity) Nulliparity & Late menopause– due to continued cycles with no anovulation Unopposed oestrogen HRT – x4 risk (only x1 with opposed HRT or if mirena also used) Oestrogen secreting tumours – rare Less common with COCP, smokers (bec earlier menopause) Type 1 More common, oestrogen dependent, seen around menopause, detected earlier & better prognosis. Cells have oestrogen & progesterone receptors; May be endometrial hyperplasia before Type 2 Seen in older women, less common, not preceeded by hyperplastic/in situ, progresses rapidly. Features Abnormal uterine bleeding (PMB 70-80%. malignant until proven otherwise in postmenopausal & suspicious in > 40s) Vaginal discharge – blood stained, watery or purulent Pain – late sign, indicates spread to LN / Nerve / Bone Abnormal smear – showing cells consistent with endometrial origin Investigation Hysteroscopy - +/- GA. Is gold standard. Biospy / curettage can be performed at same time Dilatation & Curettage – under GA. Used alone will miss 10% of Ca Endometrial biopsy – pipelle. Will miss 1/3 of Ca Ultrasound – TV to measure endometrial thickness. 5mm is cut off for hysteroscopy. Fluid in endometrial cavity can be due to malignancy Endometrial hyperplasia Premalignant condition. Due to prolonged oestrogenic stimulation. Presents with PMB / heavy irregular periods Increased gland/stromal ratio on histology. Simple hyperplasia common in teenagers & menopause. Complex atypical hyperplasia à Ca (approx 25%) Rx – progestogens will decrease lining thickness & prevent growths. Hysterectomy = definitive Rx Endometral Carcinoma Mostly over 40yrs old Variety of histological types – can indicate prognosis Prognosis based on histology, differentiation, stage, invasion, peritoneal, LN & adnexal involvement Staging I – confined to corpus (75%) II – spread to cervix (13%) III – confined to pelvis (6%) IV – spread to bladder, rectum, inguinal nodes or distant mets Treatment Should have CXR & LFTs to look for mets pre surgery – can also use USS/MRI/CT Best treatment is hysterectomy with BSO & node removal Staged by FIGO (based on histology once removed) Radiotherapy – post surgery if high risk of residual disease – can also be used if patient unfit for thetre (heymans capsules) Chemotherapy – (doxorubicin & cisplatinum) not suitable if wounds/bed sores Recurrence Most occur early (within 2 yrs) & 80% with recurrence will die with 2 yrs Most common in lungs, bone, vagina & LN. Can use high dose progestogens (30% successful)