Cervical and endometrial cancer slides

1
Cervical Cancer & HPV

2
Presentation Overview
Cervical cancer Cause: Human Papilloma Virus (HPV)
“Natural history”
Treatment

Preventing cervical cancer

Avoiding exposure to HPV
Current screening guidelines
The new HPV vaccines

3
Cervical Cancer
Abnormal cell growth on cervix (lowest part of the uterus)
Caused by HPV infection, especially during the first years after puberty
Pre-cancerous changes long before invasive cancer develops
Rarely fatal in this country
A major cause of death worldwide


4
Human Papillomavirus (HPV)
• Long known to cause warts
• Found in many cancers too
• Over 100 types identified
• Most benign, but 15-20 can cause cancers





5
HPV & Cervical Cancer
HPV recognized as the underlying cause of
cervical cancer since 1996

6
Common HPV Types and their effects

HPV Types

Lead to:
Low-Risk

High-Risk
HPV 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81
HPV 16, 18,31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, 82


Benign cervical changes
Genital warts
Precancer cervical changes
Cervical cancer
Anal and other cancers

1. Cox. Baillière’s Clin Obstet Gynaecol. 1995;9:1.2. Munoz et al. N Engl J Med. 2003;348:518.

7
Natural History of HPV Infections
Sexually transmitted
Usually no symptoms
No treatment for HPV infection before symptoms
Immune system clears most cases; some persist

HPV present in >99% of cervical cancers

High risk types (16, 18) associated with cancer
Low risk types (6, 11) are associated with genital warts
All can cause abnormal Pap tests
Human Papillomavirus. ACOG Practice Bulletin No. 61. 2005; 105: 905-18.


8
Co-factors for HPV Infection
• Smoking
• HIV infection
• Other immune system defect
• Pregnancy
• Oral contraceptive use
Ferris et al. Modern Colposcopy. 2004.

9
HPV Infections: Summary
Most people are infected by HPV at some time
Immune system usually clears HPV, but not always
Persistent low-risk HPV can lead to genital warts
Persistent high-risk HPV can lead to pre-cancer

Cancer

HPV
Long persistence of HPV can lead to cancer

10
Preventing Cervical Cancer
Screening for precancerous changes (and treatment if problems found)


Vaccination against HPV

11
History of the Conventional Pap Smear
Developed by Dr. George N. Papanicolaou in 1940’s
Most common cancer screening test
Key part of annual gynecologic examination
Has greatly reduced cervical cancer mortality in U.S.

Ferris et al. Modern Colposcopy. 2004: 2-4, 49.

Photo accessed from http://www.cytology-iac.org/Cytopaths/1998/cytoFall98.htm

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Screening with the Conventional Pap Smear
Widely available
Inexpensive
But not perfect
Screening test – not diagnostic
7-10% of women need further evaluation
Low sensitivity – need regular repeats


Cervical Cytology Screening. ACOG Practice Bulletin No. 45. 2003; 102:417-27.

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New Liquid Pap Tests
More accurate test
Thin, uniform layer of cells
Screening errors reduced by half
Screening needed less often
Can test for HPV with same specimen if abnormal cells found
Expensive
Linder J. et al. Arch Pathol Lab Med. 1998; 122: 139-144.



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Cervical Cancer Screening Guidelines
• First screen 3 years after first intercourse or by age 21
• Screen annually with regular Paps or every 2 years with liquid-based tests
• After three normal tests, can go to every three years
• Stop at 65-70 years with history of negative tests
• Still need annual check-ups
Cervical Cytology Screening. ACOG Practice Bulletin No. 45. 2003; 102:417-27.


Cervical cancer

Introduction

Cancer of the cervix is the most common female genital cancer in developing countries every year about 500,000 women , acquire the disease and 75% are from frame developing countries.
About 300,000 women also die from the disease annually and of these 75% are from developing countries

Incidence

4-6 % of female genital cancers.

Age
40-50 years old

Risk factors and aetiology

• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
Risk factors and aetiology
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
Risk factors and aetiology
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
Risk factors and aetiology
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
Risk factors and aetiology
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
Risk factors and aetiology
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
Risk factors and aetiology
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
Risk factors and aetiology
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
Risk factors and aetiology
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of
• Coitus at young age: <16 years old increased risk by 50%
• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
• Smoking
• Smoking for> 12 years increase the risk by 12.7 folds.
• Male related risk factors:
• number of the partners previous sexual relationships is relevant .
• cervical cancer risk increased if partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
• HPV (Human papilloma virus ) infection mainly 16,18
• the main aetiological is infection with subtypes of HPV (16,18)
• Low socioecomic class of


Type of patient:
Multiparous.
Low socioeconomic class.
Poor hygiene.
Prostitutes.
Low incidence in Muslims and Jews.

Predisposing factors:

Cervical dysplasia.
(Cervical intraepithelial neoplasia)
CIN III / CARCINOMA IN SITU
THE LESION PROCEEDS THE INVASION BY 10-12 YEARS

Symptoms:

• Early symptoms
• Late symptoms
• - None.
• - Thin, watery, blood tinged vaginal discharge frequently goes unrecognized by the patient.
• - Abnormal vaginal bleeding
• Intermenstrual
• Postcoital
• Perimenopausal
• Postmenopausal
• - Blood stained foul vaginal discharge.
• - Pain, leg oedema.
• - Urinary and rectal symptoms
• dysuria
• haematuria
• rectal bleeding
• constipation
• haemorrhoids
• - Uraemia


Pathology type
Squamous cell carcinoma- 90%.
Adenocarcinoma- 10%.

Types of growth

Exophytic: is like cauliflower filling up the vaginal vualt.
Endophytic: it appears as hard mass with a good deal of induration.
Ulcerative: an ulcer in the cervix.

DIAGNOSIS

• 1- History.
• Many women are a symptomatic .
• Presented with abnormal routine cx smear
• Complain of abnormal vaginal bleeding
• I M bleeding
• post coital bleeding
• perimenopausal bleeding
• postmenopausal bleeding
• blood stain vaginal discharge

2- Examination:

Mainly vaginal examination using cuscu’s speculem nothing is found in early stage .
Mass ,ulcerating fungating in the cervix
P/V P/R is very helful.



Preoperative evaluation
• Review her history.
• General examination:
• Anaemia.
• Lymphadenopathy-Supraclavicular LN.
• Renal area.
• Liver or any palpable mass.
• Oedema.
• Laboratory tests:
• CBC, LFT, RFT, Urine analysis.
• Tumour markers.
• Chest X- ray, abdominal X- ray, IVU.
• CAT, MRI, if necessary.
• Ultrasound.
• Lymphography, if necessary.

Staging

Best to follow FIGO system.
Examination under anaesthesia.
Bimanual palpation.
P/V, P/R.
Cervical biopsy, uterine biopsy.
Cystoscopy, Proctoscopy, if necessary.


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STAGES OF CANCER CERVIX

Once cancer cervix is found (diagnosed), more tests will be done to find out if the cancer cells have spread to other parts of the body. This testing is called staging.
TO PLAN TREATMENT, A DOCTOR NEEDS TO KNOW THE STAGE OF THE DISEASE.

SPREAD:

• Direct
• Lymphatic
• Dissemination (late)
• - Uteruq.
• - Vagina.
• - Parametrium.
• - Bladder and rectum.
• A- primary node:
• parametrial.
• Paracervical.
• Vesicovaginal.
• Rectovaginal.
• Hypogastric.
• Obturator and external iliac
• B-Secondary nodes:
• Common iliac
• Sacral
• Vaginal
• Paraaortic
• Inguinal.
• - parametrial spread causes obstruction of the ureters, many deaths occur due to uraemia.
• - Obstruction to the cervical canal results in pyometria.


DIFFERENTIAL DIAGNOSIS
Cervical ectropion.
Cervical tuberculosis.
Cervical syphilis, Schistosomiasis, and Choriocarcinoma are rare causes.

TREATMENT

Surgical.
Radiotherapy.
Radiotherapy & Surgery.
Radiotherapy and Chemotherapy followed by Surgery.
Palliative treatment.

The choice of treatment will depend on

Fitness of the patients
Age of the patients
Stage of disease.
Type of lesion
Experience and the resources avalible.

Surgical procedure

The classic surgical procedure is the wertheim’s hystrectomy for stage Ib,IIa, and some cases of IIb in young and fat patient


Werthemeim’s hystrectomy
Total abdominal hystrectomy including the parametrium.
Pelvic lymphadenectomy
3 cm vaginal cuff
The original operation conserved the ovaries ,since squamouss cell carcinoma does not spread dirctly to the ovaries.
Oophorectomy should be performed in cases of adenocarcinoma as there is 5-10% of ovarian metastosis

Surgery offers several advantage

It allows presentation of the ovaries (radiotherapy will destroythem).
There is better chance of preserving sexual function.
(vaginal stonosis occur in up 85% of irradiates.
Psychological feeling of removing the disease from the body .
More accute staging and prognsis

COMPLICATIONS OF SURGERY

Haemorrhage: primary or secondary.
Injury to the bladder, uerters.
Bladder dysfunction.
Fistula.
Lymphocele.
Shortening of the vagina.


INDICATIONS OF P/O XRT FOLLOWING WERTHEIM’S HYSTERECTOMY (STAGE I , IIa):
Positive pelvic lymph nodes.
Tumour close to resection margins and/or parametrial extension.

Radiotherapy

Stage IIb and III
Radical Radiotherapy
External irradiation (Teletherapy).
Intracavitary radiation (Brachytherapy).
In some cases of stage IIa or b radio and chemotherapy to be given then followed by simple hysterectomy -------

Palliative therapy

• For stage IV – individualized therapy.
• Some suitable for palliative XRT ( usually intracavitary Caesium).
• Some suitable for extensive surgery.
• Some suitable for chemotherapy.
• Good nursing care.
• Analgesia-must be used in sufficient amount to ----- pain (Codein sulfate, Pethidine, Morphine, Diamorphine).
• Antiemetic if necessary.
• IV drip, entral, and parentral feeding.
• Urinary Catheterization.
• Other measures for symptom relief.


PROGNOSIS
• Depends on:
Age of the patient.
Fitness of the patient.
Stage of the disease.
Type of the tumour.
Adequacy of treatment.

THE OVERALL 5 YEARS SURVIVAL FOLLOWING THERAPY:

Stage I -------80%
Stage II-------50-60%
Stage III-------30-40%
Stage IV-------4%

MANAGEMENT OF RECURRENT DISEASE

• Radiation – if not used.
• Pelvic exenturation.
• Chemotherapy.

Endometrial carcinoma

Endometrial carcinoma is the fifth leading cancer in the women worldwide. In developed countries it’s the most common gynaecological cancer but in developing countries it’s surpassed by cervical cancer.

• Age groups:

• Mean age of presentation is 56 years .
• 75% after menopause.
• 20% perimenopausal.
• 5% before age of 40.
• Aetiology:
• a- indiscriminate use of oestrogen.
• b- un opposed oestrogen.
• c- Theca granulosa cell tumours.

• Prediposing factors:

• Atypical adenomatous hyperplasia
• (complex atypical ) –25% (10 - 60%)
• to progress to cancer
• Type of patient:
• Nullipara or low parity
• Middle or upper social class
• Overweight and obese patients
• Early menarche and late menopause


• Associated factors:
• Diabetes or abnormal glucose tolerance test.
• Hypertension.
• Fibroids.
• Polycystic ovarian syndrome.
• Infertility, Arthritis, and Thyroid disease.
• Use of TAMOXIFEN.
• Previous pelvic irradiation.
• Positive family history of breast, ovarian, and to lesser extent colon cancer.

• Protective factors:

• Smoking !
• Use of oral contraceptive.
• Use of progesterone.

• Pathology:

• Adenocarcinoma ------------------------------------------------59%
• Adenoacanthoma(adeno + squamous metaplasia)------21%
• Adenosquamous carcinoma------------------------------------7%
• Clear cell carcinoma----------------------------------------------6%
• Papillary adenocarcinoma---------------------------------------5%
• Secretory carcinoma----------------------------------------------2%
• Mixed type------------------------------------------------------------ ~


Spread :
Invasion through the myometrium and by filling the uterine cavity.
Invasion to the cervix with subsequent lymphatic spread involving the iliac and para-aortic nodes.
From upper uterus may spread to round ligament to the deep inguinal nodes.
In advanced cases, the blood-stream spread may carry to the lungs, liver, and to the bone.

Diagnosis and assessement:

• A-History:
• postmenopausal bleeding or staining( this symptom should be assumed to be caused by carcinoma of the endometrium until proved otherwise), only 10% of PMB have endometrial carcinoma.
• Perimenopausal menstrual irregularities.
• Blood stained vaginal discharge.
• Heavy and irregular vaginal bleeding.

Diagnosis and assessement:

• B-Examination:
• physical examination of the patient with endometrial carcinoma is frequently entirely normal, it should include palpation of supraclavicular and inguinal lymph nodes, abdominal palpation might be difficult due to obesity.
• Gynaecological examination:
• inspection of vulva, vaginal skin in suburethral area
• and cervix.
• Bimanual vaginal examination assesses uterine size, and mobility, state of parametria and adnexa.
• Bimanual recto-vaginal examination.


Diagnosis and assessement:
• C-Investigation:
• CBC.
• Liver function test.
• Renal function test.
• Chest X ray.
• Cytology brush from lower cervical canal and posterior fornix to analyze the cells.
• Endometrial sampling :-

Endometrial sampling :-

• ONE sample for histology:
• - Piplle
• - Vabra
• - Jet suction
• - Other
• Two Examination under anaesthesia and
• D&C.
• Three Hysteroscopy & biopsy.
• -ultrasound for endometrial thickness, myometrial
• invasion and lymph nodes.
• -MRI – to assess site, thickness, and myomtrial invasion
• for staging.
• -proctoscopy and / or sigmoidoscopy, cystoscopy, and bone
• scan for some exceptional cases, when there is a clinical
• suspicion of metastasis.


• Method
• Advantage
• Disadvantage
• Endometrial biopsy
• Outpatient procedure
• Well tolerated
• Blind sample
• Not always possible
• D&C
• Patient completely relaxed
• Requires anaesthesia
• Blind sample
• USS
• Painless
• Reasonable resolution
• Available at outpatient
• Endometrial thickness
• measured
• endometrium not actually visualized and no histology
• Hysteroscopy
• Direct visualization
• Guided biopsy possible
• Can be outpatient procedure
• Invasive
• Can be painful

Stage I:

Carcinoma confined to the corpus
I a – tumour limited to endometrium.
I b – invasion of less than ½ of myometrium.
I c – invasion of more than ½ of myometrium.

Histopathology :

Degree of differentiation.
G1= 5% or less of non-squamous or non-morular solid growth pattern.
G2= 6-50% of a non-squamous or non-morular solid growth pattern.
G3= more than 50% of a non-squamous or non-morular solid growth
Pattern.

• Prognostic factors included in final surgical staging:

• Histologic type (pathology).
• Histologic differentiation.
• Stage of disease.
• Depth of myometrial invasion.
• Result of peritoneal wash.
• Lymph node metastasis.
• Adnexal metastasis.
• Other (capillary- like space involvement, tumour size, hormonal receptors!).
• Ploidy and growth factors.
• Age and body morphology.


TREATMENT:
The mainstay of treatment for endometrial carcinoma is an extrafascial total abdominal hysterectomy and bilateral sapingo-oopherectomy, peritoneal washing, and ?lymph node biopsy. (TAH+BSO+PW+?LNB ).
The role of preoperative radiotherapy has become controversial with the introduction of the new (FIGO) staging system. Preoperative radiotherapy will severely affect the surgicopathological staging.

ONCE STAGING IS PERFORMED.

l-For stage I, Gl Adenocarcinoma:
-Total abdominal hysterectomy, bilateral salpingo-oopherectomy and peritoneal wash.
-In some cases of stage I the uterus is enlarged- and an extended hysterectomy and BSO and removing a cuff of vagina is indicated.

Indications for post operative radiotherapy:

-Moderate or poor differentiation(G2,G3).
-Other histological type than adenocarcinoma as papillary or clear cell carcinoma.
-Invasion of myometrium of> 1/2.
-Positive peritoneal wash.
-Positive lymph nodes.

2-stage II adenocarcinoma:

- WERTHEIM'S HYSTERECTOMY- which includes removal of the upper half of the vagina, pelvic lymphadenectomy and para-aortic lymph node sampling is best for surgically fit patients.
This is not always possible as the patient, usually very old, obese, hypertensive, diabetic and high risk for extensive surgery.
-if surgery is not possible- radiotherapy is chosen, to the whole pelvis in 5 ~ weeks, in some cases additional of extrafascial hysterectomy 6 weeks after pelvic irradiation and intracavity brachytherapy may improve survival.
N.B- in those patients in whom spread to the cervix is occult, with the diagnosis being made on hysteroscopy or endocervical curettage, management should be identical to those patients with high risk stage I disease.


3-stage III adenocarcinoma:
-If the disease confined to the pelvis (parametrial extension or vaginal involvement) radiotherapy is the treatment of choice, and should be given as in a manner similar to stage 11
-When there is clinical spread to the adnexae a laparatomy should still be undertaken to define accurately the extent of the disease, and to remove as much tumour as possible. Following removal of the pelvic disease, omentectomy, lymphadenectomy should be performed together with multiple peritoneal biopsies. If the disease is central - notfixed to side wall, and the patient suitable for surgery there is possibility for pelvic exenturation

4-stage IV adenocarcinoma:

management needs to be individualized with the primary aim being
control of tumour growth, so:
-palliative surgery.
-Radiotherapy.
-Cytotoxic drugs.
-Hormonal therapy
May all be required. Rarely limited surgery to stop the bleeding as palliative procedure is carried out.

Radiotherapy may be used as :

1- An adjuvant to surgery - as in stage I disease.
2- Radical treatment for stage ILIII.
3- Palliative therapy as for stage IV.
Usually external radiation followed by intracavitary radiation.

*adjuvant hormonal therapy:

-Medroxyprogesterone acetate (200- 400 mg daily)
- Gn RH analogues
The rule of chemotherapy is limited
- Anthracycline.
-Doxorubine.
- platinum drugs
All are effective drugs can be used in a single course.


Summary of treatment
Consult expert advice.
patients with low risk stage I disease i.e. well differentiated, only superficially invasive, may be treated with a total abdominal hysterectomy and bilateral salpingo-oophorectomy
patients with high risk stage I disease i.e. poorly differentiated, deeply invasive, are treated as above with additionally, post-operative radiotherapy. This management approach reduces the risk of local recurrence from 20 to 5%
stage II disease is managed as for high risk stage I
stages III and IV - which fortunately, are rare - are managed on an individualised basis. Surgery is rarely employed. Progestogen therapy may be helpful. Chemotherapy may occasionally be used in metastatic disease