1. Uterine cancer Uterine mesenchymal neoplasms
Assoc. Prof. Małgorzata Walentowicz-Sadłecka, MD, PhD

2. Classification of uterine cancers
Endometrial carcinoma
Pure endometroid carcinoma
Serous or clear cell adenocarcinoma
Mesenchymal neoplasms
Endometrial stromal sarcoma
Carcinomasarcoma
Uterine leiomyosarcoma
Classification of uterine cancers

3. Endometrial carcinoma

4. Epidemiology of endometrial carcinoma
Endometrial cancer is the most common malignancy of the female genital tract. About 2-3% of women will develop endometrial cancer.
Endometrial cancer occurs usually in postmenopausal women (90%).
Most cases (approximately 70%) are diagnosed in early stage (FIGO Ia, Ib)
Fig. Distribution of the expected cases and deaths for the 5 most common cancers in Europe 2012 in females. IARC 2013.

5. Two types of endometrial cancer
Type 1 – estrogen-dependent
Type 2 – estogen-independent
80-90%
10-20%
Related to estrogen-exposure risk factors
Not related to estrogen-exposure risk factors
High differentiated tumors
- Endometroid adenocarcinoma, G1, G2
Poorly differentiated tumors:
- Clear cell adenocarcinoma
- Serous carcinoma
- Squamous carcinoma
- Undifferentiated carcinoma
- Mixed carcinoma
Endometrial hyperplasia
Endometrial atrophy
Favorable prognosis
Poor prognosis
Precancerous lesion

6. Endometrial hyperplasia
A spectrum of excessive proliferation of the endometrial cells ranging from physiologic states to carcinoma in situ.
Type of hyperplasia
Risk of cancer
Simple without atypia 1%
Complex without atypia 2%
Simple with atypia 8%
Complex with atypia
29%
Simple – dialted or cystic glands complex = architecture changes: crwoded glands with less stroma
Simple = dilated or cystic glands
Complex = architecture changes; crowded glands with less stroma
Atypia = large nuclei; variable size and shape

7. Risk factors
Prolonged, estrogen stimulation, in the absence of progestin
Higher risk
Lower risk
Nulliparity
Early age of first birth, last pregnancy at a later age
Late menopause
Late age of menarche
Short, irregular ovulatory cycles, unopposed estrogen therapy
Longer use of combination oral contraceptives, hormonal intrauterine device
Obesity
Physical activity
Diabetes mellitus
Smoking cigarettes
Tamoxifen therapy
Lynch II syndrome

8. Symptoms Abnormal uterine bleeding or discharge (90% patients);
Cyclical bleeding that continues past the usual age of menopause;
Pelvic pressure or discomfort (uterine enlargement);
Asymptomatic (<5% patients).
Awarness of pathological mass in pelvic/abdominal

9. Diagnosis (according to ACOG)
Transvaginal ultrasonography (TVS)
Normal endometrium thickness in postmenopausal women <5mm
Normal endometrium thickness in postmenopausal women used estrogen therapy <8mm
Hysteroscopy -> dilation and curettage (D&C) to fully evaluate the endometrial lining and exclude a premalignant or benign lesion.

10. Clinical staging FIGO Stage Characteristic 5-years survival IA
Tumor confined to the uterus, no or < ½ myometrial invasion
96%
IB 
Tumor confined to the uterus, > ½ myometrial invasion
87% II
Cervical stromal invasion, but not beyond uterus
80%
IIIA
Tumor invades serosa or adnexa
48%
IIIB
Vaginal and/or parametrial involvement
53%
IIIC1
Pelvic node involvement
60%
IIIC2
Para-aortic involvement
IVA  
Tumor invasion bladder and/or bowel mucosa
57%
IVB
Distant metastases including abdominal metastases and/or inguinal lymph nodes
16%

11. Treatment and prognosis
Minimally invasive surgery is preferred for endometrial cancer.
Routine lymphadenectomy is not recommended in low-grade cases.
High-risk patients (grade 2 or 3, clear cell or serous histology, suspicion of extrauterine disease, family history of disease) benefit from postoperative adjuvant radiotherapy.
Endometrial hyperplasia: for women with atypical complex hyperplasia
with no longer desire fertility, hysterectomy is reccomended. Other
cases may be treated with progestins to try to reverse the lesion.
Although women with low-grade, minimally invasive disease do not appear to benefit from routine lymphadenectomy, no definitive pre- or intraoperative predictors exist that can reliably identify them. Consequently, preoperative consultation with a gynecologic oncologist is recommended, especially in the context of preoperative high-risk features or limited intraoperative ability to either assess the extent of uterine disease or adequately stage the patient’s disease. Endometrial cancer is considered high-risk if it is grade 2 or 3 disease, there is evidence of clear cell or papillary serous histology, or any clinical or radiologic suspicion of cervical or extrauterine disease, and when it is diagnosed in a woman with a family history of the disease.
Prognosis
Overall 5-years survival rate in endometrial cancer is approximately 75%

12. Uterine sarcoma

13. Epidemiology of uterine sarcoma
Uterine sarcomas constitute 2-6% of uterine malignancies.
The development of uterine sarcomas is increased by previous radiation therapy.
Carcinosarcomas, leiomyosarcomas, and high- grade endometrial stromal sarcomas are clinically aggressive tumors with local extension by lymphatic or hematogenous pathways.

14. Symptoms and diagnosis of uterine sarcoma
abnormal bleeding,
pelvic pain,
a polypoid mass or enlarged uterus (50%)
Diagnosis:
Biopsy of endocervical mass or endometrial curettage

15. Treatment of uterine sarcomas
Reccurences develop in >50% of patients (most common in abdominal or lungs)
I and II stage – surgical treatment
III stage – combination of surgery, radiation and chemiotherapy
IV stage – combinaton of chemiotherapy

16. Summary
Most risk factor of endometrial carcinoma are related to prolonged estrogen stimulation.
First step in diagnosis of (obese) postmenopausal women with vaginal bleeding is transvaginal ultrasonography.
Most patients with endometrial cancer should undergo surgical treatment. Postoperative, adjuvant radiotherapy is recommended in high- risk cases and high-grade cases.
Overall 5-years survival is approximately 75%.
Uterine sarcomas are the most malignant uterine tumors.