Endometrial cancer

Incidence:

• Mc gynecologic malignancy in the US
• 4th most common CA of American women (breast, bowel, lung)
• MC curable GYN Cancer in US
• MC postmenopausal 50-60y peak
• 3rd MC cause of GYN CA deaths (behind ovarian & cervical)
• 25% pre 75% postmenopausal 61 median age

Risk factors:

• Unopposed estrogen dependent neoplasm
• HRT w/o Progesterone
• Obesity – with ↑ adipose → ↑ peripheral Δ of androstenedione to estrone via aromatase
• Nulliparous – longer period of unopposed estrogen (b/c progesterone ↑ in pregnancy)
• Chronic anovulation or late menopause
• DM & HTN – b/c these pts often obese
• PCOS – ↑ unopposed estrogen
• BRCA or HNPCC, ovarian CA, FHx

Fun fact:  Smoking actually protective → nicotine induces P450 → ↑ metabolism of estrogen

OCP’s or other factors that ↓ lifetime estrogen exposure are also protective

Pathophysiology

• Most common type is adenocarcinoma

Clinical Presentation:

• Irregular postmenopausal bleeding MC sx
• Menorrhagia
• Postcoital
• intermenstrual bleeding)

Signs of metastases –

• pleural effusion
• Ascites
• Hepatosplenomegaly
• lymphadenopathy
• abdominal masses

Common DDx of postmenopausal bleeding:

• Fibroids
• endometrial atrophy or hyperplasia
• exogenous estrogen or HR,
• endometrial or cervical polyps,
• endometrial cancer

 

Dx tests:

• Initial work up for abnml vaginal bleeding: TSH, PRL, pap (only 30 % have abnml pap)
• pelvic US to r/o fibroids, polyps, hyperplasia and usually endometrial stripe >4mm
• Endometrial bx: adenocarcinoma MC
• MRI useful prior to surgery for determining depth of myometrial invasion

4 primary routes of spreading:

• direct extension (MC)
• lymphatic – when significant myometrial penetration
• transtubally to ovaries, parietal peritoneum, omentum
• hematogenous – less frequent to liver, bone, lungs

Stages of endometrial cancer

• Stage 1: limited to uterus →1A (limited to endometrium), 1B (extension to myometrium < 50%), 1C (> 50 % in myometrium but not touching serosa)
• Stage 2: extension to cervix → 2A (epithelial), 2B (epithelial & stroma)
• Stage 3: local extension to pelvis → 3A (visible on serosal surface or ovaries), 3B (+ paraaortic or inguinal LN), 3C (+ pelvic wash prior to surgery)
• Stage 4: distant metastasis

Treatment

• Stage I: hysterectomy (TAH-BSO) +/- post-op radiation therapy
  • Most are well differentiated (one of the most curable of the gynecologic cancers)
• Stage II, III: TAH-BSO + lymph node excision +/- post-op radiation therapy
• Stage IV (advanced): systemic chemotherapy

 

 

Cervical Cancer

Incidence:

• Median age of dx is 52, average is 45 y/o

Pathophysiology:

• Squamous Cell Carcinoma 90%; Adenocarcinoma 10% (Clear-cell, a type of adenocarcinoma associated w/ DES)
• Cervical cancer PAP & HPV testing ↓ risk by 90%

Risk Factors:

• HPV serotypes 16, 18, 31 & 45
• smoking,
• ↑ # of sexual partners,
• early age of sexual activity & immunosuppression

Clinical Presentations:

• postcoital bleeding
• abnormal vaginal bleeding
• pelvic pain

Speculum exam

→ friable cervical lesion or mass Bimanual → palpable mass

Dx:

• PAP is not sufficient → must be dx with biopsy
• CT or US may confirm PE findings and help determine extent of dz

 

Staging: (via CXR, Cystoscopy, IVP & barium enema)

• 0: CIS, intraepithelial carcinoma
• I: confined to cervix
• II: extends beyond cervix, but not to pelvic sidewalls or lower 1/3 of vagina
• III: to pelvic sidewalls or lower 1/3 of vagina
• IV: beyond pelvis, bladder, rectum, distant mets

 

Treatments:

• Preinvasive (stage 0) or microinvasive (1a-1): simple hysterectomy or cone biopsy
• Early disease (stage 1&2 →radical hysterectomy (uterus, parametria, upper vaginal cuff, uterosacral/cardinal ligaments, local vascular & lymphatic supplies) with BIL pelvic lymph node dissection, or radiation therapy.
• advanced disease (IIb →IV): chemoradiation therapy
• recurrence: radiation