Chapter 093. Gynecologic Malignancies (Part 6)

Uterine CancerIncidence and EpidemiologyCarcinoma of the endometrium is the most common female pelvic malignancy. Approximately 39,080 new cases are diagnosed yearly, although in most (75%), tumor is confined to the uterine corpus at diagnosis, and therefore most can be cured. The 7400 deaths yearly make uterine cancer only the eighth leading cause of cancer death in females.
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Chapter 093. Gynecologic Malignancies (Part 6) Chapter 093. Gynecologic Malignancies (Part 6) Uterine Cancer Incidence and Epidemiology Carcinoma of the endometrium is the most common female pelvicmalignancy. Approximately 39,080 new cases are diagnosed yearly, although inmost (75%), tumor is confined to the uterine corpus at diagnosis, and thereforemost can be cured. The 7400 deaths yearly make uterine cancer only the eighthleading cause of cancer death in females. It is primarily a disease ofpostmenopausal women, although 25% of cases occur in women ages ages Endometrial carcinoma occurs most often in the sixth and seventh decadesof life. Symptoms often include abnormal vaginal discharge (90%), abnormalpostmenopausal bleeding (80%), and leukorrhea (10%). The risk of endometrialcancer associated with postmenopausal bleeding increases with advancing age(9% at age 50 vs. 60% at age 80). Evaluation of such patients should include ahistory and physical with pelvic examination followed by an endometrial biopsyor a fractional dilation and curettage. Outpatient procedures such as endometrialbiopsy or aspiration curettage can be used but are definitive only when positive. Pathology Between 75 and 80% of all endometrial carcinomas are adenocarcinomas,and the prognosis depends on stage, histologic grade, and extent of myometrialinvasion. Grade I tumors are highly differentiated adenocarcinomas, grade IItumors contain some solid areas, and grade III tumors are largely solid orundifferentiated. Adenocarcinoma with squamous differentiation is seen in 10% ofpatients; the most differentiated form is known as adenoacanthoma, and thepoorly differentiated form is called adenosquamous carcinoma. Other lesscommon pathologies include mucinous carcinoma (5%) and papillary serouscarcinoma ( Staging The staging of endometrial cancer requires surgery to establish the extent ofdisease and the depth of myometrial invasion. A total abdominal hysterectomy andbilateral salpingo-oophorectomy should be performed and peritoneal fluidsampled. Frozen sections of the uterine specimen are used to determine thehistology and grade and depth of invasion. If indicated, pelvic and para-aorticlymphadenectomy is performed. After evaluation and staging, ~75% of patientsare stage I, 13% are stage II, 9% are stage III, and 3% are stage IV. Five-yearsurvival declines with advancing stage: stage I, 89%; stage II, 73%; stage III, 52%;and stage IV, 17% (Table 93-1). Uterine Cancer: Treatment Patients with uncomplicated stage I endometrial carcinoma are effectivelymanaged with total abdominal hysterectomy and bilateral salpingo-oophorectomy.Pre- or postoperative irradiation has been used, and although vaginal cuffrecurrence is reduced, survival is not altered. In women with poor histologicgrade, deep myometrial invasion, or extensive involvement of the lower uterinesegment or cervix, intracavitary or external beam irradiation is warranted. About 15% of women have endometrial carcinoma with extension to thecervix only (stage II), and management depends on the extent of cervical invasion.Superficial cervical invasion can be managed like stage I disease, but extensivecervical invasion requires radical hysterectomy or preoperative radiotherapyfollowed by extrafascial hysterectomy. Once disease is outside the uterus but stillconfined to the true pelvis (stage III), management generally includes surgery andirradiation. Patients who have involvement only of the ovary or fallopian tubesgenerally do well with such therapy (5-year survival of 80%). Other stage IIIpatients with disease extending beyond the adnexa or those with serouscarcinomas of the endometrium have a significantly poorer prognosis (5-yearsurvival of 15%). Patients with positive para-aortic nodes (stage IIIC) or thosewith upper abdominal involvement (stage IV) have shown improved survival withplatinum-based chemotherapy compared to whole-abdominal irradiation alone.