Malignant disease of the body ofthe uterus The most common malignant diseas

affecting the uterus is endometrial carcinoma, which arises from the lining of the uterus.

sarcomas also arise from the stroma of the endometriu'm or from the myometrium.

introduction

Incidence

The incidence about age 45 years to about 55 years and remains at the same high rate thereafter.

Etiology

The cause of endometrial carcinoma is unknown Manyof the factors are related to an increase in oestrogenlevels. excess oestrogen as the prime factor in the development

of endometrial cancer. The interactionbetween oestrogen, insulin and insulin-like growth factor-may be

more important.In the postmenopausal period, the majorityof circulating oestrogen is derived from aromatizationof peripheral androgens. This conversion takes placeprincipally in adipose tissue. In addition, postmenopausalwomen with diabetes have increased oestrogen levels.women

with polycystic disease increase oestrogen level.

Increasing evidence suggests that it is simplistic to view excess oestrogen as the prime factor in the development

of endometrial cancer. The interaction

between oestrogen, insulin and insulin-like growth factor-1 may be more important.

risk factor

number of factors that increase the risk of endometrial cancer are :

Obesity. Impaired carbohydrate tolerance. Nulliparity Late menopause. Unopposed oestrogen therapy. Functioning ovarian tumours. Previous pelvic irradiation. Family history of carcinoma of breast, ovary.

women who use oral contraception or progestogens have up to a 50 per cent reduction in the incidence of endometrial cancer and the protection lasts for many years after stopping these drugs.

Cigarette smoking has also been associated with the reduced risk of endometrial cancer.

Pathology

The commonest subtype of endometrial carcinoma is called endometrioid because it resembles the normal proliferative endometrium.

Squamous metaplasia can occur within adenocarcinomas and this can result in an adenoacanthoma or an adenosquamous carcinoma.

Papillary serous and clear cell carcinomas . primary squamous cell carcinoma of the

endometrium is extremely rare.

uterus with adenocarcinoma ofthe endometrium.

Clinical presentation

1-Most women with endometrial carcinoma will present with postmenopausal bleeding.

2- a postmenopausal discharge, particularly a bloodstained discharge.

3-premenopausal period, many women with endometrial carcinoma will present with intermenstrual bleeding.

4-one-third will present with heavy periods only.

Diagnosis

Traditionally, postmenopausal bleeding was investigatedby a dilatation and curettage. More recently,however, diagnosis has shifted to the outpatient setting,with the ultrasound determination of endometrialthickness and outpatient sampling of theendometrium using instruments such as a Pipellesampler in cases where the ultrasound suggests thatthe endometrium is more than 5 mm thick. If thesampler has been fully introduced into the uterusand no malignant tissue is identified, the test can be

regarded as negative. Outpatient hysteroscopy may beUndertaken.

Diagnosis

Ultrasound also allows the ovaries to be imaged, as a number of patients with postmenopausal bleeding will have ovarian pathology. It is important to advise women to return if the bleeding recurs.

StagingThe FIGO classification and staging

are

│ The carcinoma is confined to the corpus

II The carcinoma has involved the corpus and the cervix but has not extended outside the uterus

III The carcinoma has extended outside the uterus but not outside the true pelvis

IV The carcinoma has extended outside the true pelvis or has obviously involved the mucosa of the bladder or rectum Bullous oedema as such does not permit a case to be allotted to Stage IV

Staging is usually by histopathology postoperative.

TreatmentSurgery

The treatment of choice in patients with endometrialcarcinoma is total abdominal hysterectomy and bilateralsalpingo-oophorectomy. Most women with Stage IIdisease are not diagnosed until

after the hysterectomyhas been performed. In such women, the prognosis is much the same as for Stage 1.

Radical hysterectomy and bilateral pelvic lymphadenectomy with paraaortic node sampling is only performed if the cervical spread is clearly recognized before surgery. Even then,it is often wiser to treat the patient with radiotherapy like a cervical cancer

Lymphadenectomy has not achieved an establishedplace in the treatment of endometrial cancer only samplingThe age, the obesity and the high rate of co-morbidity in these women detract further from the widespread adoption of lymph adenectomy in women with endometrial cancer

Radiotherapyindication1- postoperative radiotherapy deep myometrialinvasion was regarded as an indication for thisadjuvant treatment. 2-recurrent disease. In this group of women, salvageradiotherapy offers a 50 per cent cure rate.

3-the patient with more advanced disease, but surgery is not usually the first line of treatment. Pelvic radiotherapy is

performed and then occasionally residual disease maybe removed surgically.

4- radiation to para-aortic nodal disease if there is lymphatic spread.

Hormonal therapy

Progestogens

1-The only value of progestogens is in the palliation of recurrent disease. Good results are obtained rarely and only with well-differentiated tumors containing oestrogen receptors.

2-Women unfit for surgery.

Five-year survival for women with endometrial cancer 5-year survival (%)

Stage I 83 Stage II 71 Stage III 39 Stage IV 27

Leiomyosarcoma

Leiomyosarcoma arise in the uterine muscle.

aris by transformation ofa previously benign fibromyoma(0.2per cent of fibro ids).

Sarcoma also occasionally arises in the stroma of the endometrium -endometrial stromal sarcoma.

pathology Tumours of this group grow more rapidly and are softer

than fibromyomata. They may increase in size after the menopause.by naked-eye inspection, the tumour may

be seen to have invaded the uterine wall or the capsuleof the fibromyoma, and the cut surface often showssmall haemorrhages and areas of degenerative softening.Microscopically, they consist of spindle-shaped orrounded cells, many of them pleomorphic, with littlestroma and primitive blood vessels. Histological diagnosisof malignancy depends on the number of mitosesper high-power field (HPF).

Metastasis

Distant metastasis via the bloodstream and direct spread to adjacent structures often occur.

DIAGNOSIS&TREATMENT

These tumours occur in adults, who usually complain of uterine bleeding. Rapid growth of the tumour,with increasing pain, may give rise to suspicion of itsnature, but in many cases the diagnosis is made only after the tumour has been removed. In rare cases, asarcoma may be slow growing, and its nature discovered only when it recurs after operation.

Sarcoma and mixed mesodermal tumours of

the uterus

Mixed mesodermal tumours This includes tumours that contain

heterologous mesenchymal elements. In adults they often present as a large fleshy mass protruding from the uterine

wall into the uterine cavity.

Histological examination

shows that it contains some elements resembling sarcoma and others resembling carcinoma, together with bizarre components such as cartilage and striped muscle.

CLINICAL PRESENTATION

. The patient complains of bleeding from the uterus, and sometimes of pain. Tumours of this type occasionally follow uterine irradiation.

Metastasis via the bloodstream is common,as is local recurrence after removal

The prognosis is poor.

Sarcoma botryoides (embryonal rhabdomyosarcoma)is a variety of the same type of tumour that is seen in infants and young children.

Clinical presentation There is a bloodstained,watery discharge and the

vagina is found to contain grape-like masses of soft growth, usually arisingfrom the cervix.

Local recurrence often follows removal, and distant metastases occur.

Treatment

total hysterectomy and bilateral salpingo-oophorectomy is performed, followed by external radiotherapy. radiotherapy must then be taken, depending on the extent and nature of the disease.

The prognosis is poor,except for leiomyosarcoma arising in a fibromyoma.

Treatment ofSarcoma botryoides (embryonal rhabdomyosarcoma)

In children, as with many other forms of malignant disease, the prognosis with conventional treatment has been very poor. The modern use of a combination

of external irradiation and chemotherapy hasaltered the outlook

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