Precancer, benign and
malignant tumors of the
uterus and ovary
Eduard Kučera
UTERINE FIBROIDS
RISK FACTORS
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They are many risk factors1 associated with the development of uterine fibroids
1.Flake GP et al, Environmental Health Perspectives 2003; 111(8):1037-54
WHAT ARE THE SYMPTOMS?
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Not all fibroids are symptomatic
When symptomatic, fibroids can be linked
to at least three major problems3
However, for the 50% of
women with symptomatic
fibroids, the condition is
debilitating.1
Bleeding
complaints
Pregnancy
complications
Symptoms can include:
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Abnormal or heavy menstrual
bleeding1, 2
Pain,1,2 pressure
symptoms1,2 and urinary
symptoms2
Impairment of Quality of Life
Mass effects
related to the size
and location
of fibroids
These symptoms and consequences
have been shown to diminish quality of life3
2
1. Tropeano G, Amoroso S, Scambia G. Hum. Reprod. Update (2008) 14 (3): 259-274.
2. Downes E, Sikirica V, Gilabert-Estelles J. et al. Eur J Obstet Gynecol Reprod Biol. 2010; 152(1): 96-102.
3. Viswanathan M, Hartmann K, McKoy N. et al. Evid Rep Technol Assess (Full Rep). 2007 Jul;(154):1-122. Review.
MECHANISMS FOR FERTILITY IMPACT
• Mechanistic: space; abnormal contractions
• Local inflammation for sperm and embryo
• Inadequate blood supply
DIAGNOSIS - WHEN AND HOW?
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Physical examination may be the first signal that a woman might have uterine
1
fibroids.
Imaging methods to evaluate
1
these benign tumours:
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Ultrasonography
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Hysteroscopy
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Magnetic resonance imaging
(MRI)
1. Evans P, Brunsell S. Am Fam Physician. 2007 May 15;75(10):1503-1508.ian
Uterine Fibroids
TREATMENT
THERAPEUTIC APPROACH
Currently, therapies are intended to reduce
or eliminate uterine fibroid symptoms
through one of the following options
1
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Reduction of the size of tumours
Reduction of the amount of bleeding
Removal of the uterine fibroids or uterus
1. Miller CE, Journal of Minimally Invasive Gynecology 2009; 16:11–21
THERAPEUTIC APPROACH
The choice of therapy is influenced by the
patient’s
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Symptom severity
Tumour characteristics (e.g. volume, localisation)
Age
Uterine preservation wishes
Fertility preservation wishes
Endometrial cancer
Endometrial cancer – most common
gynecological malignancy
4th most frequent malignancy in women
In Czech Rep. incidence 32/100 000 year
1500 new cases diagnosed per year
(e.g. in UK 6,430)
Maximum around 60 - 70 years
Obesity of women – typical phenotype
Etiology
 so called „endometrial carcinoma syndrome“: obesity, (DM,
hypertension)
- peripheral transformation of androgens
- insufficiency of ShBG
 recently often used so celled.: postmenopausal syndrome
 age: 6. - 7. decade
 nulliparity (RR=2,8)
 Infertility (RR=8)
 late menopause (RR= 2,4)
 estrogen producing ovarian cancers
 high intake of animal proteins and fats
 exogenous estrogens - unopposed gestagens (RR=2,3)
 tamoxifen (RR=2,4)
Carcinogenesis in periand postmenopausal women
younger women
older women
complex hyperplasia
de novo
hyperplasia with atypia
endometrial carcinoma
( Type I usually well diff. )
endometroid carcinoma
( Type II usually poorly diff. )
papillary serous
clear cell carcinoma
Histological types
 Carcinoma (98%)
 endometroid adenocarcinoma
 adenocarcinoma with squamous cells
 clear cell carcinoma
 papillary serous
 spinocellular
 Sarcoma (2%)
 leiomyosarcoma
 endometrial stromal sarcoma
 mixed mesodermal cancers
Hyperplasia of endometrium
Complex atypical hyperplasia =
precancerosis of endometrial
carcinoma ( especially endometroid
type)
-
cell polymorphism, mitosis,
index, hyperchromatosis
nucleoplasmic
-
creation is independent on estrogen stimulation in
atrophic endometrium
Motlík,K, Živný,J.:Patologie v ženském
lékařství,Grada,2001.
FIGO staging 2010
The 2010 FIGO staging system is as follows: Carcinoma of
the Endometrium
IA Tumor confined to the uterus, no or < ½ myometrial
invasion
IB Tumor confined to the uterus, > ½ myometrial invasion
II Cervical stromal invasion, but not beyond uterus
IIIA Tumor invades serosa or adnexa
IIIB Vaginal and/or parametrial involvement
IIIC1 Pelvic lymph node involvement
IIIC2 Para-aortic lymph node involvement, with or without
pelvic node involvement
IVA Tumor invasion bladder mucosa and/or bowel mucosa
IVB Distant metastases including abdominal metastases
and/or inguinal lymph nodes
5 – year survival year
Stage
5 year survival rate
I-A
90%
I-B
88%
I-C
75%
II
69%
III-A
58%
III-B
50%
III-C
47%
IV-A
17%
IV-B
15%
Hysteroscopy and dg. curettage
Curettage – frequent false negative results (10-50%)
Curettage – in polyps up to 61%
Hysteroscopy and targeted biopsy < 2% false
negative results (Gimbelson, Loffer 1988, 1989,
AJOG)
Studies in 1383 histological findings obtained with
D&C - 60% inadequate results (Smith, 1985)
In 60% patients curetted < 1/2 cavity of the uterus
(Stock, Obst.Gyn.,1975)
Diagnostic hysteroscopy - options
Panoramatic view – magnified 1x
conventional hysteroscopy allows viewing the whole uterine
cavity and locate pathologies
panoramatic macro-hysteroscopy – 20x magnification
in distance < 1 cm
Micro-contact hysteroscopy – 80x magnification
allows evaluation of endometrial vascularisation, gland
characteristic and their openness
Tamoxifen a endometrium
Nonsteroidal synthetic anti-estrogen
Adjuvant therapy in breast carcinoma
Accumulation of effective substance in basal
endometrium
Endometrial proliferative abnormality (up to 40%
postmenopausal women) - polyps, hyperplasia
as much as endometrial carcinoma (2-3/1000/year)
Higher risk of endometrial carcinoma after using
more then 5 (?) years (2-7.5x)
Most safe and effective screening is hysteroscopy
in yearly intervals
Tamoxifen – endometrium
pathology
Length of therapy not more then 5 years
Metrorrhagia always indication to endometrial
examination
In asymptomatic women (cca 70%) HSK vs. UZ
part of periodic yearly check ups
High percentage of false positive results with
ultrasound examination– stromal edema (vacuolar
degeneration)
Tamoxifen - 37 - 71% incidence of polyps –
proliferative activity in epithelial and stromal part
Incidence of endometrial carcinoma cca in 3%
Tamoxifen and endometrium
International agreement – 1997
Bioptical examination of the endometrium
before beginning the therapy
After 3 years of using observation in yearly
intervals
Lancet,1698-1711,2000.
Tamoxifen and endometrium
Hysteroscopy with biopsy – first choice in
patients with Tamoxifen therapy
Symptomatic patients and therapy longer
then 3 years
Positive family history
Taponeco,F et al. Indication of hysteroscopy in tamoxifen
treated breast cancer patients. J.Exp.Clin.Cancer,21,2002
Endometrial cancer - therapy
Surgery - radical
Radiotherapy
Hormonal therapy