​Kembara Xtra - Medicine - Endometrial Cancer and Uterine Sarcoma

​Kembara Xtra - Medicine - Endometrial Cancer and Uterine Sarcoma 
Endometrial cancer is a malignant condition that affects the endometrial lining of the uterus. There are two forms of endometrial cancer.
○ Type I: estrogen-dependent, grade 1 or grade 2, better prognosis, endometrioid histology
Type II: estrogen-independent, higher grade, more aggressive, encompasses grade 3 endometrioid and nonendometrioid: serous, clear cell, mucinous, bad prognosis. Type I: estrogen-dependent, lower grade, less aggressive.

● Cell types: adenocarcinoma, adenosquamous (malignant squamous components), clear cell, and papillary serous 
Sarcomas are a type of cancer that affects the uterine mesenchyme and are classified as mixed tumors. - Mixed müllerian sarcoma, also known as a carcinosarcoma: Heterologous sarcoma components are not native to the müllerian system (e.g., cartilage or bone); homologous sarcoma elements are native to the müllerian system (40–50% prevalence of all sarcomas).s) — Leiomyosarcoma is a cancer that originates in the myometrium and is distinguished by the presence of cellular atypic mitoses and coagulative necrosis (30% prevalence of all sarcomas).s) — Endometrial stromal sarcoma is a cancer that originates in the stromal component of the endometrium (15% prevalence of all sarcomas).s). – Poorer prognosis

The age at which endometrial cancer is most common: Most patients are postmenopausal:
63 years old is the typical age at which a diagnosis is made.
— Sarcomas are prevalent in both premenopausal and postmenopausal women.
The age range of patients diagnosed is on average between 40 and 69 years old
At the time of diagnosis, stage I affects 70% of all cases of endometrial cancer.
Affected System(s): the Reproductive System
uterine cancer; endometrial cancer; corpus cancer are all synonyms for uterine cancer. Pregnancy Considerations
There is no link between pregnancy and this form of cancer.

The study of epidemiology, including incidence and prevalence. 

Incidence Endometrial cancer is the most prevalent type of gynecologic malignancy, the fourth most common type of cancer in women, and the eighth greatest cause of death in women around the world due to cancer.
According to the SEER database, it is anticipated that there will be 61,380 new cases of endometrial cancer in the United States in 2017, as well as 10,920 deaths related to the disease. The incidence is higher in Caucasians than in African Americans; however, African Americans have stage-matched higher mortality.
Prevalence
In the United States, there are approximately 500,000 females.

Causes and effects: etiology and pathophysiology 
Endometrial: unopposed estrogen - Estrogen replacement therapy without concurrent progesterone increases the risk. Continuous estrogen stimulation that is not resisted by progesterone. The addition of progesterone results in a lower risk compared to the population as a whole.

Sarcomas: the cause of these tumors is not known Genetics
Endometrial: Lynch syndrome (hereditary nonpolyposis colorectal cancer), which has a lifetime risk of up to 30% (3); Cowden syndrome 
The risk factors for sarcoma include being African American, having a greater incidence of leiomyosarcoma, and having survived retinoblastoma in childhood.

Having an early menarche or a late menopause, not having children, having a personal or family history of colon or reproductive system cancer, being overweight, having diabetes, and having high blood pressure are all risk factors.

• Polycystic ovarian syndrome • Advancing years

● Estrogen-secreting tumor ● Endometrial hyperplasia ● Unopposed estrogens ● Tamoxifen use

Prevention 

Oral contraceptive pills, permanent weight loss, or using cyclic progesterone to counteract the effects of unopposed estrogen on the uterus can lessen the risk of endometrial cancer in young women who are obese or anovulatory. These women also stand a better chance of surviving the disease if they take oral contraceptive pills.
Except in cases where the lady has previously undergone a hysterectomy, estrogen replacement therapy should always include progesterone.
Cigarette smoking has been linked to a reduced risk of developing type I endometrial cancer; however, despite this, it is not recommended due to the numerous problems it poses to one's health and the increased risk it poses for developing type II endometrial cancer.

Conditions That Often Occur Together 

● Endometrial hyperplasia: 1–25% will develop to endometrial adenocarcinoma: - Straightforward in the absence of atypia – Intricate in the absence of atypia
– Straightforward with atypia – Intricate with atypia
Approximately 43 percent of patients who have complicated hyperplasia with atypia also have endometrial cancer.
Patients diagnosed with endometrial cancer should undergo routine screening tests for breast and colon cancer, as recommended by standard screening guidelines.
Patients who have previously been diagnosed with breast or colon cancer have an increased likelihood of developing endometrial cancer.

Granulosa cell tumors of the ovary are known to release estrogen, which leads to an elevated risk of endometrial cancer in the women who have them.

Diagnosis 
Postmenopausal bleeding is the most common indication of endometrial cancer, which is caused by the disease. Evaluation is necessary in the event that you notice any spotting or abnormal discharge. Patients who are premenopausal and have a history of anovulation as well as heavy, irregular, or protracted periods and have not responded favorably to several medical managements are required to undergo examination.
Sarcoma - Mullerian sarcoma mixed: bleeding and prolapsing tissue, pain and discomfortn – Leiomyosarcoma: pelvic pain, pressure, uterine mass, abnormal bleeding 

Examination Clinical Pelvic exam revealed an enlarged and fixed uterus.

Differential Diagnosis Atypical complex hyperplasia is a premalignant lesion of the endometrium. Cervical cancer. Ovarian cancer infiltrating the uterus. Endometriosis. Adenomyosis. Leiomyoma. Endometriosis. Adenomyosis. Leiomyoma. Endometriosis. Adenomyosis. Leiomyo


Results From the Laboratory 

Initial Tests (lab, imaging)
Tests to evaluate liver and kidney function
A normal transvaginal ultrasound will typically reveal an increased endometrial thickness (>4 mm in postmenopausal individuals or in patients with irregular or heavy periods who are above the age of 35, with a 100% negative predictive value).

When intra-abdominal illness is present, there is a possibility that the levels of cancer antigen 125 (CA-125) will be high.

Chest x-ray (CXR): The lung is the most often occurring site of metastasis.
Mammograms and colonoscopies are recommended since endometrial cancer is linked to both breast and colon cancer.
MRI, CT, or PET scans as part of routine preoperative testing are not advised Follow-Up Tests and Special Considerations
Since endometrial cancer is almost always contained within the uterus, a preoperative assessment for metastasis is not required unless there is a reasonable suspicion that the cancer has already spread.

CT scan, PET/CT, MRI, CA-125: not part of the routine evaluation but may be needed if metastasis is suspected, patient is a poor operative candidate, or pathology returns high grade (G3 endometrioid, papillary serous, clear cell, carcinosarcoma) MRI has been reported to accurately show the depth of myometrial penetration but is not always cost-effective.

Diagnostic Methods and Other Procedures

Office endometrial biopsy (accuracy of 90%): If negative with a strong suspicion for cancer or if the woman continues to experience bleeding, a dilatation and curettage (D&C) procedure is required. Endometrial stromal sarcoma and leiomyosarcoma rarely are diagnosed preoperatively. Prior to endometrial ablation operations, an endometrial biopsy should be performed on any patient who has a medical history of periods that have been irregular, heavy, or unusually protracted.
The accuracy of fractional D&C testing is 99%, with the exception of sarcoma diagnoses.
D&C with hysteroscopic guidance is suggested over D&C alone because of its ability to pick up discrete lesions. If a surgical approach is preferred, this is because D&C alone does not have this capability.

The relevance of this dispersion of malignant cells is uncertain, despite the fact that meta-analyses point to hysteroscopic peritoneal dissemination of cancerous cells.
 
Interpretation of Tests IFGO Staging System (International Federation of Gynecology and Obstetrics): amended in 2009
- Stage I (limited to corpus uteri)
A: no invasion of the myometrium or less than half of the myometrium B: invasion of less than half of the myometrium - In Stage II, the tumor has spread into the cervical stroma but has not yet spread outside of the uterus.
- Third Stage: The disease has spread locally and/or regionally
A: invasion of the uterine serosa and/or the adnexa; B: involvement of the vagina and/or the parametrium
C: metastases to pelvic and/or para-aortic lymph nodes IIIC1: +pelvic nodes IIIC2: +para-aortic lymph nodes C: metastases to pelvic and/or para-aortic lymph nodes pelvic lymph nodes that are positive - Tumor has invaded the mucosa of the bladder and/or bowel, and/or there have been distant metastases: A: the tumor has spread to the mucosa of the bladder and/or the colon; B: the cancer has spread to distant organs, including the intra-abdominal organs and/or the inguinal lymph nodes.
The following characteristics are diagnostic of uterine sarcoma: mitotic index, cellular atypia, and regions of coagulative necrosis that are separated from the tumor. 

Management 

Surgery is the primary method of treatment for uterine cancer. Radiation therapy is utilized to reduce the risk of tumor recurrence at the vaginal cuff.

Medication 

First Line
Endometrial – Chemotherapy for advanced or recurring disease that is incurable with surgery and radiation Paclitaxel + carboplatin Doxorubicin + cisplatin + paclitaxel Hormonal therapy – Medroxyprogesterone acetate: for recurrence or metastases Hormonal therapy – Doxorubicin + carboplatin + paclitaxel  – Megestrol (Megace), 160 milligrams per day, for at least two months, for people who want to get pregnant but have premalignant lesions, atypical complicated hyperplasia, or well-differentiated endometrial carcinoma. Continue with D&C to ascertain whether or not the malignancy has resolved.
– Intrauterine device carrying levonorgestrel: as was discussed earlier for patients who wish future fertility
Chemotherapy Doxorubicin as a single agent or in combination Hormonal – Tamoxifen or aromatase inhibitors; not thoroughly researched, +/ progesterone – Progesterones Sarcoma – Chemotherapy Doxorubicin as a single agent or in combination 


Extra Medical Interventions
Radiation therapy Nonoperative candidates: radiation therapy alone Low risk: no adjuvant radiation therapy Intermediate risk: consider adjuvant vaginal brachytherapy; reduces local recurrences but has no effect on overall survival Vaginal brachytherapy is equivalent to whole pelvic radiation in regard to overall survival Vaginal brachytherapy is equivalent to whole pelvic radiation in regard to overall survival.

Chemotherapy and radiation therapy, in some instances, both carry a high risk. 

Surgical Methods and Operations 
The following procedures are included in surgical staging: extrafascial hysterectomy and bilateral salpingoophorectomy; cytologic washings; pelvic and para-aortic lymph node dissection; omental sampling, as necessary, and for papillary serous aspiration;

● Optimal tumor debulking, survival benefit

The LAP2 experiment found that minimally invasive surgery and laparotomy both resulted in similar 5-year survival rates.

Considerations Regarding the Aged

Patients who are elderly or obese also run a higher risk of complications during surgery.
Consideration may be given to other treatments such as radiation or progesterone.

Admission 
● Admission criteria/initial stabilization – Excessive vaginal bleeding – Preoperative stabilization
Nursing care should be routine; focus on pain management after surgical procedures.
Postoperative criteria include pain control, diet tolerance, ability to walk, and urinating independently. 

Keep in Touch 

Follow-up visits with a speculum and rectovaginal exam once every three to six months for the first two years, then once every six months for the next three years, and then once yearly thereafter for the rest of your life.


Patient Monitoring It is no longer suggested to get a chest x-ray every year. CT scans or PET/CT scans of the chest, abdomen, and pelvis should only be used to explore the possibility of recurrent disease and should not be performed routinely.

● Control comorbid conditions.
As tolerated and in accordance with any existing comorbidities

Education of the Patient 

After the operation:

Do not anticipate to be able to return to your normal level of activity for at least a month. Do not engage in sexual activity for at least a month. Do not lift more than 10 to 15 pounds. Do not drive.


Complications 

Complications related to surgery include excessive bleeding, infection of the wound, lymphedema, deep vein thrombosis (DVT), and injury to the urinary or digestive systems.
Side effects of radiation include constipation, diarrhea, ileus, intestinal blockage or fistula, radiation cystitis, proctitis, vaginal stenosis, and deep vein thrombosis (DVT).
Chemotherapy: as prescribed by the medicine administered 

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