Cancers of Women – Body of Uterus – Endometium
It is the most common genital tract malignancy in females. It occurs primarily in the postmenopausal women. (average age 60 years)
Who are at risk?
- Nulliparous women i.e. women who have never borne any children
- Infertility
- Irregular menses (prolonged cycles)
- Late menopause – natural menopause occurring after 52 years of age increases the cancer risk 2.4 times.
- Obesity
- Polycystic ovarian syndrome
- Diabetes Mellitus
- Use of tamoxifen – which is a drug for the treatment of breast cancer
- Use of oestrogen replacement therapy without the use of progestins alongwith.
What are the symptoms?
- Abnormal pattern of vaginal bleeding – abnormal bleeding during or after the time of menopause should always be taken seriously and should be investigated, no matter how minimal or non persistent it is. The abnormality may be in the form of heavy persistent bleeding or irregular bleeding or any vaginal bleeding that occurs once menopause has set in.
- Persistent or purulent or foul smelling vaginal discharge.
- Pelvic pressure or discomfort.
- Less than 5% of women may be totally asymptomatic.
What needs to be done?
- A complete and thorough examination by a gynaecologist who would carry out a complete general physical examination as well as a pelvic examination to evaluate the genital tract to localise the site of bleeding and also the spread of the disease to the extragenital organs.
- Ultrasound of the pelvis – will help to assess the uterus size, any growth inside its cavity, thickness of the endometrium i.e. the living of the uterus & the ovaries adjacent to it.
- Sampling of the endometrium by D&C and hysteroscopy is the gold standard in evaluating a woman with abnormal vaginal bleeding. The cavity of the uterus is directly visualised under mangnification by a hysteroscope and biopsy is taken from the suspicious working areas. It is a daycare procedure.
- Pap smear is to be taken from the cervix to see for a concomitant cervical pathology. 30-50% of patients with endometrial cancer will have an abnormal pap test result.
What happens after the biopsy test result of endometrial cancer?
After establishing the diagnosis of endometrial carcinoma, the next step is to thoroughly evaluate the patient in order to decide the best and safest approach to the management of the disease.
Pre operative investigations would include:
- Blood type & screen
- Complete blood count & platelet counts
- Serum biochemistry studies including liver & kidney function tests
- Urine analysis
- Chest X-Ray
- ECG
- MRI or CT of abdomen & pelvis is done to assess the spread of the disease.
- Other studies like cystoscopy, proctosigmoidoscopy etc. are done depending upon the patients signs and symptoms.
- A detailed evaluation of the associated medical or surgical illnesses is also done.
- The patient is assessed by the anaesthetist and if required the internist before surgery
- Most patients with endometrial cancer should undergo surgical staging. The surgical procedure would involve.
§ Sampling of the peritoneal fluid
§ Exploration of the abdomen & pelvis
§ Biopsy of any extrauterine lesions suggestive of disease spread
§ Hysterectomy with removal of both tubes & ovaries
§ Removal of pelvic & para-aortic lymph nodes – either suspicious or in those women with risk factors.
What factors determine the postoperative outcome?
- Age – younger women in general have a better prognosis and a decreased risk of recurrence of the tumour & grade
- Type & grade of tumour & lymph vascular space invasion
- Myometrial invasion
- Extension to the cervix
- Involvement of adnexa
- Lymph node metastasis
- Spread to peritoneum
- Size of tumor
- Hormone receptor status etc.
What happens after surgery?
Postoperative therapy is based on prognostic factors determined by surgical and pathologic staging. Options for postoperative management include
- Observation
- Radiation to the vaginal vault / external pelvis / extended fluid / whole abdomen radiation
- Chemotherapy
Follow-up:
- Patients are examined every 3 months during the first 2-3 years and thereafter every 6 months with particular emphasis on a detailed history and physical examination.
- Chest X ray is recommended every 6-12 months.
- Other special & radiological investigations are carried out as and when required.
- About 75% of the recurrences occur within 3 years of initial treatment.
Compiled by:
Dr. Nidhi Khera
Consultant,
Department of Obst. & Gynae.