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 CANCER OF
THE
UTERINE
BODY
TODUȚ OANA CRISTINA resident physician
 •Uterine cancers can be of two types:
–endometrial cancer (common)
–uterine sarcoma (rare).
•Endometrial cancer can often be cured.
•Uterine sarcoma is often more aggressive and harder
to treat.
 ENDOMETRIAL CANCER
Endometrial cancer is a disease in which malignant
(cancer) cells form in the tissues of the endometrium.
• Endometrial cancer is the most common gynecological
malignancy in developed countries.
• The number of new cases in 2012 in Europe was
approximately 100,000.
• More than 90% of cases occur in women over 50, with
a median age of diagnosis of 63.
• However, approximately 4% of cases occur in women
under 40, many wanting to preserve their fertility.
Anatomy of the female
reproductive system

• The organs in the female

reproductive system include the
uterus, ovaries, fallopian tubes,
cervix, and vagina.
• The uterus has a muscular outer layer
called the myometrium and an inner
lining called the endometrium.
 Risk factors for endometrial cancer include the
following
• Taking estrogen-only hormone replacement therapy (HRT) after menopause.
• Taking tamoxifen to prevent or treat breast cancer.
• Obesity.
• Having metabolic syndrome.
• Having type 2 diabetes.
• Exposure of endometrial tissue to estrogen made by the body. This may be
caused by:
• Never giving birth.
• Menstruating at an early age.
• Starting menopause at a later age.
 Risk factors for endometrial cancer include the
following
• Having polycystic ovarian syndrome.
• Having a family history of endometrial cancer in a first-degree
relative (mother, sister, or daughter).
• Having certain genetic conditions, such as Lynch syndrome.
• Having endometrial hyperplasia.
• Older age is the main risk factor for most cancers. The chance of
getting cancer increases as you get older.
• Taking tamoxifen for breast cancer or taking estrogen alone
(without progesterone) can increase the risk of endometrial cancer.
• Endometrial hyperplasia is an abnormal thickening
of the endometrium (lining of the uterus). It is not
cancer, but in some cases, it may lead to
endometrial cancer.
• Estrogen is a hormone made by the body. It helps
the body develop and maintain female sex
characteristics. Estrogen can affect the growth of
some cancers, including endometrial cancer.
 • A woman's risk of developing endometrial cancer is increased by being
exposed to estrogen in the following ways:
 Estrogen-only hormone therapy: Estrogen may be given to replace the estrogen
no longer produced by the ovaries in postmenopausal women or women whose
ovaries have been removed. This is called hormone therapy (HT). The use of HT
that contains only estrogen increases the risk of endometrial cancer, and the risk
grows higher the longer the estrogen is used. For this reason, estrogen therapy
alone is usually prescribed only for women who do not have a uterus.
 When estrogen is combined with progestin (another hormone), it is called
combination estrogen-progestin therapy. For postmenopausal women, taking
estrogen in combination with progestin does not increase the risk of
endometrial cancer, but it does increase the risk of breast cancer.
 Early menstruation: Beginning to have menstrual periods at an early age
increases the number of years the body is exposed to estrogen and
increases a woman's risk of endometrial cancer.
 Late menopause: Women who reach menopause at an older age are
exposed to estrogen for a longer time and have an increased risk of
endometrial cancer.
 Never being pregnant: Because estrogen levels are lower during
pregnancy, women who have never been pregnant are exposed to
estrogen for a longer time than women who have been pregnant. This
increases the risk of endometrial cancer.
• Tamoxifen

– Tamoxifen is one of a group of drugs called selective estrogen receptor

modulators, or SERMs. Tamoxifen acts like estrogen on some tissues in the
body, such as the uterus, but blocks the effects of estrogen on other tissues,
such as the breast. Tamoxifen is used to prevent breast cancer in women who
are at high risk for the disease. However, using tamoxifen for more than 2
years increases the risk of endometrial cancer. This risk is greater in
postmenopausal women.
– Raloxifene is a SERM that is used to prevent bone weakness in
postmenopausal women. However, it does not have estrogen-like effects on
the uterus and has not been shown to increase the risk of endometrial cancer.
• Obesity, gaining weight as an adult, or having metabolic syndrome
increases the risk of endometrial cancer. Obesity is related to other
risk factors such as high estrogen levels, having extra fat around the
waist, polycystic ovary syndrome, and lack of physical activity.
• Having metabolic syndrome increases the risk of endometrial
cancer. Metabolic syndrome is a condition that includes extra fat
around the waist, high blood sugar, high blood pressure, and high
levels of triglycerides (a type of fat) in the blood.
• Having type 2 diabetes may increase the risk of endometrial cancer.
 •Lynch syndrome is an inherited disorder caused by changes in
certain genes. Women who have Lynch syndrome have a much
higher risk of developing endometrial cancer than women who do
not have Lynch syndrome.
•Polycystic ovary syndrome and Cowden syndrome are inherited
conditions that are linked to an increased risk of endometrial cancer.
•Women with a family history of endometrial cancer in a
first-degree relative (mother, sister, or daughter) are also at
increased risk of endometrial cancer.
 Endometrial Cancer Prevention
• Avoiding risk factors and increasing protective factors may help prevent
cancer.
• The following protective factors decrease the risk of endometrial cancer:
– Pregnancy and breast-feeding
– Hormonal contraceptives
– Weight loss
– Physical activity
• Cigarette smoking is also a protective factor for endometrial cancer; however,
there are many known harms of smoking that outweigh this benefit.
• It is not known if the following factor affects the risk of endometrial cancer:
•Pregnancy and breast-feeding
–Estrogen levels are lower during pregnancy and
when breast-feeding. The risk of endometrial cancer is
lower in women who have had children. Breastfeeding
also decreases the risk of endometrial cancer.
•Weight loss
–It is not known if losing weight decreases the
risk of endometrial cancer.
–However, having bariatric surgery (a surgery
that changes how your digestive system works so you
will lose weight) decreases the risk of endometrial
cancer. After bariatric surgery, other obesity-related
conditions, such as diabetes and metabolic syndrome
often improve or go away.
–Having bariatric surgery also includes risks, such
as infection, blood clots, breathing or heart problems,
and digestive issues.
•Physical activity

–Physical activity
(exercise) may lower the risk
of endometrial cancer. This
includes any physical activity
you do at your job or at
home.
 •Cigarette smoking is also a protective factor
for endometrial cancer; however, there are many
known harms of smoking that outweigh this
benefit.
–Although cigarette smoking has been linked to
a decreased risk of endometrial cancer, it has been
proven to have many other serious harmful effects.
–Studies show that women who smoke at least
20 cigarettes a day may have a lower risk of
endometrial cancer than women who do not smoke.
–The risk of endometrial cancer is even lower in
postmenopausal women who smoke.
 Signs and symptoms of
endometrial cancer
 Vaginal bleeding or discharge not
related to menstruation (periods).
 Vaginal bleeding after menopause.
 Difficult or painful urination.
 Pain during sexual intercourse.
 Pain in the pelvic area.
 Tests that examine the endometrium to diagnose
endometrial cancer.

• Because endometrial cancer begins inside the uterus, it does

not usually show up in the results of a Pap test.
• For this reason, a sample of endometrial tissue must be
removed and checked under a microscope to look for cancer
cells.
 Endometrial biopsy: The removal of tissue from the endometrium (inner lining of the
uterus) by inserting a thin, flexible tube through the cervix and into the uterus. The
tube is used to gently scrape a small amount of tissue from the endometrium and then
remove the tissue samples. A pathologist views the tissue under a microscope to look
for cancer cells.
 Dilatation and curettage: A procedure to remove samples of tissue from the inner
lining of the uterus. The cervix is dilated and a curette is inserted into the uterus to
remove tissue. The tissue samples are checked under a microscope for signs of disease
 Hysteroscopy: A procedure to look inside the uterus for abnormal areas. A
hysteroscope is inserted through the vagina and cervix into the uterus. A hysteroscope
is a thin, tube-like instrument with a light and a lens for viewing. It may also have a
tool to remove tissue samples, which are checked under a microscope for signs of
cancer.
 •A speculum is inserted into the vagina to widen it in order to look at the cervix (first panel). A dilator is used to widen the cervix
(middle panel). A curette is put through the cervix into the uterus to scrape out abnormal tissue (last panel).
• Transvaginal
ultrasound exam:
– Images from the TVUS can
be used to see if the uterus
contains a mass (tumor), or if
the endometrium is thicker
than usual, which can be a
sign of endometrial cancer. It
may also help see if cancer is
growing into the muscle layer
of the uterus (myometrium).
 Tests to look for cancer spread

• Chest x-ray
• Computed tomography (CT) CT scans are not used to diagnose endometrial
cancer. But they can help see if the cancer has spread to other organs and to see if
it has come back after treatment.
• Magnetic resonance imaging (MRI) MRI is a good way to tell whether, and
how far, the endometrial cancer has grown into the body of the uterus. MRI scans
may also help find enlarged lymph nodes with a special technique that uses very
tiny particles of iron oxide.
• Positron emission tomography (PET) PET scans are not a routine part of the work-
up of early endometrial cancer, but may be used for more advanced cases.
• CA-125 blood test
– CA-125 is a substance released into the bloodstream by many, but not all,
endometrial and ovarian cancers. If a woman has endometrial cancer, a
very high blood CA-125 level suggests that the cancer has likely spread
beyond the uterus.

• Some doctors check CA-125 levels before surgery or other

treatment. If they're elevated, they can be checked again to see
how well the treatment is working (levels will drop after surgery if
all the cancer is removed).
• CA-125 levels are not needed to diagnose endometrial cancer, so
this test isn’t done on all patients.
 There are three ways that cancer spreads
in the body

• Tissue. The cancer spreads from where it began by

growing into nearby areas.
• Lymph system. The cancer spreads from where it
began by getting into the lymph system. The
cancer travels through the lymph vessels to other
parts of the body.
• Blood. The cancer spreads from where it began by
getting into the blood. The cancer travels through
the blood vessels to other parts of the body.
 Stages for endometrial cancer
• In stage I, cancer is found in the uterus only.
– Stage IA: Cancer is in the endometrium only or less than halfway through the myometrium (muscle layer
of the uterus).
– Stage IB: Cancer has spread halfway or more into the myometrium.
• In stage II, cancer has spread into connective tissue of the cervix, but has not spread outside the uterus.
• In stage III, cancer has spread beyond the uterus and cervix, but has not spread beyond the pelvis.
– Stage IIIA: Cancer has spread to the outer layer of the uterus and/or to the fallopian tubes, ovaries, and
ligaments of the uterus.
– Stage IIIB: Cancer has spread to the vagina and/or to the parametrium (connective tissue and fat around
the uterus).
– Stage IIIC: Cancer has spread to lymph nodes in the pelvis and/or around the aorta (largest artery in the
body, which carries blood away from the heart)
• In stage IV, cancer has spread beyond the pelvis
– Stage IVA: Cancer has spread to the bladder and/or bowel wall.
– Stage IVB: Cancer has spread to other parts of the body beyond the pelvis, including the abdomen
and/or lymph nodes in the groin.
 In stage I, cancer is found in the uterus only. In stage IA, cancer is in the endometrium only or less than halfway through the myometrium
(the muscle layer of the uterus). In stage IB, cancer has spread halfway or more into the myometrium.
• In stage II, cancer has spread into connective tissue of the cervix, but has not spread
outside the uterus.
• In stage III, cancer has spread beyond the uterus and cervix
, but has not spread beyond the pelvis.
In stage IV, cancer has spread beyond the pelvis.
 Treatment
• Surgery (removing the cancer in an operation) is the
most common treatment for endometrial cancer.
• The following surgical procedures may be used:
– Total hysterectomy
– Bilateral salpingo-oophorectomy
– Radical hysterectomy
– Lymph node dissection: This procedure is also called
lymphadenectomy.
• Radiation therapy

– Radiation therapy is a cancer treatment that uses high-energy

x-rays or other types of radiation to kill cancer cells or keep
them from growing. There are two types of radiation therapy:
• External radiation therapy .
• Internal radiation therapy .
– The way the radiation therapy is given depends on the type
and stage of the cancer being treated. External and internal
radiation therapy are used to treat endometrial cancer, and
may also be used as palliative therapy to relieve symptoms
and improve quality of life.
• Chemotherapy

– Chemotherapy is a cancer treatment that uses drugs to stop

the growth of cancer cells, either by killing the cells or by
stopping the cells from dividing.
– When chemotherapy is taken by mouth or injected into a vein
or muscle, the drugs enter the bloodstream and can reach
cancer cells throughout the body (systemic chemotherapy).
• Hormone therapy
– Hormone therapy is a cancer treatment that removes hormones or blocks
their action and stops cancer cells from growing.
• Targeted therapy
– Targeted therapy is a type of treatment that uses drugs or other substances
to identify and attack specific cancer cells. Targeted therapies usually cause
less harm to normal cells than chemotherapy or radiation therapy do.
– Monoclonal antibodies, mTOR inhibitors, and signal transduction inhibitors
are three types of targeted therapy used to treat endometrial cancer.
 UTERINE SARCOMA
Uterine sarcoma is a disease in which malignant (cancer)
cells form in the muscles of the uterus or other tissues
that support the uterus
• Uterine sarcoma is a very rare kind of cancer that forms in the
uterine muscles or in tissues that support the uterus.
• Uterine sarcoma is different from endometrial cancer, a disease
in which cancer forms in the tissue that lines the uterus.
• Carcinosarcoma is a subtype of endometrial cancer and is
staged using endometrial cancer definitions. Uterine sarcomas
include leiomyosarcomas, endometrial stromal sarcomas, and
adenosarcomas.
• Risk factors for uterine sarcoma include the
following:
 Past treatment with radiation therapy to the pelvis.
 Treatment with tamoxifen for breast cancer. If you are
taking this drug, have a pelvic exam every year and
report any vaginal bleeding (other than menstrual
bleeding) as soon as possible.
 Signs of uterine sarcoma
• Abnormal bleeding from the vagina and
other signs and symptoms may be caused by
uterine sarcoma or by other conditions.
• Bleeding that is not part of menstrual periods
.
• Bleeding after menopause.
• A mass in the vagina.
• Pain or a feeling of fullness in the abdomen.
• Frequent urination.
 Tests that examine the uterus are used to diagnose uterine sarcoma.

• Pelvic exam
• Pap test -Because uterine sarcoma
begins inside the uterus, this cancer
may not show up on the Pap test.
• Transvaginal ultrasound exam:
• Dilatation and curettage
• Endometrial biopsy
• Chest x-ray
• CT scan (CAT scan)
 There are three ways that cancer spreads in the body

 Tissue. The cancer spreads from where it began by growing into nearby areas.
 Lymph system. The cancer spreads from where it began by getting into the lymph
system. The cancer travels through the lymph vessels to other parts of the body.
 Blood. The cancer spreads from where it began by getting into the blood. The
cancer travels through the blood vessels to other parts of the body.
 TREATMENT
• Surgery is used to diagnose, stage, and treat uterine sarcoma.
• During this surgery, the doctor removes as much of the cancer as possible.
• The following procedures may be used to diagnose, stage, and treat
uterine sarcoma:
– Laparotomy:
– Abdominal and pelvic washings
– Total abdominal hysterectomy
– Bilateral salpingo-oophorectomy
– Lymphadenectomy
• Radiation therapy
– Radiation therapy is a cancer treatment that uses high energy x-rays or other types of radiation
to kill cancer cells or keep them from growing. There are two types of radiation therapy:
 External radiation therapy
 Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that
are placed directly into or near the cancer.

 Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by
killing the cells or by stopping them from dividing
• Hormone therapy
– Hormone therapy is a cancer treatment that removes hormones or blocks their action and
stops cancer cells from growing
 TO REMEMBER
• Uterine cancer is the second most common form of genital cancer in romania after cervical
cancer

• Abnormal uterine bleeding is the most common symptom.

• The diagnosis of certainty is histopathological.

• Transvaginal ultrasound has an indicative value, and the other imaging methods are mainly
intended to evaluate the extension.

• The treatment of choice for uterine cancer is surgery.

• The prognosis of uterine sarcoma is much worse compared to that of endometrial cancer