Benign and Malignant Conditions of the Uterus Mihretu

Benign and Malignant Conditions of the Uterus Mihretu Molla (Bsc, Msc) 2/14/2022 Mihretu Molla 1

Presentation outline • Leiomyoma of the Uterus • Endometriosis • Endometrial polyp • Endometrial hyperplasia • Uterine cancer 2/14/2022 Mihretu Molla 2

Leiomyoma of the Uterus (Fibromyoma, Fibroid, Myoma, Leiomyomata) 2/14/2022 Mihretu Molla 3

Learning objectives After learning this topic students are expected to • Explain brief anatomy of ux • characterize Leiomyoma of the Uterus • List the possible risk factors of Leiomyoma of the Uterus • Classify Leiomyoma of the Uterus • Explain the degenerative variants of Leiomyoma of the Uterus • State the clinical features of Leiomyoma of the Uterus • Explain the effect of Leiomyoma of the Uterus on pregnancy and vice versa • Identify possible DDx for Leiomyoma of the Uterus • Explain management options for Leiomyoma of the Uterus • Identify possible complications of Leiomyoma of the Uterus 2/14/2022 Mihretu Molla 4

Leiomyoma of the Uterus (Fibromyoma, Fibroid, Myoma, Leiomyomata) Introduction • Benign clonal tumors arising from the smooth muscle cells of the uterus • Contains an increased amount of extracellular matrix proteins (collagen and elastin) • Surrounded by a thin pseudocapsule of areolar tissue and compressed muscle fibers 2/14/2022 Mihretu Molla 5

Myoma …. . Epidemiology • The most common pelvic tumors(95% of all benign female genital tract tumors) • Clinically apparent in ~ 25% of reproductive aged women. • Noted on pathological examination in ~ 80% of surgically excised uteri • Common in reproductive age • 3 -9 times more common in blacks 2/14/2022 Mihretu Molla 6

Etiology • • • cause is not known Estrogen-dependent tumors occasionally grow during pregnancy(caused by estrogen) 2/14/2022 Mihretu Molla 7

Myoma …. . Risk factors • Early menarche • high intake of beef, red meat • Smoking Reduces risk of fibroid • Having one or more pregnancies beyond 20 weeks decreases the chance, women at least given birth to 2 children have 2 x less risk 2/14/2022 Mihretu Molla 8

Classification of leiomyomas • Classified based on their location and direction of growth Intramural (Interstitial) �fibroids within the wall of the uterus �located in the myometrium and accounts for 70% of myomas. 2/14/2022 Mihretu Molla 9

Classification…. . Submucous leiomyomas • Are proximate to the endometrium • Grow toward and bulge into the endometrial cavity. • When they protrudes into the cervical canal and the vagina they are called delivered myomas. 2/14/2022 Mihretu Molla 10

Classification…. . Subserosal leiomyomas • Originate from myocytes adjacent to the uterine serosa • Their growth is directed outward. • When attached by a stalk to their progenitor myometrium, they are called pedunculated leiomyomas. • Parasitic leiomyomas are subserosal variants that attach themselves to nearby pelvic structures from which they derive vascular support. 2/14/2022 Mihretu Molla 11

Classification…. . Intraligamentary � If a subserosal myoma is projecting between the layers of the broad ligament Cervical • a myoma that grows on the cervix • usually subserous in growth • rare and is commonly single ØLeiomyomas have also been found infrequently in the ovary, fallopian tube, broad ligament, vagina, and vulva. 2/14/2022 Mihretu Molla 12

Classification…. . 2/14/2022 Mihretu Molla 13

Degenerative Changes of Myomas • Myomas usually have a firm consistency and are non tender. • This appearance may change if smooth muscle is replaced with various degenerative substances following necrosis. • This process is collectively termed degeneration • Necrosis and degeneration develop frequently in leiomyomas because of the tenuous blood supply within these tumors. 2/14/2022 Mihretu Molla 14

Degenerative Changes …. . Hyaline degeneration • The most common of all secondary changes • Asymptomatic • Yellowish, soft and often gelatinous area is seen 2/14/2022 Mihretu Molla 15

Degenerative Changes …. . Cystic degeneration • Liquefaction follows extreme hyalinization • Formation of multiple small cystic spaces, giving a sponge-like appearance and soft consistency to the tumor • Sometimes mimic cystic ovarian tumor 2/14/2022 Mihretu Molla 16

Degenerative Changes …. . Septic degeneration • Infection may follow necrosis due to circulatory inadequecy • Example: torsion of a pedunculated myoma. Fatty(Myxomatous) degeneration • Is rare and asymtomatic • usually occurs after menopause • Follows hyaline and cystic degeneration • precursor for calcareous degeneration. 2/14/2022 Mihretu Molla 17

Degenerative Changes …. . Calcification (Calcareous) degeneration • Is when calcium is deposited in the myoma. • Occurs when there is some circulatory disturbance • Subserous leiomyomata are most commonly affected by circulatory deprivation, which causes precipitation of calcium carbonate and phosphate within the tumor 2/14/2022 Mihretu Molla 18

Degenerative Changes …. . Carneous (red) degeneration • Commonly seen during pregnancy or near the menopause, but can occur any time. • Venous thrombosis and congestion with interstitial hemorrhage are responsible for the color of the myoma undergoing red degeneration. • The process is usually associated with extreme pain but is always self limited. • Its exact mechanism is not known 2/14/2022 Mihretu Molla 19

Degenerative Changes …. . Atrophic degeneration • Signs and symptoms regress or disappear as tumor size decreases at menopause or after pregnancy. Sarcomatous degeneration • is malignant transformation of myoma. • should be suspected when there is significant growth in a short period associated with pain. • Malignanat transformation is quite rare (1: 1000) • usually occurs in postmenopausal women 2/14/2022 Mihretu Molla 20

Clinical features of myomas Symptoms • present in only 35– 50% of patients with leiomyomas. • AUB(menorrhagia or menometrorrhagia). • Relatively infrequent pain • sensation of heaviness or fullness in the pelvic area, a feeling of a mass in the pelvis, or a feeling of a mass palpable through the abdominal wall. • Pressure effects (urinary symptoms, hydroureter , intestinal obstruction) • Infertility • Spontaneous abortion 2/14/2022 Mihretu Molla 21

Clinical features of myomas. . . Physical Examination �Most myomas are discovered by routine bimanual examination of the uterus or sometimes by palpation of the lower abdomen. �The diagnosis is obvious when the normal uterine contour is distorted by one or more smooth, spherical, irregular, firm masses �A pelvic ultrasound generally assists in establishing the diagnosis, as does excluding pregnancy as a cause of uterine enlargement. 2/14/2022 Mihretu Molla 22

Clinical features of myomas. . . Investigations • Hct , Blood group & Rh , Pelvic ultrasound • IVP may be useful in the work-up of any pelvic mass because it frequently reveals ureteral deviation or compression and identifies urinary anomalies. • MRI can also be used to evaluate the urinary tract and is highly accurate in depicting the number, size, and location of leiomyomata. • Hysteroscopy may assist in identification, and may also be used for removal, of submucous leiomyomas. • Laparoscopy is often definitive in establishing the precise origin of leiomyomata and is increasingly being used for myomectomy. 2/14/2022 Mihretu Molla 23

DDX of myomas �Pregnancy �Adenomyosis �Ovarian tumor �Tubo-ovarian abscess �Endometriosis �Endometrial ca. 2/14/2022 Mihretu Molla 24

Pregnancy & Myoma �Increase during pregnancy by 22% �Effect of myoma on pregnancy may include �Abortion �Preterm labour �Malpresentation: 4 x �Placental abruption: 4 x �Dysfunctional labour � obstructed labour �Increased operative delivery: C/S-6 x �PPH �Effect of pregnancy on myoma �Red degeneration 2/14/2022 Mihretu Molla 25

Management of Myomas �Asymptomatic ones are managed expectantly �Factors considered prior initiating treatment -Size of myoma(s) - Location of myoma(s) - Symptoms - Woman’s age (eg menopause) - reproductive plans 2/14/2022 Mihretu Molla 26

Management… Management options • Conservative • Medical • Surgical • uterine artery embolization(UAE) • Myolysis • Immunotherapy 2/14/2022 Mihretu Molla 27

Management of Myomas. . . Expectant management • Indicated for asymptomatic myomas of < 12 weeks. • Monitoring of the growth of myoma by bimanual pelvic examination and hemtocrit determination of bleeding. • Bed rest , analgesics and/or tocolytics for red degeneration during pregnancy 2/14/2022 Mihretu Molla 28

Management of Myomas. . . Medical management • Gonadotrophic analogs(Gn. RHa) • Gn. RH agonists • Gn. RH antagonists 2/14/2022 Mihretu Molla 29

Management of Myomas. . . Surgical management • The mainstay of therapy Indications • Abnormal uterine bleeding • High level of suspicion of pelvic malignancy • Growth after menopause • Infertility 2 ry to distortion of the endometrial cavity/ tubal obstruction • Recurrent pregnancy loss (with distortion of the endometrial cavity) • Pain or pressure symptoms (that interfere with quality of life) • Urinary tract symptoms (frequency and/or obstruction) • Iron deficiency anemia secondary to chronic blood loss 2/14/2022 Mihretu Molla 30

Management of Myomas. . . Surgical management options • Hysterectomy • Myoma is most common indication for hysterectomy • eliminates both current symptoms and the chance of recurrent problems • Has Disadvantages of High morbidity and cost • Myomectomy • For women who desire future pregnancies • For women who wish to retain their uterus 2/14/2022 Mihretu Molla 31

Complications of Myomas Medical • Anemia Gynecological • Torsion with gangrene, sarcomatous changes, rupture of the surface blood vessel, chronic inversion and infection of delivered myoma, infertility, recurrent abortion, etc Obstetrical • Preterm labour, malpresentation, uterine inertia, obstructed labour, postpartum hemorrhage, red degeneration, etc… 2/14/2022 Mihretu Molla 32

Endometriosis Mihretu Molla (Bsc, MSc) 2/14/2022 Mihretu Molla 33

Learning objectives After learning this session students will be able to • Define Endometriosis • Identify and discuss theories on histogenesis of Endometriosis • Identify risk factors of Endometriosis • Identify clinical features of Endometriosis • Identify diagnostic modalities of Endometriosis • Identify DDx of Endometriosis • Explain mgt options of Endometriosis • Identify possible complications of Endometriosis 2/14/2022 Mihretu Molla 34

Endometriosis • Endometriosis is the presence of endometrial glands and stroma outside of the endometrial cavity. • common benign gynecologic disorder chiefly found in reproductiveaged women. • most commonly found on the pelvic peritoneum • may also be found on the ovaries, rectovaginal septum, and pleura 2/14/2022 Mihretu Molla 35

Endometriosis…. • Adenomyosis is uterine enlargement caused by ectopic rests of endometrium (both glands and stroma) located deep within the myometrium. • These rests may be scattered throughout the myometrium (diffuse adenomyosis), or may form a localized nodular collection (focal adenomyosis). 2/14/2022 Mihretu Molla 36

Etiology of endometriosis • The definitive cause of endometriosis remains unknown. • Several theories have been proposed to explain the histogenesis of endometriosis • No single theory can account for the location of endometriosis in all cases. 2/14/2022 Mihretu Molla 37

Etiology of endometriosis…. . Theories on Etiology of Endometrosis 1. Ectopic transplantation of endometrial tissue (Retrograde Menstruation ) 2. Coelomic metaplasia 3. The induction theory 4. Lymphatic or Vascular Spread 2/14/2022 Mihretu Molla 38

Theories…. . Transplantation Theory • based on the assumption that endometriosis is caused by the seeding or implantation of endometrial cells by transtubal regurgitation during menstruation • Refluxed endometrial fragments adhere to and invade the peritoneal mesothelium and develop a blood supply, which leads to continued implant survival and growth. • Substantial clinical and experimental data support this hypothesis. 2/14/2022 Mihretu Molla 39

Theories…. . Coelomic Metaplasia • suggests that the parietal peritoneum is a pluripotential tissue that can undergo metaplastic transformation to tissue histologically indistinguishable from normal endometrium. • Because the ovary and the progenitor of the endometrium, the müllerian ducts, are both derived from coelomic epithelium, metaplasia may explain the development of ovarian endometriosis. • This theory is attractive in instances of endometriosis in the absence of menstruation, such as in premenarchal and postmenopausal women, and in males treated with estrogen and orchiectomy for prostatic carcinoma. 2/14/2022 Mihretu Molla 40

Theories…. . Induction Theory • an extension of the coelomic metaplasia theory. • It proposes that an endogenous or exogenous (undefined) biochemical factor can induce undifferentiated peritoneal cells to develop into endometrial tissue. • These substances may be exogenous or released directly from the endometrium. 2/14/2022 Mihretu Molla 41

Theories…. . Lymphatic or Vascular Spread • Extra pelvic endometriosis, although rare (1%– 2%), potentially may result from vascular or lymphatic dissemination of endometrial cells to many gynecologic (vulva, vagina, cervix) and non gynecologic sites. • The latter include bowel (appendix, rectum, sigmoid colon, small intestine, hernia sacs), lungs and pleural cavity, skin (episiotomy or other surgical scars, inguinal region, extremities, umbilicus), lymph glands, nerves, and brain. 2/14/2022 Mihretu Molla 42

Possible Implantation sites • Cervix(50%) • Uterine cul- de -sac • Posterior broad ligament • Uterosacral ligament • Ux, and fallopian tube • sigmoid colon • Appendix NB These is not all inclusive list of possible implantation sites Mihretu Molla 43

Risk factors for endometriosis • Familial Clustering ØPolygenic / multifactorial inheritance pattern • Genetic mutations & polymorphisms • Anatomic Defects ØReproductive outflow tract obstruction • Environmental toxins: Ø 2, 3, 7, 8 -tetrachlorodibenzo-p-dioxin (TCDD) and other dioxinlike compounds. • Deficient cellular immunity 2/14/2022 Mihretu Molla 44

Clinical Presentation • 25% are asymptomatic • Pain (Cyclic or chronic) ØChronic pelvic pain ( most common symptom) • Infertility • Dysmenorrhea ( less responsive to (NSAIDs) and COC pills) • Dyspareunia • Dysuria • Defecatory pain • Pleural lesions 2/14/2022 Mihretu Molla 45

Classification of Endometriosis The American Society for Reproductive Medicine (ASRM) classified as Stage I (Minimal disease) • characterized by isolated implants and no significant adhesions. Stage II (Mild endometriosis) • consists of superficial implants < 5 cm in aggregate, scattered on the peritoneum and ovaries. • No significant adhesions are present. Stage III (Moderate disease) • exhibits multiple implants, both superficial and invasive. • Peritubal and periovarian adhesion may be evident. Stage IV (Severe disease) • is characterized by multiple superficial and deep implants, including large ovarian endometriomas. • 2/14/2022 Filmy & dense adhesions are usually present Mihretu Molla 46

Diagnosis of endometriosis 1. History 2. Physical Examination Visual Inspection • As the disease is confined to the pelvis, there are often no abnormalities on visual inspection. • Some exceptions include endometriosis within an episiotomy scar or surgical scar, most often within a Pfannenstiel incision. 2/14/2022 Mihretu Molla 47

Diagnosis…. . Speculum Examination • Examination of the vagina and cervix by speculum examination often reveals no signs of endometriosis. • Occasionally, bluish or red powder-burn lesions may be seen on the cervix or the posterior fornix of the vagina. • These lesions may be tender or bleed with contact. 2/14/2022 Mihretu Molla 48

Diagnosis…. . Bimanual Examination • Uterosacral ligament nodularity and tenderness may reflect active disease or scarring along the ligament. • Enlarged cystic adnexal mass may represent an ovarian endometrioma, which may be mobile or adherent to other pelvic structures. • Retroverted, fixed, tender uterus, or a firm, fixed posterior culde-sac. 2/14/2022 Mihretu Molla 49

Diagnosis…. Laboratory Testing • CBC • urinalysis and urine cultures • vaginal cultures and cervical swabs. • Serum CA 125 • Cancer antigen 19 -9 (CA 19 -9) Diagnostic Imaging • Sonography • Magnetic Resonance Imaging 2/14/2022 Mihretu Molla 50

Diagnosis …. . Diagnostic Laparoscopy • the primary method used for diagnosing endometriosis. • Laparoscopic findings are variable and may include discrete endometriotic lesions, endometrioma, and adhesion formation. • Patient symptoms correlate poorly with findings at laparoscopy 2/14/2022 Mihretu Molla 51

Differential Diagnosis of Endometriosis Gynecologic Pelvic inflammatory disease Tubo-ovarian abscess Salpingitis Endometritis Hemorrhagic ovarian cyst Ovarian torsion Primary dysmenorrhea Degenerating leiomyoma 2/14/2022 Nongynecologic Interstitial cystitis Chronic urinary tract infection Renal calculi Inflammatory bowel disease Irritable bowel syndrome Diverticulitis Mesenteric lymphadenitis Musculoskeletal disorders Mihretu Molla 52

Management of Endometriosis Management depends on • Woman's specific symptoms • Severity of symptoms • Location of endometriotic lesions • Goals for treatment, and • Desire to conserve future fertility 2/14/2022 Mihretu Molla 53

Medical management Nonsteroidal Anti-Inflammatory Drugs • first-line therapy in women with primary dysmenorrhea or pelvic pain prior to laparoscopic confirmation of endometriosis. • in women with minimal or mild pain symptoms associated with known endometriosis • Combination Oral Contraceptives • Mainstay for the treatment of pain associated with endometriosis. 2/14/2022 Mihretu Molla 54

Medical Management … • Progestins • Androgens: (Danazol) • Gn. RH Agonists (Depot leuprolide acetate; Lupron Depot ) 2/14/2022 Mihretu Molla 55

Surgical Management of Endometriosis Lesion Removal and Adhesiolysis • Laparoscopic excision or ablation of lesions. • Adhesiolysis is postulated to effectively treat pain symptoms in women with endometriosis by restoring normal anatomy. Endometrioma Resection • Cystectomy or aspiration coupled with ablation of the cyst capsule is done. 2/14/2022 Mihretu Molla 56

Surgical management contd. Presacral Neurectomy • For some women, transection of presacral nerves lying within the interiliac triangle may provide relief of chronic pelvic pain. Hysterectomy with Bilateral Oophorectomy • definitive and most effective therapy for women with endometriosis who do not wish to retain their reproductive function. 2/14/2022 Mihretu Molla 57

Complications of endometriosis • Ruptured chocolate cyst • Infected chocolate cyst • Obstructive features like intestinal obstruction, ureteric obstruction • Malignant transformation (rare) 2/14/2022 Mihretu Molla 58

Endometrial Polyp Mihretu Molla (Bsc, Msc) 2/14/2022 Mihretu Molla 59

Learning Objectives After the end of this topic students will be able to • Define endometrial polyp • Explain clinical features of endometrial polyp • Explain diagnostic modalities of endometrial polyp • Explain mgt options of endometrial polyp 2/14/2022 Mihretu Molla 60

Endometrial Polyp • A mass of tissue that projects outward or away from the surface of the endometrium. • Visible grossly as spheroidal or cylinderic structure that may be either pedunculated or broad- based Pathology • Fibrous stroma with thick walled, dilated vessels • Gland like spaces, lined with endometrial epithelium 2/14/2022 Mihretu Molla 61

Endometrial Polyp …. . Clinical feature • AUB (menorrhagia , intermenstrual , premenstrual bleeding ) Investigation • Endometrial biopsy • U/S • HSG - irregularities in out line of Ux cavity or filling defect • Hysteroscopy - gold standard for dx & Rx • Saline sonohysterography Management • surgical excision • Hysterectomy if associated malignancy 2/14/2022 Mihretu Molla 62

Endometrial Hyperplasia Mihretu Moll (Bsc, Msc) 2/14/2022 Mihretu Molla 63

Learning objectives After learning this topic students will be able to • Define Endometrial Hyperplasia • Explain the clinical significance of Endometrial Hyperplasia • Classify Endometrial Hyperplasia • Discuss risk of malignant transformation of Endometrial Hyperplasia • Explain mgt options of Endometrial Hyperplasia 2/14/2022 Mihretu Molla 64

Endometrial Hyperplasia • A spectrum of morphologic and biologic alterations of the endometrial glands and stroma • Results mainly from chronic estrogen stimulation unopposed by effects of progesterone 2/14/2022 Mihretu Molla 65

Endometrial Hyperplasia…. . Clinical significance • May cause AUB • Associated with estrogen producing ovarian tumor • Precede or occur simultaneously with endometrial carcinoma 2/14/2022 Mihretu Molla 66

Endometrial Hyperplasia…. . Classification Simple or complex • Based on the degree of architectural complexity Hyperplasia without Atypia or Atypical hyperplasia • By cytological features 2/14/2022 Mihretu Molla 67

Classification… Simple Hyperplasia with out atypia • Dilated or cystic glands • Increased glandular to stromal ratio without glandular Crowding • No cytologic atypia Complex hyperplasia without atypia • Architecturally complex (budding and enfolding crowded glands with less intervening stroma). • No cytologic atypia 2/14/2022 Mihretu Molla 68

Classification… Atypical hyperplasia (simple and complex) • Refers to cytologic atypia • Are generally considered premalignant 2/14/2022 Mihretu Molla 69

Risk of Malignancy (WHO) Classification Progression to cancer(%) Simple hyperplasia without atypia 1 Complex hyperplasia without atypia 3 Simple atypical hyperplasia 8 Complex atypical hyperplasia 29 2/14/2022 Mihretu Molla 70

Treatment Hysterectomy • treatment of choice for endometrial hyperplasia with atypia and who are not planning future pregnancy. Progestin RX • Atypical endometrial hyperplasia who wish to preserve fertility or cannot tolerate surgery. • For Rx of endometrial hyperplasia without atypia 2/14/2022 Mihretu Molla 71

Treatment…. . Progestin RX …. • Cyclic progestin RX ØMPA 10 to 20 mg/day for 14 days/month for 2 to 3 month • Continuous progestin Ømegestrol acetate 20 to 40 mg/day • Endometrial biopsy 3 to 4 months after completion of RX to asses response 2/14/2022 Mihretu Molla 72

Uterine Cancer Mihretu Molla (Bsc, Msc) 2/14/2022 Mihretu Molla 73

Learning objectives After learning this session students will be able to • Identify types of uterine cancer • Identify risk factors of uterine cancer • Identify clinical features of uterine cancer • Describe FIGO classification of uterine cancer • Describe diagnosis and mgt options of uterine ca 2/14/2022 Mihretu Molla 74

Uterine cancer May be endometrial ca or sarcoma 1. Endometrial cancer • The most common malignancy of female genital tract in developed country. • The 4 th most common cancer, ranking behind breast, bowel, lung cancer. • 2. 6% of women develop during their life time. 2/14/2022 Mihretu Molla 75

Endometrial cancer … Epidemiology and Risk factors • Most often occurs in 6 th and 7 th decade of life, average 61 yrs • Nulliparity • infertility and Hx of irregular menses due to anovulatory cycle • early menarche, late menopause • Obesity • Pcos and functioning ovarian tumors • Unopposed est and tamoxifen Rx • D. M • combined OCP risk • Age the greatest independent risk factor 2/14/2022 Mihretu Molla 76

Endometrial cancer…. Patho-genetic types Endometrioid (type I) endometrial carcinoma • Most common, occur in younger perimenopausal women • Tumor begin as hyperplastic endometrium and progress to carcinoma • Well differentiated(grade 1 and 2) , more favorable prognosis 2/14/2022 Mihretu Molla 77

Pathogenetic types…. . Estrogen independent tumor(Type 11) • No source of estrogen stimulation of the endometrium • No associated endometrial hyperplasia • May arise on a back ground of atrophic endometruium • Type II endometrial carcinomas (eg, serous, clear cell) • Less differentiated(grade 3), poor prognosis 2/14/2022 Mihretu Molla 78

Endometrial cancer … Clinical features Symptoms • Assymptomatic (5%) • Vaginal bleeding or discharge (Most common) • Pelvic pressure or discomfort • Cervical stenosis in older patient (hematometra or pyometra) 2/14/2022 Mihretu Molla 79

Clinical features…. Signs • Asses Lymph nodes, breasts • Abdomen (Ascites, hepatic or omental metastasis palpable ) • Bimanual rectovaginal examination üSize of uterus, mobility, adnexal masses üParametrial indurations üCulde-sac modularity 2/14/2022 Mihretu Molla 80

Endometrial cancer … Diagnosis • Office endometrial aspiration biopsy • Hysteroscopy and D &C (cervical stenosis) 2/14/2022 Mihretu Molla 81

Endometrial cancer … Histologic classification Endometriod adenocarcinoma • accounts 80% • Composed of glands resembling normal endometrial glands mucinous Ca (5%) • Need to differentiate it from endocervical adenocarcinoma Others • Papillary serous Ca, clear Cell Ca • Squamous Ca, undifferentiated Ca • Mixed Ca 2/14/2022 Mihretu Molla 82

Endometrial cancer …Figo surgical staging Stage I • Tumor confined to corpus uteri • IA – Tumor limited to endometrium or invades less than one-half of the myometrium • IB -Tumor invades one-half or more of the myometrium Stage II • Tumor invades stromal connective tissue of the cervix but does not extend beyond uterus 2/14/2022 Mihretu Molla 83

Figo surgical staging…. . Stage IIIA • Tumor involves serosa and/or adnexa (direct extension or metastasis) Stage III B • Vaginal involvement (direct extension or metastasis) or parametrial involvement Stage IVA • Tumor invades bladder mucosa and/or bowel mucosa Stage IVB • distant metastasis including intra –abdominal &/or inguinal lymph nodes 2/14/2022 Mihretu Molla 84

Endometrial cancer … Treatment • Total abdominal hysterectomy + Bilateral salpingo – oophorectomy Øthe primary operative procedure for Ca of the endometrium • Vaginal hysterectomy ( extremely obese, poor medical status) • Radical hysterectomy ( stage II disease) • Radiation therapy (inoperable Ca) • Chemotherapy (advanced disease (stage III & IV) ) • Hormone Rx (progestines ) 2/14/2022 Mihretu Molla 85

2. Uterine sarcoma • Rare tumors of mesoderm origin(from myometrium or from C. tissue elements within the endometrium). • Behave more aggressively and are ass’ted with poorer prognosis • Constitute 3% to 5% of Ux malignancies. 2/14/2022 Mihretu Molla 86

Uterine sarcoma…… Histologic variants Endometrial stromal sarcoma • Endometrial stromal tumors can be either benign (endometrial stromal nodules) or malignant (ESS). • ESSs are low grade, well differentiated tumors that lack significant cellular atypia. • The cells resemble proliferative endometrial stroma. • The tumor arises within the endometrium and often infiltrates the myometrium; lymphatic extension is common. 2/14/2022 Mihretu Molla 87

Histologic variants……. Undifferentiated endometrial sarcoma • Aggressive tumors that lack specific differentiation and show no endometrial stromal features. • Can grow to large sizes. Leiomyo sarcomas • Mitotic index > 10/HPF • Severe Cytologic atypia • Coagulative tumor cell necrosis 2/14/2022 Mihretu Molla 88

Histologic variants……. . Other variants of uterine smooth muscle tumors • Myxoid leiomyosarcoma • Leiomyoblastoma • Intravenous leiomyomatosis • Benign metastasizing Ux leiomyoma • Disseminated peritioneal leiomyomatosis 2/14/2022 Mihretu Molla 89

Uterine sarcoma…… Assessment • P/E -Enlarged uterus -Polypoid mass protruding from the cervical canal • Dx Biopsy of endo cervical mass or endometrial curettage 2/14/2022 Mihretu Molla 90

Treatment of uterine sarcomas Stage I and II • Hysterectomy + BSO + Rx of the pelvic lymphatics by irradiation or surgery Stage III • Combined surgery , radiation therapy and chemotherapy Stage Iv • Combination chemotherapy 2/14/2022 Mihretu Molla 91

K N A H ! U O Y T Mihretu Molla 92