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Uterine Cancer

Chapter 17 – Gynaecological Cancer in the Senior Patient

Uterine cancer is the most common malignancy of the female tract in the industrialised world. Its incidence in women < 65 years is 13.1/100,000 and in women >65 years 98.5/100,000. The incidence worldwide is 17.8/100,000. The 2008 FIGO staging system is used.

Stage I

In stage I the tumour is confined to the uterine corpus. The five-year survival is about 90%.

Stage I can be divided into the following:

  • IA: None or less than half of the myometrium is invaded. Treatment consists of hysterectomy with bilateral salpingo-oophorectomy; lymph node dissection should be considered if the tumour is FIGO grade II/III. In patients with papillary serous or clear cell carcinoma histology, a lymph node dissection should also be performed.
  • IB: Invasion to at least half of the myometrium. The preferred treatment is a hysterectomy with bilateral salpingo-oophorectomy with pelvic and para-aortic lymph node dissection.

More recently the sentinel lymph node mapping algorithm is being performed in clinically early stage disease in lieu of a systematic lymph node dissection.  Adjuvant radiotherapy is indicated in case of lymph node involvement. Other factors for adjuvant treatment include depth of myometrial invasion, the presence of LVSI, age, and grade. Adjuvant chemotherapy is probably as effective as radiotherapy in early stage endometrial cancers. In patients with high risk pathology such as papillary serous or clear cell carcinoma, the preferred treatment is carboplatin in combination with paclitaxel.

Stage II

In stage II the tumour invades the cervical stroma but does not extend beyond the uterus. The five-year survival is between 70% and 80%. Treatment is similar to that for stage IB. Adjuvant radiation therapy is usually recommended.

Stage III

In this stage there is local and/or regional spread of the tumour. Positive cytology has to be reported separately without changing the stage. The five- year survival is about 30% to 60%.

Stage III can be divided into the following:

  • IIIA: Tumour invades the serosa of the corpus uteri and/or adnexae.
  • IIIB: Vaginal and/or parametrial involvement.
  • IIIC: Metastases to pelvic and/or para-aortic lymph nodes.
  • IIIC1: Positive pelvic nodes.
  • IIIC2: Positive para-aortic lymph nodes with or without positive pelvic lymph nodes.

Treatment is similar to stage IV disease.

Stage IV

In stage IV the tumour invades bladder and/or bowel mucosa, and/or distant metastases are present. The five-year survival is about 10%.

Stage IV can be divided into the following:

  • IVA: tumour invasion of bladder and/or bowel mucosa
  • IVB: distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes

Stages III and IV are best treated by optimal cytoreductive surgery followed by systemic chemotherapy and/or radiotherapy. Chemotherapy regimens should preferably include doxorubicin and cisplatin or carbo platin and paclitaxel. When there is widespread metastatic disease and the tumour is Oestrogen receptor and/or progesterone Receptor positive, hormonal therapy (progestins, tamoxifen, or aromatase inhibitors) should be considered. This can be alone or following chemotherapy.

Pelvic exenteration should be considered when the tumour is limited to the bladder or rectum.

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