17 Gynecologic Tumors
Endometrial cancer is the most common gynecologic malignancy with uterine sarcomas and is very rare (3%). The etiology is thought to be the chronic stimulation of the endometrium by estrogen, unopposed by progesterone.
Use of tamoxifen in postmenopausal breast cancer.
Use of estrogen-only hormone replacement therapy.
Lynch’s syndrome due to faulty deoxyribonucleic acid (DNA) mismatch repair genes, autosomal dominant. 5
Endometrial hyperplasia is the precursor lesion for endometrioid adenocarcinoma, which is the most common (75%), and is graded by the amount of solid masses within tumor cells; the larger the solid masses, the higher the grade. Endometrial thickening can be seen on transvaginal ultrasound or magnetic resonance imaging. 6 , 7
Serous carcinoma (uterine papillary serous cancer) represents about 10% of endometrial carcinoma and is aggressive with early spread to lymph nodes and peritoneum. 8
Lynch’s syndrome (hereditary nonpolyposis colorectal cancer) can be associated with about 5% of endometrial cancer, presents 40–60% risk of endometrial cancer, and results in lower mean age of onset than the general population.
The International Federation of Gynecology and Obstetrics Staging system 9 is used:
Stage I: Tumor confined to body of the uterus.
IA: Less than half of the myometrium invaded.
IB: More than half of the myometrium invaded.
Stage II: Invades cervical stroma but does not extend beyond uterus.
Stage III: Locoregional spread of tumor.
Stage IV: Invades bladder or bowel or has distant metastases.
Treatment followed for different stages of endometrial cancer are as follows:
Stages I–II: Simple hysterectomy/bilateral salpingo-oophorectomy (BSO).
About 5% may have adnexal involvement. 10
If the patient is younger than 50 years, synchronous ovarian cancer may occur in 9% of cases. Laparoscopic hysterectomy has fewer postoperative adverse events with the same overall survival as with transabdominal hysterectomy. Radiation therapy (RT) with intravaginal brachytherapy is only indicated in patients older than 60 years with lymphovascular invasion in stage IA, grade 1 or 2. In higher grades, RT is indicated since vaginal recurrence may be as high as 14%. 11 Adjuvant chemotherapy is not usually used.
Stage III: Heterogenous group of patients usually treated with chemoradiation with 50 Gy of intensity-modulated radiation therapy (IMRT) coupled with cisplatin (50 mg/m2), then four courses of paclitaxel/carboplatin. This regimen results in a 5-year disease-free survival of 88% and an overall survival at 5 years of 97%. 12
Stage IV: Incurable disease; however, the regimen of paclitaxel, cisplatin, and doxorubicin results in a 57% response rate, progression-free survival of 8.3 months, overall survival of 15 months. 13 Antiangiogenic agents, mTOR (mammalian target of rapamycin) inhibitors, anti-EGFR (anti-epidermal growth factor receptor) agents and numerous single-agent chemotherapy trials are ongoing for second-line chemotherapy.
Role for Interventional Radiology
Since this cancer may invade the bladder, renal obstruction and hydronephrosis are a possibility and are treated with percutaneous nephrostomy and ureteral stents. These tumors may also invade and cause hemorrhage, which can be treated with embolotherapy. Chemotherapy should not be utilized as this tumor is likely being treated with chemotherapeutic agents that are nephrotoxic (such as cisplatin) and their addition does nothing to assist in the shrinkage of the tumor beyond the embolic effect. Particles that are approximately 100 µ in diameter are preferred since it is unlikely that they will result in necrosis, only ischemia. Larger particles will produce collateral vessels almost immediately and will likely result in recurrent hemorrhage.