Medical brain notes 42

  Endometrial Carcinoma Approximately 2% to 3% of women will develop  uterine cancer during their lifetime. Ninety-sevenpercent of all uterine cancers arise from the glands of the endometrium and are known as  endometrial car cinomas.  The remaining 3% of uterine cancers arise frommesenchymal uterine components and are classified as  sarcomas.   Endometrial carcinoma is the most common genital tract malignancy and the fourth most common cancer after breast, bowel, and lung carcinoma.  Approximately 39,000 new casesof endometrial carcinoma were diagnosed in 2007, result-ing in over 7400 deaths. Fortunately, patients with this disease usually present early in the disease course with some form of abnormal uterine bleeding (AUB), particularly postmenopausal bleeding. With early diagnosis, survival rates are excellent.

  PATIENT HISTORY AUB is the hallmark symptom of both endometrial hyper-plasia and cancer.   Further evaluation to rule out underlying carcinoma is warranted in two general scenarios: (1) a postmenopausal woman with any bleeding who is not on hormone replace-ment therapy, or (2) a premenopausal woman with AUB in the presence of additional risk factors (family history of breast, colon, or gynecologic cancer; obesity; prior endometrial hyperplasia; chronic anovulation; tamoxifen use; or estrogen therapy).

  EVALUATION   Histologic evaluation of a sample of the endometrium establishes the diagnosis of endometrial hyperplasia or carcinoma.  Endometrial biopsy  is most easily accom-plished by any number of different atraumatic aspiration devices used in the office.   The diagnostic accuracy of office endometrial biopsy is 90% to 98%, compared with dilation and curettage (D & C) or hysterectomy.   The routine Pap smear is not reliable in diagnosing endometrial hyperplasia or cancer, as only 30% to 40% of patients with endometrial carcinoma have abnormal Pap test results. On the other hand, endometrial carci-noma must be considered, and endometrial sampling obtained, when atypical endometrial cells or atypical glan-dular cells of undetermined significance (AGUS) are found on the Pap smear.   The most common indication for endometrial sampling is abnormal bleeding.  After ruling out pregnancy in pre-menopausal women, an adequate tissue sample can be ...

  ENDOMETRIAL POLYPS   Most endometrial polyps represent focal, accentuated, benign hyperplastic processes.  Their histologic architecture is charac-teristic and may commonly be found in association with other types of endometrial hyperplasia or even carcinoma. Polyps occur most frequently in perimenopausal or imme-diately postmenopausal women, when ovarian function is characterized by persistent estrogen production due to chronic anovulation. The most common presenting symp-tom is abnormal bleeding. Small polyps may often be inci-dentally found as part of endometrial sampling or curettage done for evaluating AUB. Rarely, a large polyp may begin to protrude through the cervical canal. Such cases present with bleeding irregularities, and low, dull, midline pain, as the cervix is slowly dilated and effaced. In these cases, surgical removal is necessary to reduce the amount of bleeding and to prevent infection developing within the exposed endometrial surface.  Less tha...

  ENDOMETRIAL CANCER   Endometrial carcinoma is typically a disease of post-menopausal women.  Between 15% and 25% of postmenopausalwomen with bleeding have endometrial cancer.  A majority ofcases are diagnosed while in stage I (72%). Despite recog-nition at early stages, endometrial cancer is the eighth leading site of cancer-related mortality among women in the United States.   Most primary endometrial carcinomas are  adenocar-cinomas  (Fig. 45.4).  Because squamous epithelium may  coexist with the glandular elements in an adenocarcinoma, descriptive terms that include the squamous element may be used. In cases where the squamous element is benign and makes up less than 10% of the histologic picture, the term  adenoacanthoma  is used. Uncommonly, the squamous ele-ment may appear malignant on histologic assessment and is then referred to as  adenosquamous carcinoma.  Other descriptions, such as  clear cell carcinoma ...

  UTERINE SARCOMA   Uterine sarcomas represent an unusual gynecologic malignancy accounting for approximately 3% of cancers involving the body of the uterus, and only about 0.1% of all myomas.  Progressiveuterine enlargement occurring in the postmenopausal years should not be assumed to be the result of simple uterine leiomyomata, because appreciable endogenous ovarian estrogen secretion is absent, thereby minimizing the poten-tial for growth of benign myomas. Even postmenopausal women on low-dose hormone therapy are not at risk for stimulation of uterine enlargement. When progressive growth is present in postmenopausal women, uterine sar-coma should be considered. Other symptoms of uterine sarcoma include postmenopausal bleeding, unusual pelvic pain coupled with uterine enlargement, and an increase in unusual vaginal discharge. Surgical removal is the method of most reliable diagnosis. Accordingly, hysterectomy is usu-ally indicated in patients with documented, and espec...