Malignant Conditions of the

Uterus
KRISELLE-ANN G. MERILLES, MD
Normal Endometrium
Normal Endometrium

Proliferative Phase (LPO)

Normal Endometrium

Secretory Phase (LPO)

Endometrial carcinoma
Endometrial Carcinoma

 Most common malignancy of the lower female genital tract

in the US
 Third most common gynecologic malignancy in the
Philippines

Comprehensive Gynecology 7th ed

SGOP CPG for the OB-GYN 3rd ed
 Epidemiology

 Affects women primarily in the perimenopausal and postmenopausal years usually between
50 and 65 years old
 Women diagnosed under the age of 50 are also at risk for having a synchronous ovarian
cancer
 There are 2 pathogenic types of endometrial cancer:
 Type I
 Type II
Pathogenesis

Type I Type II

Most common type Estrogen-independent neoplasm

Younger perimenopausal women with a history of
chronic estrogen exposure unopposed by progestin
Estrogen-dependent neoplasms
Usually start as atypical endometrial hyperplasia
Tend to be well differentiated
More favorable prognosis
Not generally associated with endometrial
hyperplasia
Tend to occur in older, postmenopausal women
Less differentiated
Occur more frequently in African American and
Asian women

Blueprint Obstetrics &

Gynecology
Classification

Feature Type I Type II

Unopposed estrogen Present Absent

Menopausal status Pre and perimenopausal Postmenopausal

Precursor lesion Atypical hyperplasia Endometrial intraepithelial
carcinoma

Tumor grade Low High

Myometrial invasion Variable, often minimal Variable, often deep
Histologic types Endometrioid Serous and clear cell
Behavior Indolent Aggressive

Blausteins Pathology of the Female

Genital Tract 6th ed
Type I Endometrial Cancer

Increased Risk Decreased Risk

Increasing age OCP use
Residence in North America or Northern Non medicated plastic or copper IUD
Europe Consumption of some phytoestrogens such as
Higher socioeconomic states isoflavones and lignans
White race Diet rich in fruits , vegetables and fibers
Nulliparity Physical activity
Infertilty Cigarette Smoking
Menstrual irregularities
Early menarche
Late menopause
Treatment with unopposed estrogen
Tamoxifen use
Anovulatory disorders such as PCOS
Estrogen producing tumors
Obesity
Hypertension
Diabetes
High-fat diet
HNPCC

Telinde’s Operative Gynecology 11th Edition

Type II Endometrial Cancer

 There are no clear risk factors for Type II endometrial cancers

 Tumors are high grade and often have papillary serous or clear cell pathology
 Tend to be diagnosed at a later stage, but have a poor prognosis even if diagnosed at an
early stage
 Characteristics Type 1 Type 2
Age 55-65 65-75
Clinical Setting Unopposed Estrogen Atrophy
Obesity Thin Physique
Hypertension
Diabetes
Morphology Endometrioid Serous
Clear Cell
Mixed Mullerian Tumor
Precursor Hyperplasia Endometrial Intraepithelial
CA
Molecular Genetics PTEN P53
PIK3CA Aneuploidy
KRAS PIK3CA
MSI
Beta Catenin
P53
Behavior Indolent Aggressive
Spreads via Lymphatics Intraperitoneal, Lymphatic

Robbins, SL, Kumar V. Robbins and Cotran Pathologic Basis of Disease. 8th Ed. Philadelphia, PA: Saunders/Elsevier;
2010
Clinical presentation

 AUB is the most common presentation of endometrial cancer

 Postmenopausal bleeding
 Abnormal premenopausal bleeding
 Perimenopausal bleeding

Comprehensive Gynecology 7 th ed
Evaluation

 PELVIC UTZ
- First line imaging to evaluate etiologies of abnormal bleeding
- To determine the endometrial thickness
- If <4mm in postmenopausal, biopsy is not warranted
- If <4mm, however with bleeding, biopsy is needed

SGOP Treatment Guidelines 2019

Evaluation

 Histologic examination of the endometrium

 Office endometrial biopsy using pipelle device has a sensitivity of 99.6% in the detection of
endometrial cancer in post menopausal women
 Endocervical curettage may be performed to rule out invasion of the endocervix
 Papsmear from the ectocervix detects endometrial cancer in 50%

Comprehensive Gynecology 7 th ed
 Grading
Grade 1 Grade 2 Grade 3
Well differentiated Moderately differentiated Poorly differentiated
Less than 5% solid components 5-60% solid components >50% solid components

Blausteins Pathology of the Female

Genital Tract 6th ed
Histologic types
Endometrioid Adenocarcinoma

 arises in younger women and is considered to

be estrogen dependent with a defined
precursor lesion - atypical hyperplasia /
endometrioid intraepithelial neoplasia

http://www.pathpedia.com/
Endometrioid Adenocarcinoma

Resembles endometrial glands but with architectural and nuclear features of malignancy.
Malignant glands are often back to back and complex with cribriformation. Intraluminal
necrotic foci are also seen. http://www.pathpedia.com/
Endometrioid Adenocarcinoma

Complex glands arising from the mucosa and invading into the
myometrium. A few tumor glands show obvious necrosis in the lumen
http://www.pathpedia.com/
Poor Histologic Types

A. SEROUS
 Relatively uncommon type (5-10% of cases)
 Aggressive variant
 Deep myometrial and frequent vascular invasion
 High grade carcinoma arising in postmenopausal women - mean patient age is
70 years
 Occurs disproportionately in african-american women
 Has predilection for peritoneal spread
 Papillary projection is frequently present
Pathology of Endometrial Carcinoma, 2019, Gordon, M, Ireland, K, Glob. Libr.
women’s med., (ISSN: 1756-2228) 2008; DOI 10.3843/ GLOWM. 10238
Serous

 Often arises within endometrial polyps;

background endometrium often atrophic
 Tumor appears large and bulky with small
tufts, papillae and necrosis
 Immunohistochemistry shows mutational
pattern of p53 expression

http://www.pathologyoutlines.com/
Serous

Papillary clusters of high-grade neoplastic cells. Numerous mitotic figures can be seen.
Other features include necrosis, psamomma bodies and invasion of myometrium.
Poor Histologic Types

B. CLEAR CELL CARCINOMA

 1-5% of endometrial CA
 Assoc. with poor prognosis (5 year survival rate of 35%)
 Occurs almost exclusively in postmenopausal women
 Patterns in decreasing frequency: papillary, tubulocystic,
glandular and solid

Pathology of Endometrial Carcinoma, 2019, Gordon, M, Ireland, K, Glob. Libr.

women’s med., (ISSN: 1756-2228) 2008; DOI 10.3843/ GLOWM. 10238
Clear cell carcinoma

Complex papillae with fibrovascular cores lined by 1 to multiple layers of clear cells. Hobnail cells
protrude into cystic space. Other cells display typical clear cell morphology with irregularly appearing
nuclei with abundant clear cytoplasm that is rich in glycogen. Solid pattern consisting of sheets of
clear cells separated focally by thin fibrous bands
http://www.webpathology.com/
Pathology of Endometrial Carcinoma, 2019, Gordon, M, Ireland, K, Glob. Libr. women’s med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/ GLOWM. 10238
 Poor Histologic Types

C. UNDIFFERENTIATED CARCINOMA

 Tumors lacking definitive glandular or squamous differentiation

 Prognosis is comparable to a grade 3 endometrial carcinoma
 Often divided into large and small cell categories

Pathology of Endometrial Carcinoma, 2019, Gordon, M, Ireland, K, Glob. Libr.

women’s med., (ISSN: 1756-2228) 2008; DOI 10.3843/ GLOWM. 10238
undifferentiated

Sheets of round to oval cells with granular chromatin and often dot-like
nucleoli. Nests of tumor cells and necrosis

http://www.webpathology.com/
 Poor Histologic Types

D. CARCINOSARCOMA
 Consist of carcinoma and sarcoma elements native to the uterus that may resemble the
endometrial stroma of smooth muscle (homologous) or of sarcomatous tissues foreign to
the uterus (heterologous)
 Markedly worse prognosis than patients with high grade endometrial carcinoma
 Patients tend to be older, primarily postmenopausal, usually beyond 62 y/o
carcinosarcoma

High grade malignant stromal and epithelial components arranged in a

biphasic pattern.
http://www.webpathology.com/
FIGO Staging 2009

 Positive cytology has to be reported separately without

changing the stage.
 Histopathology: Degree of Differentiation
 Grade 1: 5% or less of a solid growth pattern
 Grade 2: 6-50% of a solid growth pattern
 Grade 3: More than 50% of a solid growth pattern
 Notable nuclear atypia, inappropriate for the
architectural grade, raises the grade of a grade 1 or
grade 2 tumor by 1
 Uterine papillary serous carcinomas and clear cell
carcinomas of the endometrium are always high-grade
tumors, by definition.
Prognostic Feature of Endometrial Cancer

Comprehensive Gynecology 7th edition, Lobo. Gershenson..Lentz.Valea

Stage and Survival of Endometrial Cancer

Stage 5-year Survival

IA 90.0%
IB 88.2%
IC 81.0%
II 71.6%
III 51.4%
IV 8.9%

Comprehensive Gynecology 7th edition, Lobo. Gershenson..Lentz.Valea

High-Intermediate Risk for Recurrence

a. Any age with greater than or equal to 3 or more risk factors

b. Age greater than or equal to 50 but less than 70 with greater than or equal to 2 or
more risk factors
c. Age greater than or equal to 70 with greater than or equal to 1 or more risk factors

 These are the patients who should be targeted for surgical staging and/or
postoperative adjuvant therapy
Screening for Endometrial Cancer

 For average-risk, symptomatic individuals:

 education of women at the time of menopause regarding the risks and symptoms of
endometrial cancer
 strongly encouraged to report any unexpected bleeding or spotting
 For high-risk individuals
 Annual endometrial biopsy by the age of 35
Evaluation of the Symptomatic Patient

 AUB is the most common presenting symptom of endometrial cancer

 The risk of malignancy increased with increasing age, Peak incidence: between 65-69
y/o
 All patients with postmenopausal bleeding should undergo evaluation for possible
endometrial cancer
 Gold standard of endometrial sampling: D&C
Algorithm for the Evaluation of Post Menopausal Bleeding

Telinde’s Operative Gynecology 11th Edition

Management

 Initial surgical management:

 Extrafascial hysterectomy, PFC, BSO and pelvic and para-aortic lymphadenectomy
 Ovarian preservation during hysterectomy may be considered in young patients with early
stage, low-grade endometrial cancer, however synchronous ovarian malignancy should be
meticulously ruled out

SGOP Treatment Guidelines 2019

Management of Endometrial Carcinoma By Stage

Stage I: Confined to the Corpus

Surgery: EHBSO, PFC, Lymph Node Dissection
Surgico-Pathologic Staging Adjuvant Treatment

IA G1, G2 No Adjuvant Treatment

G3 Vaginal Brachytherapy
IB G1, G2 Vaginal Brachytherapy
G3 Pelvic EBRT

Stage II: Tumor Extension To The Cervix Confirmed By Biopsy or Imaging

*For Good Surgical Risk Patients
Surgico- Primary Treatment Adjuvant Treatment
Pathologic
Staging

II G1, RHBSO, PFC, Lymph Node Observe unless with poor

G2, G3 Dissection surgicopathologic factors
Management of Endometrial Carcinoma By Stage

Stage II: Cervical Stromal Involvement Noted After EHBSO, PFC, Lymph Node
Dissection
Surgico-Pathologic Staging Adjuvant Treatment
II G1, G2 Vaginal Brachytherapy
G3 Pelvic EBRT
+/- vaginal brachytherapy
+/- chemotherapy

Stage II: Tumor Extension To The Cervix Confirmed By Biopsy or

Imaging
*For Poor Surgical Risk Patients
1971 FIGO Preoperative pelvic RT and vaginal brachytherapy
Clinical Stage II followed by PFC and EHBSO with lymph node evaluation
G1, G2, G3

SGOP Treatment Guidelines 2018

Management of Endometrial Carcinoma By Stage

Stage III: Tumor Extension Outside the Uterus, Within the Pelvis
Surgery: EHBSO, PFC, Lymph Node Evaluation, Debulking
Surgico-Pathologic Staging Adjuvant Treatment
IIIA Chemotherapy and Pelvic EBRT
IIIB Chemotherapy and Pelvic EBRT +/- vaginal
brachytherapy
IIIC1 Chemotherapy and Pelvic EBRT +/- vaginal
brachytherapy
IIIC2 Chemotherapy and Pelvic EBRT +/- vaginal
brachytherapy

SGOP Treatment Guidelines 2018

Chemotherapy Options

1. Carboplatin-Paclitaxel Regimen: 3hr infusion every 3 wks for 3 cycles

2. TAP Regimen
 Day 1:Doxorubicin – Cisplatin IV
 Day 2: Paclitaxel (3hr infusion)-Filgrastim Support
 Day 3-12: Filgrastim 5mg/kg BW subcutaneous injection

3. AP Regimen: Doxorubicin – Cisplatin every 3 wks for a max dose of Doxorubicin at 500 mg/m2 or until disease
progression or unacceptable toxicity occurs
4. Cisplatin-Paclitaxel Regimen with RT:
 Day 1 and 28: Cisplatin concurrent with EBRT 4500 cGy followed by vaginal brachytherapy the Cisplatin-Paclitaxel
every 4 weeks for 4 courses

5. Carboplatin with Pegylated Liposomal Doxorubicin IV every 4 weeks for 6 cycles

6. Dose-Dense TC: Paclitaxel on days 1,8 and 15 and carboplatin IV on day 1 for 21day cycles

SGOP Treatment Guidelines 2018

Management of Endometrial Carcinoma By Stage

Stage IV: Tumor Invades Bladder and/or bowel mucosa, +/- distant metastasis

Surgico-Pathologic Primary Treatment Adjuvant Treatment

Staging

IV G1, G2, EHBSO, debulking Chemotherapy and EFRT +/-

G3 vaginal brachytherapy

SGOP Treatment Guidelines 2018

Poor Histologic Types

 General Guideline:
 CA-125 and MRI or Chest/Abdominopelvic CT Scan is recommended before surgery to
assess extent of disease
 Staging is as in Endometrial adenocarcinoma
 Adjuvant therapy is individualized

SGOP Treatment Guidelines 2018

Poor Histologic Types

A. Uterine Papillary Serous/Clear Cell Carcinoma/Undifferentiated Carcinoma

Surgico-Pathologic Staging Primary Treatment Adjuvant Treatment

IA with endometial EHBSO, IO, PFC, 1. Chemotherapy +/- vaginal brachytherapy OR

involvement only PALS, RPB (Extended 2. Observation if no residual tumor in
Surgical Staging) hysterectomy specimen OR
3. EBRT +/- brachytherapy

IA with myometrial EHBSO, IO, PFC, 1. Chemotherapy +/- vaginal brachytherapy

invasion and all others PALS, RPB (Extended OR
Surgical Staging) 2. EBRT + brachytherapy

SGOP Treatment Guidelines 2018

Poor Histologic Types

A. Uterine Papillary Serous/Clear Cell Carcinoma/Undifferentiated Carcinoma

• Chemotherapy Options:
1. Paclitaxel Carboplatin IV every 21 days
2. Doxorubicin IV plus Cisplatin IV on day 1 repeat every 21 days
3. Addition of Trastuzumab to Carboplatin/Paclitaxel for patients with advanced or recurrent HER
2 Neu positive uterine serous carcinoma improved progression free survival

SGOP Treatment Guidelines 2018

Poor Histologic Types

B. Carcinosarcoma/Malignant Mixed Mullerian Tumor

Stage Primary Treatment Adjuvant Treatment

IA EHBSO, PFC, Observation or

Lymphadenectomy, IO, chemotherapy
peritoneal biopsy

IB to IV EHBSO, PFC, Chemotherapy

Lymphadenectomy, IO,
peritoneal biopsy

SGOP Treatment Guidelines 2018

Poor Histologic Types

B. Carcinosarcoma/Malignant Mixed Mullerian Tumor

• Chemotherapy options
1. Paclitaxel – carbolatin IV every 21 days
2. Ifosfamide, paclitxel: Ifosfamide IV for 3 days + Paclitaxel + Filgrastim support

SGOP Treatment Guidelines 2018

Final Histopathology Report of Endometrial Cancer Specimens

1. Histologic type 9. Lymph nodes – location and number

2. Histologic grade 10. Peritoneal fluid
3. Presence or absence of LVSI 11. Tumor size
4. Depth of myometrial invasion
5. Type of cervical involvement
6. Adnexal involvement
7. Parametria
8. Vaginal rim or cuff (to include distance from
tumor to margin)

SGOP Treatment Guidelines 2018

Persistent or Recurrent Disease

 Treatment will depend on site, extent of disease and receptor status

 For localized recurrences (pelvis and para aortic lymph nodes) or distant metastasis in
selected sites: may give irradiation
 Chemotherapy for Stage III/IV may be given

SGOP Treatment Guidelines 2018

Persistent or Recurrent Disease

 Chemotherapeutic Agents which showed favorable responses in cases of advanced and

recurrent endometrial cancer:
a. Carboplatin IV with Pegylated Liposomal Doxorubicin IV every 4 weeks for 6 cycles
b. Liposomal doxorubicin IV every 4 weeks until toxicity or progression
c. Weekly paclitaxel 1-hour infusion until with response
d. Weekly docetaxel IV for 6 weeks with a 2-week break in between cycles to complete 3 cycles
e. Bevacizumab intravenously every 3 weeks until disease progression or prohibitive toxicity
f. Temsirolimus intravenously once a week days 1, 8, 15, and 22.

SGOP Treatment Guidelines 2018

Special Clinical Situations For Endometrioid Adenocarcinoma

A. Endometrial Carcinoma Diagnosed on the Postoperative Hysterectomy Specimen

1. For patients who underwent total hysterectomy alone:

Surgico-Pathologic Result Adjuvant Treatment
• G1,G2 Options
• <50% myometrial invasion 1. Reoperate and remove adnexa and preform
• No LVSI surgical staging and give adjuvant treatment
• </= 2 cm accordingly
2. No further treatment or close observation

• G3 Reoperate to do BSO, BLND, PALS

• 50% myometrial invasion
• Tumor more than 2cm
• No LVSI
• No evidence of metastasis
All Others Reoperate to do BSO, BLND, PALS
SGOP Treatment Guidelines 2018
Special Clinical Situations For Endometrioid Adenocarcinoma

2. For patients who underwent subtotal hysterectomy:

 Reoperation to remove the cervix and adnexa and to perform lymphadenectomy is

recommended

SGOP Treatment Guidelines 2018

Special Clinical Situations For Endometrioid Adenocarcinoma

3. For patients who underwent TAHBSO:

Surgico-Pathologic Result Adjuvant Treatment
<50% myometrial invasion G1,G2 None
Stage IA
G3 Reoperate to BLND, PALS or Vaginal
Brachytherapy or Pelvic EBRT
>50% myometrial invasion G1,G2 Reoperate to BLND, PALS or Vaginal
Stage 1B Brachytherapy or Pelvic EBRT
G3 Reoperate to BLND, PALS
Cervical Involvement G1,G2, Reoperate to BSO, BLND, PALS and
Stage II G3 manage accordingly
Uterine Serosa and/or adnexal G1,G2, Reoperate to BSO, BLND, PALS and
involvement G3 manage accordingly
Stage III
Positive LVSI G1,G2 Reoperate to BSO, BLND, PALS and
G3 manage accordingly
SGOP Treatment Guidelines 2018
Special Clinical Situations For Endometrioid Adenocarcinoma

B. Endometrial CA in Patients Desirous of Fertility (<40y/o)

 Conservative management must be done by a Gynecologic Oncologist

 If conservative treatment is contemplated, pre treatment evaluation must be
employed.

SGOP Treatment Guidelines 2018

 Conservative treatment is only offered to patients who have
 Well differentiated tumor (endomerioid type)
 No myometrial invasion (as evaluated in MRI)
 No cervical involvement
 No extrauterine involvement (adnexal/parametrial)
 No vaginal involvement
 No suspicious retroperitoneal nodes or no evidence of lymph node metastasis
 Negative PFC
 No LVSI
 No contraindications for medical management
Special Clinical Situations For Endometrioid Adenocarcinoma

B. Endometrial CA in Patients Desirous of Fertility (<40y/o)

 Agents used:
Progesterone Dose and Duration
Megestrol Acetate PO daily continuously for 3 months, may increase dose to
double if no regression occurs after 3 months

Medroxyprogesterone Acetate PO daily continuously for 3 to 6 months

Levonorgestrel releasing IUD with an This releases 15-20 mcg/day and can be kept in place for
oral progestin 3 to 6 months. Endometrial biopsy can be performed with
IUD in place PLUS
Medroxyprogesterone acetate PO OD or Megestrol acetate
PO OD

SGOP Treatment Guidelines 2018

Monitoring
Special Clinical Situations For Endometrioid Adenocarcinoma

Endometrial CA in Patients Desirous of Fertility (<40y/o)

 Patients who wish to delay pregnancy after reversal to normal endometrium may be
maintained on progestin for a maximum of 6 months
 After completion of childbearing, definitive staging surgery must be performed: THBSO,
PFC, BLND. Ovaries may be retained depending on age, extent of disease and genetic risk
factors.

SGOP Treatment Guidelines 2018

sarcomas
Uterine sarcomas

 arise from the myometrium or the

connective tissue elements of the
endometrium
 Comprise less than 5% of uterine
malignancies and are much less
frequent than endometrial
carcinomas
Uterine sarcomas

 These sarcomas may exist exclusively (PURE) or may be admixed (MIXED)

with epithelial adenocarcinoma, in which case the term carcinosarcoma
(malignant mixed Müllerian tumor) is applied

 OPERATIVE STAGE: MOST IMPORTANT PREDICTOR OF SURVIVAL

LEIOMYOSARCOMA
LEIOMYOSARCOMA

 Represent 1% to 2% of uterine malignancies and approximately one third of

uterine sarcomas
 Not thought to arise from benign leiomyomas
 Approximately 85% of women diagnosed with a leiomyosarcoma have clinical
stage I or II disease (i.e., disease that is limited to the uterus and cervix)
Clinical presentation

 Enlarged pelvic mass occasionally accompanied by pain or vaginal

bleeding
 Suspected if the uterus undergoes rapid enlargement, especially in
perimenopausal or postmenopausal age group
Histopathologic features

 The determination of malignancy is made in part by ascertaining the number of

mitoses in 10 hpf as well as the presence of cytologic atypia, abnormal mitotic
figures, and nuclear pleomorphism.

 A finding of more than five mitoses per 10 hpf with cytologic atypia leads to
a diagnosis of leiomyosarcoma; when there are four or fewer mitoses per 10
hpf, the tumors usually have a more benign clinical course.
MANAGEMENT

 Primary treatment includes total hysterectomy, bilateral

salpingoophorectomy, and staging

 Limited information on adjuvant treatment either radiotherapy or

chemotherapy whether early, advanced or recurrent disease
MANAGEMENT

 The prognosis for Leiomyosarcoma is poor, even for early stage

disease
 No adjuvant therapy has been shown to be effective in prolonging
survival
 Inadvertent myomectomy and/or morcellation have been reported
to be a poor prognostic factor for survival
PROGNOSIS

 Despite the low incidence of high-stage disease, approximately 50% of patients

will have a recurrence within 2 years. The recurrence in most of these patients is
outside the pelvis

 Vascular invasion and extrauterine spread of tumor are associated with worse
prognoses

 The prognosis worsens for tumors with more than 10 mitoses per 10 hpf
ENDOMETRIAL STROMAL SARCOMA
ENDOMETRIAL STROMAL SARCOMA

 Comprise approximately 10% of uterine sarcomas

 All ESSs are considered low grade
 Peak incidence in the fifth decade of life
 Majority of ESS are immuroreactive for the estrogen receptors and progesterone receptors
 No association with previous radiation nor are risk factors of endometrial carcinoma
associated with the development of ESS
 Histologically, ESS most resembles proliferative endometrial stroma
Adenosarcoma

 Adenosarcoma of the uterus

 a rare mixed neoplasm in which a benign / non-neoplastic epithelial component is
mixed with a malignant stromal element
MANAGEMENT

 SURGERY – PRIMARY TREATMENT

 Hormonal treatment
 Radiation – role in ESS must be individualized
 The role of adjuvant radiation, chemotherapy, or hormone therapy for the
treatment of adenosarcoma is unclear. Treatment is as ESS
PROGNOSIS

 Depends on the extent of disease and ability to remove all of the tumor at the time of
surgery

 In general, ESSs are indolent, slowly progressing tumors

 ESS tends to recur locally in the pelvis or peritoneal cavity and frequently spreads to the
lungs
2009 FIGO Staging
Management
High Grade Undifferentiated Sarcomas Of Uterus

 Undifferentiated Endometrial Sarcoma or High Grade Undifferentiated Endometrial

Sarcomas
 Very rare biologically aggressive mesenchymal tumor of the uterus originating in the
endometrial stroma
 Rare and quite recently defined
 Nonspecific presentations: pelvic pain, menorrhagia, post coital bleeding
High Grade Undifferentiated Sarcomas Of Uterus

 Prognostic factors:
 Stage – single most important prognostic factor
 Recurrence and overall prognosis cannot be assessed due to insufficient data
2009 FIGO Stage

Endometrial Stromal Sarcoma ( ESS ) and Adenosarcoma

 I Tumor limited to uterus
 IA Tumor limited to endometrium/endocervix with no myometrial invasion
 IB Less than or equal to half myometrial invasion
 IC More than half myometrial invasion
 II Tumor extends to the pelvis
 IIA Adnexal involvement
 IIB Tumor extends to extrauterine pelvic tissues
 III Tumor invades abdominal tissues ( not just protruding into the abdomen ) IIIA one site

 IIIB > one site

 IIIC Metastasis to pelvic and/or para aortic lymph nodes
 IV IVA Tumor invades bladder or rectum
 IVB Distant metastasis
Management

Stage Primary Treatment Adjuvant Treatment

I EHBSO, PFC, Pelvic/Peri-aortic 1. Observation or
LND/Assessment 2. Doxorubicin IV every 3 weeks for 8 cycles
or
3. Gemcitabine IV D1 and D8 + Docetaxel IV
D8 with GCSF D9-15 q 21 days with
GCSF support
II-IV EHBSO, PFC, Pelvic/Peri-aortic 1. Doxorubicin IV every 3 weeks for 8 cycles
LND/Assessment, abdominal or
debulking and resection of 2. Gemcitabine IV D1 and D8 + Docetaxel IV
distant metastasis D8 with GCSF D9-15 q 21 days with
GCSF support
References

 Comprehensive Gynecology 7th edition, Lobo. Gershenson..Lentz.Valea

 SGOP Treatment Guidelines 2018
 SGOP Treatment Guidelines 2019
 Telinde’s Operative Gynecology 11th Edition
 Blausteins Pathology of the Female Genital Tract 6 th ed
 Pathology of Endometrial Carcinoma, 2019, Gordon, M, Ireland, K, Glob. Libr. women’s
med., (ISSN: 1756-2228) 2008; DOI 10.3843/ GLOWM. 10238
 http://www.webpathology.com/