Uterine Cancer

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What is Uterine Cancer ?

The pear-shaped uterus is hollow and located in a woman's pelvis between her bladder and rectum. The uterus is also known as the womb, where a baby grows when a woman is pregnant. It has three sections: the cervix (the narrow, lower section), the corpus (the broad, middle section), and the fundus (the dome-shaped top section). The wall (the inside of the uterus) has two layers of tissue: endometrium (an inner layer), and myometrium (outer layer), which is muscle tissue.

Every month during a woman's childbearing years, the lining of the uterus grows and thickens in preparation for pregnancy. If the woman does not get pregnant, this thick, bloody lining passes out of her body through her vagina during menstruation. This process continues until menopause.

About uterine cancer : Uterine cancer is the most common cancer of a woman’s reproductive system. Uterine cancer begins when normal cells in the uterus change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). Noncancerous conditions of the uterus include fibroids (benign tumors in the muscle of the uterus), endometriosis (endometrial tissue on the outside of the uterus or other organs), and endometrial hyperplasia (an increased number of cells in the uterine lining).

There are two major types of uterine cancer:

Adenocarcinoma. This type of cancer makes up more than 95% of uterine cancers. It develops from cells in the lining of the uterus, the endometrium. This cancer is also commonly called endometrial cancer.

Sarcoma. This form of uterine cancer develops in the myometrium (the uterine muscle) or in the supporting tissues of the uterine glands. Sarcoma accounts for about 2% to 4% of uterine cancers.

Other, less common types of uterine cancer include carcinosarcoma and endometrial stromal sarcoma. Carcinosarcoma starts in the endometrium and is similar to both adenocarcinoma and sarcoma. Endometrial stromal sarcoma starts in the connective tissue of the endometrium. Treatment for these types of uterine cancer can be similar to the treatment of adenocarcinoma. Cancer specifically in the uterine cervix may be treated differently than uterine cancer. The rest of this section covers endometrial (adenocarcinoma) cancer.

Symptoms and Signs : Women with uterine cancer may experience the following symptoms or signs. Sometimes, women with uterine cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.

The most likely time for uterine cancer to occur is after menopause. The most common symptom is abnormal vaginal bleeding, ranging from a watery and blood-streaked flow to a flow that contains more blood. Vaginal bleeding during or after menopause is often a sign of a problem.

Unusual vaginal bleeding, spotting, or discharge

Difficulty or pain when urinating

Pain during sexual intercourse

Pain in the pelvic area

Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Risk Factors and Prevention

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors may raise a woman’s risk of developing uterine cancer:

Age. Uterine cancer most often occurs in women over 50; the average age is 60.

Obesity. Fatty tissue in women who are overweight produces additional estrogen, a sex hormone which can increase the risk of uterine cancer. This risk increases with an increase in body mass index (BMI; the ratio of a person's weight and height).

Race. White women are more likely to develop uterine cancer than black women.

Genetics. Uterine cancer may run in families where colon cancer is hereditary. Learn more about the genetics of colorectal cancer. For instance, women in families with hereditary non-polyposis colorectal cancer (HNPCC), or Lynch syndrome, have a higher risk for uterine cancer. 

Other health conditions. Women may have an increased risk of uterine cancer if they have had endometrial hyperplasia or if they have diabetes.

Other cancers. Women who have had breast, colon, or ovarian cancer have an increased risk of uterine cancer.

Tamoxifen. Women taking the drug tamoxifen (Nolvadex) to prevent or treat breast cancer have an increased risk of developing uterine cancer. However, the benefits of tamoxifen may outweigh the risk of developing uterine cancer, so women should discuss the benefits and risks of tamoxifen with their doctor.

Radiation therapy. Women who have had previous radiation therapy in the pelvic area (the lower part of the abdomen between the hip bones) for another cancer have an increased risk of uterine cancer.

Diet. Women who eat foods high in animal fat may have an increased risk of uterine cancer.

Estrogen. Longer exposure to estrogen and/or an imbalance of estrogen is relevant to many of the following risk factors:

Women who started having their periods before age 12 and/or go through menopause later in life

Women who take hormone replacement therapy (HRT) after menopause, especially if they are only taking estrogen; the risk if lower for women taking estrogen with another sex hormone called progesterone.

Women who have never had children

Prevention

Research has shown that certain factors can lower the risk of uterine cancer:

Taking birth control pills, especially over a long period of time

Considering the risk of uterine cancer before starting HRT, especially estrogen replacement therapy

Maintaining a healthy weight

If diabetic, maintaining good self-care, such as regularly monitoring blood glucose levels

Diagnosis

Doctors use many tests to diagnose cancer and find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. As with all types of cancer, early detection and treatment is important. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Severity of symptoms

Previous test results

Pelvic examination. The doctor feels the uterus, vagina, ovaries, fallopian tubes, bladder, and rectum to check for any unusual changes. A Pap test, often done with a pelvic examination, usually neither finds nor diagnoses uterine cancer. However, a Pap test may occasionally find abnormal glandular cells which are often caused by uterine cancer.

In addition to a physical examination, the following imaging tests may be used to diagnose uterine cancer:

Transvaginal ultrasound. An ultrasound uses sound waves to create a picture of internal organs. In a transvaginal ultrasound, an ultrasound wand is inserted into the vagina and aimed at the uterus to obtain the pictures. If the endometrium looks too thick, the doctor may decide to perform a biopsy.

X-ray. An x-ray is a way to create a picture of the structures inside of the body using a small amount of radiation.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a vein to provide better detail.

Doctors also use the following surgical tests to establish a diagnosis:

Endometrial biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed during the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease).

For an endometrial biopsy, the doctor removes a small sample of tissue with a very thin tube. The tube is inserted into the uterus through the cervix, and the tissue is removed with suction. This process takes about one minute. Afterward, the woman may have cramps and vaginal bleeding. These symptoms will go away and can be reduced by taking a nonsteroidal anti-inflammatory drug (NSAID) as directed by the doctor. Endometrial biopsy is often a very accurate way to diagnose uterine cancer. However, patients who have abnormal vaginal bleeding may still need a dilation & curettage (D&C; see below) even if no abnormal cells are found during the biopsy.

D&C. A D&C is a procedure to remove tissue samples from the uterus. A woman is given anesthesia during the procedure. A D&C is often done in combination with a hysteroscopy so the doctor can view the lining of the uterus during the procedure. During a hysteroscopy, the doctor inserts a thin, lighted flexible tube in the vagina, through the cervix, and into the uterus.

Once endometrial tissue has been removed either during a biopsy or D&C, the sample is checked for cancer cells, endometrial hyperplasia, and other conditions. In the past, there was concern that a D&C would push cancer cells out of the uterus into other reproductive organs. However, research studies have shown that this has no effect on patients who received a D&C combined with a hysteroscopy.

Stages and Grades

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. In addition, doctors may need information based on samples of tissue from surgery, so staging may not be complete before surgery to remove the tumor . Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a woman's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.

The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments. One tool that doctors use to describe the stage is the TNM system. This system judges three factors: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four).

The Roman numerals are stages used in another widely used staging system from the Federation Internationale de Gynecologie et d'Obstetrique, or FIGO. The FIGO system is the standard system used by most doctors to stage uterine cancer.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How large is the primary tumor and where is it located? (Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body? (Metastasis, M)

Tumor. Using the TNM system, "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail.

TX: The primary tumor cannot be evaluated due to a lack of information. More tests may be needed.

T0 (T plus zero): There does not seem to be a primary tumor in the uterus.

Tis: This condition is called carcinoma (cancer) in situ, which means that the cancer is found only in the layer of cells lining the uterus and has not spread to deeper tissues of the uterus.

T1/FIGO I: The tumor is found only in the corpus uteri (the body of the uterus).

T1a/FIGO IA: The tumor is found only in the endometrium has spread to less than one-half of the myometrium.

T1b/FIGO IB: The tumor has spread to one-half or more of the myometrium.

T2/FIGO II: The tumor has spread to the cervical stroma (the connective tissue of the cervix) but has not spread beyond the uterus.

T3a/FIGO IIIA: The tumor involves the serosa (the layer of tissue that covers the outer      surface of the uterus) and/or the tissue of the fallopian tubes and ovaries.

T3b/FIGO IIIB: The tumor has spread to the vagina or next to the uterus.

T4/FIGO IVA: The tumor has spread to the lining of the bladder mucosa (lining of the bladder) and/or the bowel mucosa (lining of the bowel).

Node. The "N" in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the uterus are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0 (N plus zero): There is no spread to regional lymph nodes.

N1/FIGO IIIC1: The cancer has spread to the regional pelvic lymph node(s).

N2/FIGO IIIC2: The cancer has spread to the para-aortic lymph nodes, which are located in the mid and upper abdomen, with or without spread to the regional pelvic lymph nodes.

Distant metastasis. The "M" in the TNM system describes whether the cancer has spread to other parts of the body.

M0 (M plus zero): The cancer has not metastasized.

M1/FIGO IVB: There is distant metastasis.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Stage 0: The tumor is called carcinoma in situ, which means it is very early stage cancer. It is found only in one layer of cells and has not spread (Tis, N0, M0).

Stage I: The cancer is found only in the uterus or womb and has not spread to other parts of the body (T1, N0, M0).

Stage IA: The cancer is found only in the endometrium or less than one-half of the myometrium (T1a, N0, M0).

Stage IB: The tumor has spread to one-half or more of the myometrium (T1b, N0, M0).

Stage II: The tumor has spread from the uterus to the cervical stroma but not to other parts of the body (T2, N0, M0).

Stage III: The cancer has spread beyond the uterus, but it is still only in the pelvic area (T3, N0, M0).

Stage IIIA: The cancer has spread to the serosa of the uterus and/or the tissue of the fallopian tubes and ovaries but not to other parts of the body (T3a, N0, M0).

Stage IIIB: The tumor has spread to the vagina or next to the uterus (T3b, N0, M0).

Stage IIIC1: The cancer has spread to the regional pelvic lymph nodes (T1 to T3, N1, M0).

Stage IIIC2: The cancer has spread to the para-aortic lymph nodes with or without spread to the regional pelvic lymph nodes (T1 to T3, N2, M0).

Stage IVA: The cancer has spread to the mucosa of the rectum or bladder (T4, any N, M0).

Stage IVB: The cancer has spread to lymph nodes in the groin area, and/or it has spread to distant organs, such as the bones or lungs (any T, any N, M1).

Grade 

In addition to the stage, doctors may also use the term “grade,” which is how similar the tumor is to normal tissue. Tumor grade is determined by examining the tumor tissue under a microscope. In a tumor that resembles healthy tissue, doctors can clearly see different types of cells grouped together (called well-differentiated). In a higher-grade cancer, the cancer cells usually look less like healthy cells, or “wilder” (called poorly differentiated or undifferentiated). In general, patients with a lower-grade tumor have a better prognosis.

The letter "G" is used to define a grade for uterine cancer.

GX: The grade cannot be evaluated

G1: The cells are well differentiated

G2: The cells are moderately differentiated

G3: The cells are poorly differentiated

G4: The cells are undifferentiated

Recurrent uterine cancer

Recurrent cancer is cancer that comes back after treatment. Uterine cancer may come back in the uterus, pelvis, lymph nodes of the abdomen, or another part of the body. Approximately 70% of recurrent uterine cancer happens within three years of initial treatment. Some symptoms of recurrent cancer are similar to those experienced when the disease was first diagnosed.

Vaginal bleeding or discharge

Pain in the pelvic area, abdomen, or back of the legs

Difficulty or pain when urinating

Weight loss

Chronic cough

If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

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