Myometrial Involvement Research Articles

Carcinoma of the Endometrium in Saskatchewan

Abstract Four hundred twenty-one cases of carcinoma of the endometrium, Stage I, treated in Saskatchewan from 1966 to 1971 were followed for 5+ years. The two principal modalities of treatment were (a) preoperative intracavitary and vaginal vault irradiation, and (b) primary sugery followed by selective postoperative irradiation. On the basis of this review, the following observations are made: (1) Primary surgery and selective postoperative irradiation is an effective method of management for Stage I carcinoma of the endometrium. (2) Such a scheme of management (a) is free of postoperative irradiation complications, (b) does not appear to encourage dissemination of disease, and (c) eliminates the need for irradiation in as much as 70% of all patients. (3) While both microscopic (degree of tumor differentiation) and gross (degree of myometrial involvement) pathology are apparent valid prognostic factors, they are not necessarily complementary.

Carcinoma of the endometrium with cervical involvement (stage II)

Between September 1968 and December 1976, 88 patients with Stage II endometrial carcinoma underwent treatment at Tufts-New England Medical Center, Boston. They were subclassified according to microscopic or gross cervical involvement. Five different types of treatment were administered as follows: a) Preoperative external irradiation (4000 rad) and intracavitary radium application (2500 mg hours), followed by total abdominal hysterectomy and bilateral salpingo-oophorectomy for microscopic involvement when surgery was possible; b) Radical radiotherapy alone for inoperable gross cervical involvement; c) Radical radiotherapy with external irradiation (4000 rad) and intracavitary application (3500 mg hours) for microscopic involvement when surgery was contraindicated due to poor risk of surgery; d) External irradiation (4000 rads) and intracavitary radium (3500 mg hours) followed by simple hysterectomy for gross involvement when surgery was possible; e) Postoperative treatment with external irradiation and vaginal radium for patients referred after hysterectomy. Hysterograms performed in 33 patients showed tumor arising in the fundus and extending to the cervix, and hysterograms performed in 8 patients showed tumor arising in the lower segment of the fundus. Pathologically, once the cervix became involved, there was always some degree of myometrial involvement. The preoperative microscopically involved group and the postoperative group demonstrated similar survival rates, 92% and 90%, respectively, as did the radical radiotherapy group with microscopic involvement and the group with gross cervical involvement, 72% and 70%, respectively, with a follow-up period of at least one year in all groups. Surgical findings, pathological findings, and results are analyzed in detail by treatment group.

Lymph node metastasis and prognosis of endometrial carcinoma

Recently there has been much discussion about the choice of surgical treatment for carcinoma of the body of the uterus. From the study of the literature, it is concluded that there is a high incidence of lymphatic metastases in cases with cervical involvement, so Wertheim's hysterectomy with pelvic lymphadenectomy has been carried out for such cases. Deep myometrial infiltration and involvement of lymphatic vessels within myometrium are also very important factors for pelvic lymph node involvement, but it is quite impossible to examine these two factors preoperatively. As to the sites of spread, paraaortic lymph node involvement seems not so important as was said in the literature. In the case with cervical involvement, the external iliac lymph node is the most often affected, just as in the case of cervical carcinoma. Without cervical involvement, the obturator lymph node and hypogastric lymph node seem to be a primary site for lymphatic spread. The prognosis is poor in patients with involvement of the pelvic lymph node. Radical hysterectomy should be carried out as the general condition permits.

Carcinoma of the endometrium in Saskatchewan: 1966 to 1971

Four hundred twenty-one cases of carcinoma of the endometrium, Stage I, treated in Saskatchewan from 1966 to 1971 were followed for 5+ years. The two principal modalities of treatment were (a) preoperative intracavitary and vaginal vault irradiation, and (b) primary sugery followed by selective postoperative irradiation. On the basis of this review, the following observations are made: (1) Primary surgery and selective postoperative irradiation is an effective method of management for Stage I carcinoma of the endometrium. (2) Such a scheme of management (a) is free of postoperative irradiation complications, (b) does not appear to encourage dissemination of disease, and (c) eliminates the need for irradiation in as much as 70% of all patients. (3) While both microscopic (degree of tumor differentiation) and gross (degree of myometrial involvement) pathology are apparent valid prognostic factors, they are not necessarily complementary.

Para-aortic node irradiation in carcinomas.

The authors have retrospectively analyzed the results of para-aortic node irradiation in 75 cases of metastatic carcinoma treated at the Department of Radiation Therapy, Roswell Park Memorial Institute, between 1963 and 1972. This group includes 62 patients with primary squamous cell carcinoma of the uterine cervix, 6 with adenocarcinomas of the sigmoid colon, 2 with adenocarcinomas of the endometrium, 3 with carcinomas of the vulva, 1 with adenocarcinoma of the ovary, and 1 with squamous cell carcinoma of the anus. The clinicopathologic behavior of para-aortic metastasis is studied in detail, including the relationship with the primary site, histologic grade, and degree of lymphatic invasion at the primary site. The group of cervical cancer patients seems to consist predominantly of those with advanced clinical stage, less differentiated tumors, endophytic or endocervical lesions, and those with endometrial or myometrial involvement. This study showed that the presence of metastatic carcinomas in the para-aortic nodes does not necessarily indicate the existence of more distant metastasis. These carcinomas can be safely irradiated and cured in a significant percentage of cases. Survival appears more favorable with higher radiation dosages. Six thousand rads delivered in 8 weeks, alone or concomitantly with pelvic irradiation, can be safely applied with minimal acute normal tissue reaction, and can eradicate the para-aortic node metastasis.

Factors affecting survival of patients with endometrial adenocarcinoma

A total of 307 patients with adenocarcinoma of the endometrium were studied to determine factors significantly affecting the 5year survival. This tumor represented 7.7 per cent of all female malignancies and 31 per cent of all gynecologic malignancies in the New York Medical College Tumor Registry. The relative 5year survival rate was 68 per cent. Survival was inversely proportional to increasing age; it was increased in premenopausal patients but lower in those patients who were in their first postmenopausal year. Forty-two per cent of the patients were nulliparous. There was no correlation of survival to parity. Patients with endometrial involvement only had a 5year survival of 95 per cent and survival decreased with further myometrial and pelvic involvement. Spread to the cervix offered a decidedly poor prognosis. Stage I lesions should be subclassified according to histologic grading. The preferred method of therapy is primarily surgical. Preoperative radium is reserved only for those lesions exhibiting such poor prognostic criteria as an anaplastic histologic appearance or cervical involvement.

Vaginal recurrence of endometrial carcinoma

A 10 year study at the Mayo Clinic showed a direct relationship between depth of myometrial invasion of endometrial carcinoma and both incidena of myometrial lymphatic involvement and rate of posthysterectomy vaginal recurrence. Low-grade lesions tended to recur at the vault: high-grade lesion tended to recur more rapidly and in locations other than the vault. Prompt diagnosis and adequate treatment can lead to 5 year survival in 50 per cent of patients with vaginal recurrences. Since those cases of endometrial carcinoma, regardless of grade, in which myometrial invasion extends 5.0 mm. or more (or in which there is extension to the isthmtuS or below) account for most of these recurrences, the use of prophylactic postoperative intravaginal radiation therapy may be benificial.

Carcinoma of the endometrium: A study of 256 cases from the Norwegian Radium Hospital

256 cases of adenocarcinoma of the uterine body from the most recent 3 year period have been analyzed with regard to the extent of the disease, the various forms of treatment, age differences and the prognosis.An obvious trend is an increase in tumor size with advancing age of the patients, which parallels the drop in survival rates with advancing age. Sixty-one per cent of the patients were treated by hysterectomy followed by irradiation, while 30 per cent received irradiation as the primary treatment. The prognosis gets poorer with the degree of myometrial involvement, and with tumor spread outside of the uterus. The value of external irradiation in preventing pelvic recurrences cannot be proved by the present material, whereas prophylactic irradiation of the vagina seems to prevent the occurrence of vaginal metastases.The comparisons between surgery and radiology as the primary treatment are based on a nonrandomized material. In apparently comparable groups, radium alone or if necessary followed by surgery gives results comparable to those obtained by primary surgery followed by radiation in the age groups below 70 years.

CARCINOMA OF THE CORPUS UTERI.

Prognosis in carcinoma of the corpus uteri depends on proper selection of patients for irradiation and surgery.A new classification of tumors emphasizes accurate appraisal of the extent of the disease. Staging of the carcinoma follows a fractional curettage. Myometrial involvement and the microscopic degree of differentiation of tumor are important considerations in prognosis.When the tumor involves the cervix, irradiation or radical surgery, or both, is indicated. Irradiation administered before hysterectomy markedly improves the prognosis in undifferentiated carcinoma.

ATYPICAL ENDOMETRIAL HYPERPLASIA SIMULATING ADENOCARCINOMA

Benign hyperplastic lesions of the endometrium have often been mistaken for adenocarcinoma. Areas of Swiss-cheese endometrium of considerable size may be found in normally functioning organs. The reaction of the endometrium to ovarian hormones is not always the same in all its parts. Young immature endometrium are highly responsive to the growth effect of estrogen and refractory to the differentiating hormone progesterone. The reverse is true in more mature endometrial elements. When squamous areas occur in a benign hyperplastic endometrium they are not necessarily evidence of malignancy. The gland characteristics should be used for diagnosis. Curettage or curettage plus radiologic induction of menopause was used in 18 described cases of uterine bleeding. All showed histologic changes which might have been mistaken for adenocarcinoma. 26 cases of atypical hyperplasia with subsequent hysterectomy without preliminary radiation are more extreme than the curettage cases therefore the simulation of cancer is more perfect. The absence of any gross lesion was incompatible with the malignancy diagnosis. There was no evidence of penetration of the basement membrane or of myometrial involvement. Cell characteristics are useful in some cases but not in others. It is impossible to decide whether or not a lesion is a cancer based on microscopic examination.

Atypical endometrial hyperplasia simulating adenocarcinoma

Benign hyperplastic lesions of the endometrium have often been mistaken for adenocarcinoma. Areas of Swiss-cheese endometrium of considerable size may be found in normally functioning organs. The reaction of the endometrium to ovarian hormones is not always the same in all its parts. Young immature endometrium are highly responsive to the growth effect of estrogen and refractory to the differentiating hormone progesterone. The reverse is true in more mature endometrial elements. When squamous areas occur in a benign hyperplastic endometrium they are not necessarily evidence of malignancy. The gland characteristics should be used for diagnosis. Curettage or curettage plus radiologic induction of menopause was used in 18 described cases of uterine bleeding. All showed histologic changes which might have been mistaken for adenocarcinoma. 26 cases of atypical hyperplasia with subsequent hysterectomy without preliminary radiation are more extreme than the curettage cases therefore the simulation of cancer is more perfect. The absence of any gross lesion was incompatible with the malignancy diagnosis. There was no evidence of penetration of the basement membrane or of myometrial involvement. Cell characteristics are useful in some cases but not in others. It is impossible to decide whether or not a lesion is a cancer based on microscopic examination.