Cancers of Uterus
In this article we will learn the normal features of uterus and manifestations of different cancers in uterus.

Normal structure of uterus
In layman term uterus is called as 'womb'. Uterus is a pear shaped female reproductive organ which protects the fertilized ovum and helps to form the complete fetus. It is approximately 3inches long, 2inches broad and 1inch in thickness. It weighs 30 to 35 grams. The uterus is divided into the upper part called as body while lower part is called as cervix.

On either side of uterus are the tubes called as fallopian tubes. They are the duct like which convey ova from ovaries to the uterus. Whenever the sperm enters into the vagina it pass into the uterus and then to the fallopian tubes . Fertilization takes place in fallopian tubes. Each fallopian tube is 10cm long.

Uterus is supported by the ligaments -
1) Anterior ligament
2) Posterior ligament
3) Right and left broad ligament.

Layers of uterus - Uterus is internally lined by 3 layers
1) Endometrium - It is the innermost lining of uterine cavity. Normally this endometrial lining periodically shed during menstruation or reabsorbed during the pregnancy. But whenever there is defect in the endometrial lining like increase in thickness of endometrium leads to the endometrial cancer.

2) Myometrium - It is the middle layer of uterus which is made of smooth muscles. Whenever myometrium becomes thickened the condition is called as 'adenomyosis'. The cancer of myometrium is called as uterine sarcomas.

3) Parametrium - It is the loose tissue around the uterus.

Changes in the uterus with ages and reproduction

1) Fetal life - During fetal life, cervix is larger than the upper body of the uterus and hence cervix projects out from the pelvis.

2) Puberty - Uterus enlarges and moves downward due to gravitational force.

3) Menstruation - Again during every menstrual cycle the uterus enlarges slightly and becomes more vascular.

4) Pregnancy - During pregnancy there is vast enlargement in the uterus due to hypertrophy of the muscle fibers. As the pregnancy stage advances the uterine wall stretches and gets thinner .

5) Delivery - After delivery the uterus returns to the non pregnant size.

6) Old age - Uterus becomes smaller in size and called as atrophic uterus.

What is Uterine Cancer?
Uterine cancer is a dreadful and invasive cancer of female pelvic organ - uterus. Around 15%of cancer in women has been suffering from uterine cancer especially endometrial cancer. Endometrial cancer is the most common malignant disease in the world especially in USA.

Types of uterine cancer
The cancer can e benign or malignant. Malignant cancer is invasive, spreads and destroys the normal healthy tissue but benign one does not spread and is non-invasive. There are different types of cancer-
1) Endometrial cancer
2) Uterine Sarcomas

A) Endometrial cancer- It is also called as adenocarcinoma and the most commonest type of uterine cancer. Approximately 2 women out of every 100 women would suffer from endometrial cancer in their lifetime.

Etiology and Risk factors for endometrial cancer
The main cause of endometrial cancer is excess of estrogen production either by body or by intake of estrogen tablets in hormone replacement therapy.
1) Family History of cancer
2) Women who are obese and above 40years of age
3) Infertility and never had a child
4) Irregular menstrual periods
5) Early menstruation and late menopause
6) History of ovarian or colon cancer.
7) Long term use of contraceptive pills
8) History of hypertension, diabetes and thyroidism.

Pathology of Endometrial cancer
Endometrial cancer are of two types - Type I and Type II

80% of endometrial carcinomas are included in type I which is due to imbalance or excess of estrogen levels while type II are not dependent on estrogen levels.
Endometrial carcinoma may begin either on small part of endometrium or on large wide area of endometrium. As the disease spreads the myometrium and cervix are affected too. This cancer spreads in 3 different ways beyond the uterus -

• Direct spread beyond the uterus.
• Lymphatic spread - the cancer cells spreads through lymph nodes.
• Blood - The cells may spread through blood to lungs, liver, heart and brain

Clinical presentation for Endometrial cancer

• Abnormal vaginal bleeding which can be either excess bleeding or frequent menstrual bleeding or post menopausal spotting. These symptoms may remain constant or may appear suddenly
• Bloody vaginal discharge
• Change in bowel and bladder habits.
• Pain in pelvic region
• weight loss.

Diagnostic Tests for Endometrial cancer

• Pelvic Examination- It is done by a gynecologist in the clinic. It helps to guide the shape, size or any other changes in the uterus.
• Ultrasonography of lower abdomen - It helps to view the any abnormality in the uterus.
• Endometrial biopsy - If any abnormality is seen then small piece of the endometrium is taken out with the help of fine needle and microscopic examination is done. This examination will give an idea whether any cancerous cells are present in the uterus or not.
• Dilation and curettage (D&C) - Sometimes the biopsy is not possible or enough tissue cannot be taken from biopsy and hence D and C is requires. D&C is the procedure where the lining of uterus is scrapped and the tissue examined for the cancerous cells under the microscope. It generally requires anesthesia.
• Pap smear - This test is not much helpful as it helps to detect the cervical cancer instead of endometrial cancer. Sometimes PAP smear is normal in endometrial cancerous women.

Stages or Grades of Endometrial cancer
Once the gynecologist comes to a diagnosis of endometrial cancer it is necessary to understand at which level or grade the disease is so that treatment is advised. Hence the grading system helps to come to the conclusion.

Grade I - Cancer is located only in the uterus.

Grade II - Cancer is present in cervix along with uterus.

Grade III - Cancer from uterus has spread to the pelvic lymph nodes.

Grade IV - Cancer has spread to most of the distant organs and pelvic region - abdomen, bladder and rectum.

This chart shows that grade ! is less harmful than grade IV.

Treatment for Endometrial cancer

• The treatment depends on the severity of disease. Initial treatment is Radiation and Chemotherapy. radiation helps to stop the cancer cells from growing further by exposing them to high energy.
• Most of the women require surgery like hysterectomy with salpingo-oopherectomy (removal of uterus with both the fallopian tubes and ovaries.)
• Surgery can be combined with the radiation therapy and indicated usually if the disease is in grade I and II.

Uterine Sarcomas

Uterine sarcomas is a rare kind of cancer of muscle and tissues of uterus (myometrium) that provide the support. It is a malignant tumor of smooth muscle of uterus.

Causes and Risk factor for Uterine sarcoma
1) Frequent exposure to x-rays.
2) Frequent radiation therapy to pelvis.

Types of Uterine Sarcomas

1) Leiomyosarcomas - This is a rare malignant tumor which arises from the smooth muscle cells of the uterine wall. The smooth muscles forms the involuntary muscles of the body like muscles around the uterus, intestines, stomach, etc.

2) Endometrial stromal sarcomas - The cancer cell that arise from the stroma of the uterine lining is called as endometrial stromal sarcoma.

3) Carcinosarcomas - It is the malignant tumor which is the combination of cancer of epithelial cells and (carcinoma) and cancer of connective tissues (sarcoma)

Clinical Presentation for Uterine sarcoma

1) Postmenopausal bleeding or unusual vaginal bleeding
2) Unusual vaginal discharge
3) A mass present in the vaginal area.
4) Frequent pain and sensation of fullness in abdomen along with above complaints.

Stages of Uterine Cancer
Stage I - Cancer is located in the uterus.

• Stage IA - Cancer is present in only the endometrium.
• Stage IB - Cancer is spread to the inner part of myometrium.
• Stage IC - Cancer is spread to the outer part of myometrium.

Stage II - Spread of cancer from Uterus to cervix

• Stage IIA- Cancer has spread to the part where cervix and uterus meets.
• Stage IIB - Cancer has spread to the cervix from uterus.

Stage III - Cancer has spread to the pelvis from uterus and cervix.

• Stage III A- Cancer has spread to the outer part of uterus and peritoneum.
• Stage III B -Cancer has spread to the lymph nodes of pelvis.

Stage IV - The cancer has spread outside the pelvis.

• Stage IV A- Cancer has spread to the bladder and intestines.
• Stage IV B- Cancer has spread all over pelvis, abdomen and lymph nodes.

Diagnosis and Tests for Uterine sarcomas
1) Pelvic examination and patients history - A gynecologist examines the pelvis in the clinic and look for any abnormal mass, size of uterus, unusual discharge and bleeding.

2) Dilatation and curettage (D&C) - It is the surgical procedure similarly done as in endometrial cancer tests. The tissue sample are taken and examined microscopically for the sarcomas.

Following tests are performed if the tissue examination shows presence of sarcoma cells. These tests helps to find out the stages of cancer and to what level cancer is spread.

1) Transvaginal Ultrasonography - During this procedure a probe is inserted in the vaginal opening and doctors look for abnormalities in the uterus on the screen.

2) CT Scan - Ct scan gives the complete image of the body and helps to detect if any abnormality or abnormal tissue present if the body.

3) CA 125 essay - It is a blood test which helps to measure the level of CA 125 which is a substance released into the bloodstream during cancer. If CA 125 is high then it is confirmation of Uterine cancer.

Treatment for Uterine sarcomas
There are different types of treatments available for sarcoma patients. Depending on the severity the treatments are suggested by the doctors.

Surgeries - Surgery is the primary option to get rid of cancer . Once surgery is done the radiation or chemotherapy is advised to kill the remaining cancer cells.

• Hysterectomy - The total hysterectomy is done where complete uterus with fallopian tubes and ovaries are removed. It is done either through abdominal incision or vaginally.
• Lymphadenectomy - It is a surgical procedure for removal of cancerous lymph nodes.
• Hormone Therapy - Certain hormones can cause the growth of cancer cells hence hormone therapy helps to stop the action of those hormone which certainly stops the cancerous cell growth.

Follow up after the treatment
Once the treatment is done it is necessary to follow up with your doctors once in every month or as per the doctors advise. During follow up doctor will look up how the body has adjusted to the invasive treatment and if there is any chance of spread of cancer. Doctor may advise for some routine blood tests and other examination to confirm that there is no more cancer cells in the body and blood.