CANCER OF THE UTERUS (ENDOMETRIUM)
Cancer of the uterine endometrium (fundus or corpus) has in-creased in incidence, partly because people are living longer and because reporting is more accurate. Most uterine cancers are en-dometrioid (that is, originating in the lining of the uterus). After breast, colorectal, and lung cancer, endometrial cancer is the fourth most common cancer in women and the most common pelvic neoplasm. Cumulative exposure to estrogen is considered the major risk factor (Chart 47-8). This exposure occurs with the use of estrogen replacement therapy without the use of proges-tin, early menarche, late menopause, never having children, and anovulation. Other risk factors include infertility, diabetes, hy-pertension, gallbladder disease, and obesity (American Cancer Society, 2002). Tamoxifen may also cause proliferation of the uterine lining, and women receiving this medication for treat-ment or prevention of breast cancer are monitored by their on-cologists. Another less common type of cancer of the uterus is not estrogen-dependent and is found in multiparous, thin women.
All women should be encouraged to have annual checkups, in-cluding a gynecologic examination. Any woman who is experi-encing irregular bleeding should be evaluated promptly. If a menopausal or perimenopausal woman experiences bleeding, an endometrial aspiration or biopsy is performed to rule out hyper-plasia, a possible precursor of endometrial cancer. The procedure is quick and painless. Ultrasonography can also be used to mea-sure the thickness of the endometrium. (Postmenopausal women should have a very thin endometrium due to low levels of estrogen; a thicker lining warrants further investigation.) A biopsy or aspiration is diagnostic.
Treatment of endometrial cancer consists of total hysterectomy and bilateral salpingo-oophorectomy and node sampling. Depending on the stage, the therapeutic ap-proach is individualized and is based on stage, type, differentia-tion, degree of invasion, and node involvement. Whole pelvis radiotherapy is used if there is any spread beyond the uterus. Pre-operative and postoperative treatments for stage II and beyond may include pelvic, abdominal, and vaginal intracavitary radia-tion. Recurrent cancer usually occurs inside the vaginal vault or in the upper vagina, and metastasis usually occurs in lymph nodes or the ovary. Recurrent lesions in the vagina are treated with sur-gery and radiation. Recurrent lesions beyond the vagina are treated with hormonal therapy or chemotherapy. Progestin therapy is used frequently. Patients should be prepared for such side ef-fects as nausea, depression, rash, or mild fluid retention with this therapy.
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