Uterine Cancer

In Australia, uterine cancer is the most common gynaecological cancer with more than 2000 women newly diagnosed every year. Typically it is a disease of postmenopausal women. We distinguish two types:

1. Type 1 uterine cancer is the most common form, most likely caused by obesity, diabetes mellitus or high cholesterol. These cancers require surgery but normally show a very good prognosis. The cancer type is endometrioid and not uncommonly, endometrial hyperplasia is a precancerous condition leading to uterine cancer.
2. Type 2 uterine cancer includes serious, clear cell, sarcomas and other rather aggressive types of uterine cancer. Causes of these cancer types are unknown. Treatment requires surgery followed by radiotherapy, chemotherapy or a combination of both.

Sometimes uterine cancer can be inherited. See Lynch syndrome.

Prior to surgery, the diagnosis of uterine cancer needs to be established on either an endometrial sampling (in the office) or a curette (day surgery).

Treatment

Surgery for uterine cancer will remove the uterus, tubes and the ovaries (full hysterectomy & salpingo-oophorectomy) with removal of some lymph nodes in some cases. In most instances, a frozen section examination will be performed by the pathologist while the patient is under general anaesthesia. The pathologist will inform me about the extent of the disease within the uterus while the patient is asleep. Frozen section is only 85% to 90% accurate because only a limited number of sections can be done and examined in the short time provided. Depending on the pathologist’s preliminary report, a pelvic and/or aortic lymph node dissection should be conducted in a limited or extensive way. This means that I will remove lymph glands from both side walls of the pelvis along the large vessels in the patient’s abdomen. Ten to twenty per cent of apparent “early” uterine cancers spread into lymph glands and it is very important to test the lymph nodes in exactly those patients. Patients with involved lymph nodes will need further postoperative treatment (radiotherapy, chemotherapy, or combinations of both).

In rare cases where patients are unable to tolerate surgery for medical reasons, radiotherapy or hormonal treatment need to be considered as an alternative to surgery.

Before surgery, imaging (X-ray and CT scan) and blood tests are routinely taken and give useful information prior to surgery. Usually no bowel prep is required. Patients require to fast at least 6 hours prior to surgery. Please stop smoking before the operation as it makes your postoperative management much easier.

The procedure usually takes 2 to 3 hours and is routinely carried out laparoscopically (“key hole surgery”). The procedure requires general anaesthesia.

When you wake up from general anaesthesia there will be some lines running in and out of you for support. A drip will give you the necessary fluids and a catheter will drain the urine from your bladder. An oxygen mask will supply oxygen to the respiratory system. A drain may collect body fluid from the inside of the abdomen. These lines will be removed once I am happy that your body functions have returned to normal, which is usually after a few hours.

The final histopathological report may take a few days. It forms the basis for the decision if any further treatment is required. If further treatment is required I will bring you in contact with the respective specialist.

Surgery always carries risks. Before surgery, I do everything to minimise these risks. I give antibiotics before the skin incision in order to avoid skin and other infections. Commencing prior to surgery I give calf compression stockings in order to prevent the formation of blood clots in the legs. At surgery sterile handling of instruments further reduces the risk of infectious complications. However, there are some immanent risks of surgery for uterine cancer:

• Laparoscopic surgery may need to be converted to open surgery through the opening of the abdomen. This risk is approximately 1% to 2%. The vast majority of all laparoscopic procedures proceed laparoscopically.
• Medical and anaesthetic risks associated with general anaesthetic, with epidural analgesia or with postoperative pain control do exist. In patients with pre-existing medical conditions these risks are slightly higher.
• There is a risk of injury to pelvic organs, such as the bowel, the bladder, the ureters, blood vessels and nerves. These injuries usually get repaired during surgery. However, in an exceedingly small proportion of patients these injuries can unfortunately not be recognised during surgery or injuries may even develop after surgery. Then another operation is required to repair those defects. Injury to big blood vessels may result in the need of blood transfusion. Injury of nerves is common in patients who require removal of lymph nodes in the pelvis. In that case, patients will experience some numbness of the skin around the upper thigh.
• Lymph oedema: Lymphatic fluid usually drains from the legs via the lymph glands in the pelvis and the aorta back into the blood circulation. When lymph glands have to be removed, some fluid may accumulate in the legs (lymph oedema). The risk of lymph oedema is around 20% in patients who had to have a lymph node dissection. Patients with lymphoedema require lymph drainage.

Other possible complications include ...

• Infections to the bladder, the abdominal wound, the lungs with resulting temperatures and septicaemia
• Thromboembolic complications (formation of blood clots) in the legs that can even travel to the lungs and cause life-threatening emboli. This risk is very small because of our efforts to minimise them.
• A vaginal discharge that can even be blood-stained is very common for up to 6 weeks. 
• Shoulder tip pain is common after laparoscopic surgery. It is caused by the CO2 gas that s needed for the surgery. It normally lasts only for a day but painkillers are not effective.
• Changes in bowel habits are not uncommon for a couple of months post surgery. I recommend regulation of the bowels with natural substances such as yoghurt, prune juice and natural fibre. 

You need to stay in hospital for one or two days. I recommend giving you a good break for the next couple of weeks. Especially I recommend avoiding intercourse, vaginal tampons and full baths for the next 6 weeks and other factors that could disrupt wound healing or facilitate an infection.  

Please notify me immediately if your condition becomes worse after you have been discharged from hospital.

Follow-UP: After surgery, you should be seen regularly for follow-up for 5 years. These examinations will always include pelvic examinations. After five years, the risk of a recurrence becomes very low.  Should you experience any bleeding or pain, please do not hesitate and contact my office straight away.

Outcomes: Cancers of all types and stages may recur. Recurrence may be local (vagina), in the pelvis or distant (abdomen, lungs). Treatment of recurrent cancer is more challenging than treatment of primary cancer. Survival rates for Type 1 uterine cancer are generally very good (>80% survival rate at 5 years from surgery across all stages). Our research group has developed software that enables us to predict the probability of a recurrence in individual patients (www.gyncan.org)