17) Gynae-oncology: Endometrial Flashcards
Proportion of patients with postmenopausal bleeding with endometrial hyperplasia
15%
How much more common is endometrial hyperplasia in renal transplant patients?
2 x
Underlying aetiology of endometrial hyperplasia
Unopposed oestrogen (risks include BMI, an ovulation, oestrogen secreting tumours, exogenous oestrogen)
Prognosis of hyperplasia without atypia
Cancer risk <5% over 20 years (1% “simplex”, 4% “complex”)
75% spontaneous regression rate
Prognosis of hyperplasia with atypia
8% 4 years
12% 9 years
28% 19 years
Concomitant cancer 40%
Management of hyperplasia without atypia
- Address reversible risk factors e.g. BMI
- Medical therapy increases regression rate compared to observation alone
(1) Mirena (2) Continuous oral progestogens (NOT cyclical) - Treat for minimum of 6 months
- 6 monthly endometrial surveillance - 2 negative samples before discharge.
- High risk of relapse (BMI >35, oral progestogens) then consider annual surveillance after 2 negative samples.
When to offer surgical management to patients with hyperplasia without atypia?
- Progression to atypical hyperplasia
- No regression of hyperplasia despite 12 months treatment
- Relapse after completing treatment
- Persistence of bleeding symptoms
- Patient preference
Management of hyperplasia with atypia
(1) Surgical - hysterectomy + BS +/- BO
Management of hyperplasia with atypic if patient declines surgery
Refer to MDT
Mirena first line
Hysterectomy once fertility no longer desired
Follow up 3 monthly until 2 x negative biopsies and then every 6-12m until hysterectomy
Live birth rate in women who choose fertility sparing management of their endometrial hyperplasia with atypia
25%
How to manage endometrial hyperplasia in a patient on HRT?
If cyclical HRT then either swap to continuous or add in mirena.
If continuous HRT then review whether need to continue and consider mirena.
How to manage endometrial hyperplasia within a polyp?
Complete removal of polyp and biopsy to sample background endometrium.
Subsequent management then based on type of EH.
Which breast cancer treatments increase the risk of EH?
Tamoxifen (SERM)
Aromatase inhibitors don’t
What to do if EH develops in a woman on tamoxifen?
Decision with oncologists re: risk of stopping tamoxifen v risk of EH. Effect of mirena on breast cancer recurrence unknown.
Incidence of postmenopausal bleeding
10%
Most common findings in a patient with PMB
60-80% atrophic endometritis/vaginitis 15-25% exogenous oestrogenen 25% endometrial polyp 15% endometrial hyperplasia 10% endometrial cancer
What is the most common presenting feature in a patient with endometrial cancer?
Vaginal bleeding (90%)
In a woman with PMB, what is the likelihood that she has endometrial cancer (overall)?
10%
In a woman with PMB, what is the likelihood that she has endometrial cancer (<50 years)?
1%
In a woman with PMB, what is the likelihood that she has endometrial cancer (>85 years)?
25%
In a woman with PMB, what is the likelihood that she has endometrial cancer (obese)?
18%
In a woman with PMB, what is the likelihood that she has endometrial cancer (diabetic)?
21%
In a woman with PMB, what is the likelihood that she has endometrial cancer (obese and diabetic)?
29%
Prevalence of polyps in a patient on tamoxifen
30-60%
Increased risk of endometrial cancer in a patient on tamoxifen
3-6 x increased risk
Risk of malignancy within a polyp
Asymptomatic: 0.3%
Symptomatic: 2.3%
Risk of atypical hyperplasia within polyp
Asymptomatic: 1.2%
Symptomatic: 2.2%
How to interpret endometrial thickness on USS?
4mm or less than no biopsy needed
Above 4mm recommend endometrial sampling
Risk of endometrial malignancy if ET <4mm
<1%
What percentage of pipelle samples provide insufficient tissue?
25%
Lifetime risk of endometrial cancer
3%
What is the effect of every 5kg/m2 increase in BMI on endometrial cancer risk?
60% increase
Lifetime risk of endometrial cancer in a woman with BMI >40
10-15% (10x higher)
What percentage of endometrial cancers are secondary to obesity (and therefore preventable)?
40%
What is the effect of regular physical exercise on endometrial cancer risk? (And what is meant by regular physical exercise in this context)
20 minutes moderate exercise 5 x per week reduces risk 20-30%.
What is the effect of bariatric surgery on endometrial cancer risk?
70-80% reduction
What is the effect of mirena on endometrial cancer risk?
54% reduction (increased to 75% if prolonged treatment)
What is the effect of COCP on endometrial cancer risk?
> 5 year use reduces risk 50% (protection up to 30 years)
What questionnaire screens for OSA?
STOP-BANG
Which speculum is longer than a Cusco?
Winterton
What are the two categories of endometrial cancer and their aetiology?
Type 1: Endometrioid - due to oestrogen excess, typically low grade with good prognosis.
Type 2: Non-endometrioid. Typically serous but can be any other type. Not oestrogen driven and occur in small atrophic endometrium. Aggressive.
What proportion of patients with endometrial cancer present at stage 1?
70-75%
What percentage of endometrial cancers are inherited?
2-5%
Risk of endometrial cancer with Lynch syndrome
40-60% lifetime risk
Where should patients with endometrial cancer be operated on?
FIGO 1A Endometrioid G1/G2 - DGH. Anything else should be done at a cancer centre.
What are the treatment deadlines for patient with endometrial cancer?
Should be seen 2 weeks from referral and have treatment started 62d from referral (31d from decision to treat).
What investigations are required once endometrial cancer confirmed?
Chest imaging (CXR/CT) CT A/P (or MRI) if high risk histology.
If high risk for mets or unexpected high risk findings in post-op histology: CT C/A/P.
Treatment for endometrial cancer
Stage 1/2:
- Hysterectomy and BSO
- No evidence for lymphadenectomy
- If high grade/non-endometrioid then surgical staging (including pelvic and para-aortic lymphadenectomy and mental biopsy)
Stage 3/4:
- Complete surgical resection of all visible disease
- Systematic lymphadenectomy
- Neoadjuvant chemo and then surgery an option
Adjuvant treatment for endometrial cancer
Progestogens not used routinely.
Radiotherapy:
- Not for low risk endometrioid
- Intermediate risk: EBRT or brachytherapy
- High risk: EBRT (unless had lymphadenectomy and nodes negative)
Chemo:
- Platinum based chemo offers small benefit in survival.
Management options for endometrial cancer in a patient unfit for surgery
Vaginal hysterectomy
Definitive pelvic radiotherapy
Conservative management with progestogens/aromatase inhibitors.
What proportion of endometrioid endometrial cancers occur in women <45 years and what proportion of those women have a synchronous ovarian tumour?
5% endometrioid endometrial cancer in women <45 years and 25% have a synchronous ovarian tumour.
Fertility preserving option for endometrial cancer
Short term conservative management with progestogens if closely followed up.
