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Gynaecology > 19. Uterine Cancer > Flashcards

19. Uterine Cancer Flashcards

1
Q

What are the two types of endometrial cancer?

A

Type I (Oestrogen-driven) and Type II (Non-oestrogen-driven)

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2
Q

What drives Type I endometrial cancer?

A

Oestrogen stimulation

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3
Q

What is the background pathology?

A

Endometrial hyperplasia

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4
Q

What is the typical age group affected?

A

6th decade (50s-60s)

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5
Q

What is the most common histology?

A

Endometrioid adenocarcinoma

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6
Q

What hormone receptors are typically positive?

A

Oestrogen and progesterone receptors

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7
Q

What is the prognosis?

A

Less aggressive with a better prognosis

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8
Q

What drives Type II endometrial cancer?

A

It is not oestrogen-driven

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9
Q

What is the background pathology?

A

Endometrial atrophy

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10
Q

What is the typical age group affected?

A

Older patients >70 years

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11
Q

What are the common histological types?

A

Clear cell carcinoma and Uterine papillary serous carcinoma

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12
Q

What genetic marker is often positive?

A

p53 mutation

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13
Q

What is the prognosis?

A

More aggressive with a worse prognosis

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14
Q

What are the three primary malignancies of the uterine corpus?

A
  1. Endometrial carcinoma
  2. Carcinosarcomas (Malignant Mixed Müllerian Tumours, MMMT)
  3. Uterine sarcomas
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15
Q

Risk factors for type1 or oestrogen driven uterine cancer include:

A
  1. Obesity: due to increased peripheral conversion of androgens to oestrogens
  2. Wide oestrogen window: early menarche and late menopause
  3. Low parity/ infertility
  4. Exogenous oestrogen e.g.: unopposed oestrogen/ hormone treatment, tamoxifen in breast cancer survivors
  5. Endogenous oestrogen: women with polycystic ovarian syndrome are anovulatory and hence at risk of endometrial cancer . Women with PCOS should be considered for endometrial sampling if abnormal bleeding, even below age 40 as they are at risk
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16
Q

What is the link between obesity and Type I uterine cancer?

A

Obesity leads to increased peripheral conversion of androgens to oestrogens, raising the risk of oestrogen-driven endometrial cancer.

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17
Q

How does a wide oestrogen window affect the risk of uterine cancer?

A

A wide oestrogen window (early menarche and late menopause) increases the total exposure to oestrogen, raising the risk of endometrial cancer.

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18
Q

What is the risk of low parity or infertility in Type I uterine cancer?

A

Low parity (few or no pregnancies) and infertility increase the risk of Type I uterine cancer.

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19
Q

How does exogenous oestrogen contribute to uterine cancer risk?

A

Unopposed oestrogen treatment (e.g., hormone therapy without progesterone) and tamoxifen (used in breast cancer treatment) increase the risk of uterine cancer.

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20
Q

What is the connection between polycystic ovarian syndrome (PCOS) and Type I uterine cancer?

A

Women with PCOS are anovulatory, leading to chronic unopposed oestrogen exposure, which increases the risk of endometrial cancer. Women with PCOS should be considered for endometrial sampling if abnormal bleeding occurs, even below the age of 40.

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21
Q

Are there any genetic risk factors for Type I uterine cancer?

A

Yes, familial cancer syndromes, such as Lynch 2 syndrome (hereditary non-polyposis colorectal cancer, HNPCC), which includes uterine, breast, ovarian, and prostate cancers, increase the risk of endometrial cancer.

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22
Q

How do most patients with uterine cancer present?

A

Most patients present with postmenopausal bleeding or peri-menopausal bleeding, which often leads to earlier diagnosis and a better prognosis.

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23
Q

How can uterine cancer present in more advanced stages?

A

Advanced stages of uterine cancer may present with:

  • Weight loss
  • Respiratory symptoms (due to lung metastases)
  • Abdominal distension (due to ascites and liver metastases)
24
Q

What should be the first steps in diagnosing uterine cancer in patients with abnormal bleeding?

A

Any patient with postmenopausal bleeding or irregular bleeding after age 40 should undergo:

  1. Careful history-taking
    2.Thorough examination
25
Q

What should alert the clinician about irregular bleeding in younger patients?

A

Irregular bleeding in younger patients with significant risk factors, such as polycystic ovarian syndrome (PCOS), should raise concern for uterine cancer.

26
Q

How is the diagnosis of uterine cancer made?

A

The diagnosis is made histologically, using methods like:

  • Pipelle biopsy
  • Accurette biopsy
  • Hysteroscopy with endometrial sampling
27
Q

Why is a histological diagnosis crucial before starting treatment?

A

A histological diagnosis is imperative before initiating treatment for uterine cancer, as it guides the treatment plan. Cytology samples or an abnormal ultrasound (e.g., endometrial thickness > 4 mm in postmenopausal women) are not sufficient for diagnosing endometrial cancer and planning treatment.

28
Q

What are the key components of a metastatic screen for uterine cancer?

A

The metastatic screen includes:

  1. Blood tests:
    - Full blood count
    - Renal function tests
    - Liver function tests (including GGT and ALP)
  2. Chest X-ray: To exclude lung metastases.
  3. Imaging of the abdomen:
    * Abdominal ultrasound (may be sufficient)
    * CT scan of the abdomen and pelvis (recommended for type 2 uterine cancers, as they have a higher propensity for peritoneal and upper abdominal disease)
  4. Additional imaging: Consider mammogram, colonoscopy, etc., if there are risk factors for familial cancers, such as Lynch syndrome.
29
Q

Why is a CT scan preferred over ultrasound for type 2 uterine cancers?

A

CT scans are more sensitive in detecting smaller peritoneal disease and upper abdominal metastases in type 2 uterine cancers, making them more useful for detecting metastatic spread in these cases.

30
Q

Why is it a good practice to offer a mammogram during the work-up for uterine cancer?

A

Offering a mammogram is important because endometrial cancer and breast cancer share similar hormone-sensitive risk factors, such as obesity and oestrogen exposure (E2). This can help detect concurrent breast malignancies, which may also be hormone-driven.

31
Q

Why is medical optimisation required before surgery for uterine cancer?

A

Medical optimisation is essential because endometrial cancer is typically surgically staged, and surgery may be curative in early-stage disease. Preparation may involve:

  • Assessing age and medical comorbidities
  • Conducting investigations like an ECG for patients with ischemic heart disease or hypertension
32
Q

What is the concept behind staging in cancer management?

A

Staging is used to:

  • Guide the clinician towards the best treatment options
  • Predict the prognosis of the disease Staging helps to understand how far the cancer has spread and the most appropriate treatment approach.
33
Q

How is endometrial cancer staged?

A

Endometrial cancer is divided into 4 stages based on the extent of spread

34
Q

What does Stage 1 endometrial cancer involve

A

Stage 1 cancer is confined to the corpus (body) of the uterus. The prognostic factors in this stage include:

  • Depth of invasion into the underlying myometrium
  • Tumor grade: well, moderately, or poorly differentiated
35
Q

What does Stage 2 endometrial cancer involve?

A

Stage 2 cancer involves spread to the cervical stroma.

36
Q

What does Stage 3 endometrial cancer involve?

A

Stage 3 cancer involves spread to:

  • Adnexal structures (3A)
  • Vagina or parametria (3B)
  • Pelvic or para-aortic lymph nodes (3C)
37
Q

What does Stage 4 endometrial cancer involve?

A

Stage 4 cancer involves:

  • Stage 4A: Invasion into the bladder or rectum
  • Stage 4B: Distant spread to the rest of the abdomen, lungs, or other parts of the body
38
Q

What is the mainstay treatment for Stage 1 and 2 endometrial cancer?

A

Surgical treatment is the mainstay for Stage 1 and 2 endometrial cancer, which typically includes:

  • Total Abdominal Hysterectomy (TAH)
  • Bilateral Salpingo-Oophorectomy (BSO)
  • Peritoneal washings
  • Pelvic lymph node dissection, depending on risk factors for lymph node metastases
39
Q

How is the final treatment plan determined?

A

The final treatment plan is determined by the findings from the pathologist after surgery.

40
Q

When is adjuvant radical pelvic radiation considered?

A

Adjuvant radiation is considered for high-risk patients, such as those with:

  • High-grade histology
  • Depth of myometrial invasion >50%
  • Cervical involvement
41
Q
A
42
Q

When might adjuvant chemotherapy be required?

A

Adjuvant chemotherapy may be required for patients with aggressive histological subtypes, such as uterine papillary serous carcinoma or clear cell carcinoma of the uterus.

43
Q

What is the treatment for women unfit for surgery?

A

Women who are unfit for surgery may be treated with:

  • Primary radical radiation
  • Hormonal treatment, such as high-dose progestogens (e.g., 500 mg medroxy-progesterone acetate or Mirena)
44
Q

What is the treatment for Stage 3 or 4 endometrial cancer?

A

For Stage 3 and 4 disease, palliative care options include:

  • Localized radiation treatment
  • Chemotherapy
  • High-dose progestogens
45
Q

What is the typical age group for carcinosarcoma of the uterus?

A

Carcinosarcoma typically occurs in older women, usually in the 70th decade.

46
Q

How do patients with carcinosarcoma usually present?

A

Patients may present with:

  • Postmenopausal bleeding (PMB)
  • A necrotic mass protruding through the cervix
  • Foul-smelling discharge
47
Q

What investigations and staging are done for carcinosarcoma?

A

The investigations and staging for carcinosarcoma are similar to those for endometrial cancer.

48
Q

What is the surgical treatment for carcinosarcoma?

A

The surgical management includes:

  • Total abdominal hysterectomy (TAH)
  • Bilateral salpingo-oophorectomy (BSO)
  • Peritoneal washings
  • Pelvic lymph node dissection (in early-stage disease)
49
Q

What is the prognosis and treatment approach for carcinosarcoma?

A

Carcinosarcoma has a poor prognosis. Most patients receive:

  • Adjuvant chemotherapy
  • Radiation (with limited role)
50
Q

hat are the types of sarcomas of the uterus?

A

Uterine sarcomas are classified into:

  • Leiomyosarcomas
  • Adenosarcomas
  • Endometrial stromal sarcomas, etc.
51
Q

How do patients with sarcomas of the uterus typically present?

A

Patients with uterine sarcomas typically present with:

-Postmenopausal bleeding (PMB)
- Enlarged uterus

52
Q

Why is it often difficult to diagnose uterine sarcomas prior to surgery?

A

A histological diagnosis is often difficult to make prior to surgery (hysterectomy), and diagnosis is often confirmed post-surgery.

53
Q

What is the treatment for uterine sarcomas?

A

The treatment for uterine sarcomas consists of:

  • Total abdominal hysterectomy (TAH)
  • Bilateral salpingo-oophorectomy (BSO)
  • Peritoneal washings
54
Q

What is the role of adjuvant radiation and chemotherapy in uterine sarcomas?

A

Adjuvant radiation and chemotherapy have limited success in the treatment of uterine sarcomas.

55
Q
A

Gynaecology (25 decks)

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