[26] Endometrial Cancer Flashcards
1
Q
What is endometrial cancer?
A
A cancer arising from the lining of the uterus
2
Q
How common is endometrial cancer?
A
The 4th most common cancer in women in the UK
3
Q
How many new cases of endometrial cancer are there each year in the UK?
A
8,600
4
Q
How many deaths are caused by endometrial cancer each year in the UK?
A
2,300
5
Q
What is the median age of endometrial cancer?
A
63
6
Q
What % of women with endometrial cancer are over 50?
A
90%
7
Q
Where is endometrial cancer more common?
A
Western societies
8
Q
What is the most common histological type of endometrial cancer?
A
Adenocarcinoma
9
Q
What % of endometrial cancer is adenocarcinoma?
A
80%
10
Q
What are the two main types of endometrial cancer?
A
- Type 1
- Type 2
11
Q
What is Type 1 endometrial cancer?
A
Oestrogen dependent endometrioid
12
Q
What is Type 2 endometrial cancer?
A
Oestrogen independent non-endometrioid
13
Q
What are the risk factors for endometrial cancer?
A
- Prolonged periods of unopposed oestrogen
- Nulliparous
- Menopause past 52
- Obesity
- Endometrial hyperplasia
- PCOS
- DM
- Tamoxifen
14
Q
What is the main risk factor for endometrial cancer?
A
Prolonged unopposed oestrogen
15
Q
What can cause prolonged periods of unopposed oestrogen?
A
- Medication
- Anovulatory cycles where corpus luteum does not mature and secrete progesterone
16
Q
What is endometrial hyperplasia?
A
Excessive proliferation of the cells of the endometrium
17
Q
Why is endometrial hyperplasia a significant finding?
A
It is a significant risk factor for the development of endometrial cancer
18
Q
What is essential in women with endometrial hyperplasia?
A
Careful monitoring and treatment
19
Q
What causes most cases of endometrial hyperplasia?
A
High levels of oestrogen combined with insufficient progesterone
20
Q
Why is sufficient progesterone important in preventing endometrial cancer and hyperplasia?
A
It normally counteracts the pro-proliferative effects of oestrogen on the tissues
21
Q
What are the classifications of endometrial hyperplasia?
A
- Hyperplasia without atypia
- Atypical hyperplasia
22
Q
Which type of endometrial hyperplasia is considered a pre-malignant condition of the uterus?
A
Atypical hyperplasia
23
Q
How does endometrial hyperplasia normally present?
A
- Abnormal vaginal bleeding
- Sometimes vaginal discharge
24
Q
What types of abnormal vaginal bleeding may occur in endometrial hyperplasia?
A
- Intermenstrual bleeding
- Irregular bleeding
- Menorrhagia
- Post-menopausal bleeding
25
How is endometrial hyperplasia definitively diagnosed?
Biopsy
26
How can biopsy to test for endometrial hyperplasia be obtained?
- Outpatient endometrial sampling with pipelle biopsy
| - Hysteroscopy and curettage biopsy
27
When is an endometrial curettage biopsy preferred to pipelle biopsy?
When there are polyps and other benign lesions
28
What investigation may be useful in identifying potential endometrial hyperplasia prior to biopsy?
Transvaginal USS
29
Can an endometrial biopsy be performed regardless of transvaginal USS results?
Yes, if clinical suspicion is high
30
What does the interpretation of the results of a transvaginal USS for suspected endometrial hyperplasia depend upon?
Whether she is pre- or post-menpausal
31
Which group of women is endometrial thickness on transvaginal USS less helpful in determining likelihood of endometrial hyperplasia?
Pre-menopausal women
32
Why is endometrial thickness less helpful in pre-menopausal women?
Due to the cyclical change and overlap between normal proliferative endometrium and hyperplasia
33
What can a transvaginal USS in pre-menopausal women help to identify (other than endometrial hyperplasia)?
Abnormalities such as polyps
34
What endometrial thickness in pre-menopausal women is unlikely to suggest endometrial hyperplasia?
<7mm
35
What can endometrial thickness in post-menopausal women be used to determine?
Need for biopsy/hysteroscopy
36
What is the cut off endometrial thickness for requiring endometrial biopsy/hysteroscopy in post-menopausal women?
3-4mm
37
What can treatment of endometrial hyperplasia include?
- Conservative management
- Hormonal therapy
- Hysterectomy
38
What are the management options for endometrial hyperplasia without atypia?
- Reassurance
- Address risk factors
- Watchful waiting
- Progestogen treatment
39
What reassurance can be given to women with endometrial hyperplasia without atypia?
Risk of progression to cancer is <5% over 20 years and most will return to normal spontaneously
40
What forms part of watchful waiting for endometrial hyperplasia without atypia?
6-monthly follow-up biopsies until 2 consecutive normal results
41
What is the first line progestogen treatment for endometrial hyperplasia?
Levonorgestrel IUS
42
What is the second line progestogen treatment for endometrial hyperplasia?
Oral progestogen
43
What is the advised treatment for all women with atypical endometrial hyperplasia?
Hysterectomy
44
Why is a hysterectomy recommended for all women with atypical endometrial hyperplasia?
Due to the risk of malignant progression
45
What management option is available for women with atypical endometrial hyperplasia who wish to preserve their fertility?
Progestogens with 3-monthly endometrial biopsy and hysterectomy as soon as possible
46
What is the most common presenting symptom in endometrial cancer?
Abnormal uterine bleeding
47
What % of cases of endometrial cancer present with abnormal uterine bleeding?
90%
48
What is the most common type of abnormal uterine bleeding seen in endometrial cancer?
Post-menopausal bleeding
49
What are some other potential presenting features of endometrial cancer?
- Lower abdominal pain
- Vaginal discharge
- Dyspareunia
50
What is often seen on bimanual/speculum examination in endometrial cancer?
Often normal
51
What are the symptoms of advanced disease in endometrial cancer?
- Urinary frequency
- Fatigue
- Loss of appetite
- Back pain
- Constipation
52
What are the differentials for endometrial cancer?
- Endometrial hyperplasia
- Endometrial polyp
- Endometriosis
- Cervical cancer
- Pyometria
53
What is the first line investigation for endometrial cancer in post-menopausal women?
Transvaginal ultrasound
54
Why is transvaginal USS first line investigation in post menopausal women for endometrial cancer?
It can identify women at risk of endometrial hyperplasia and cancer due to thickening of the endometrium
55
How does thickness of the endometrium in post-menopausal women correlate to risk?
Thicker = higher risk of serious pathology
56
What is the usual cut off for endometrial thickness requiring further investigations?
3mm
57
What investigations take place if transvaginal USS suggests high likelihood of endometrial pathology?
- Hysteroscopy
| - Endometrial biopsy
58
How is definitive diagnosis of endometrial cancer/hyperplasia made?
Histology of biopsy sample
59
How is a biopsy sample obtained in endometrial cancer?
Usually hysteroscopy
60
What can hysteroscopy be used for?
Detecting polyps, other benign lesions and taking biopsies
61
What is required to stage endometrial cancer?
Total abdominal hysterectomy
62
Why else is total abdominal hysterectomy needed in endometrial cancer (other than staging)?
As a primary treatment
63
What are the stages of endometrial cancer?
Stage 1-4
64
What is Stage 1 endometrial cancer?
Disease in the body of the uterus
65
What is Stage 1a endometrial cancer?
Invasion <50% of the myometrium
66
What is Stage 1b endometrial cancer?
Invasion >50% of the myometrium
67
What is Stage 2 endometrial cancer?
Disease in the body of the uterus and cervix
68
What is Stage 3 endometrial cancer?
Disease advanced within the pelvis
69
What is Stage 3a endometrial cancer?
Involvement of the ovaries
70
What is Stage 3b endometrial cancer?
Involvement of the vagina and parametrium
71
What is Stage 3c endometrial cancer?
Local lymph node involvement
72
What is Stage 4 endometrial cancer?
Disease spread outside the pelvis
73
What is Stage 4a endometrial cancer?
Involvement of the bowel/bladder
74
What is Stage 4b endometrial cancer?
Involvement of more distant organs
75
What is an important point to consider when managing Stage 1a endometrial cancer?
Whether the patient wishes to keep fertility
76
What should a patient with Stage 1a endometrial cancer who wishes preserve fertility be offered before treatment?
Counselling
77
What fertility preserving treatment can be given for Stage 1a endometrial cancer?
Progestogens
78
What is required alongside progestogens in the treatment of Stage 1a endometrial cancer?
Aggressive monitoring
79
What aggressive monitoring do women being treated for Stage 1a endometrial cancer with progestogens require?
Hysteroscopy and endometrial sampling every 3-6 months
80
What should women who are having fertility preserving treatment for Stage 1a endometrial cancer have after children?
Hysterectomy
81
What is the standard treatment for women with Stage 1a endometrial cancer that do not wish preserve fertility?
Total hysterectomy, bilateral salpingo-oopherectomy and node dissection
82
What adjunctive therapy can be given in Stage 1a endometrial cancer if certain risk factors are present?
Vaginal brachytherapy
83
What risk factors in Stage 1a endometrial cancer indicate vaginal brachytherapy?
- Age >60
- Lymphovascular space invasion
- Grade 3 tumours
84
How is endometrial cancer Stage 1b - 2 managed?
Surgery (as with Stage 1) and sometimes adjunctive therapies
85
What adjunctive therapies may be given for Stage 1b - 2 endometrial cancer?
- Pelvic radiation
- Chemotherapy
- Vaginal brachytherapy
86
How is Stage 3 or 4 endometrial cancer managed?
Surgery followed by chemotherapy
87
What additional therapy can patients with Stage 3 or 4 endometrial cancer have if they are at high risk?
External beam radiotherapy
88
What is the main therapy for recurrent or terminal endometrial cancer?
Supportive care
89
What should be managed in supportive care of endometrial cancer?
- Pain
- Nausea and vomiting
- Lymphoedema
- Bleeding
- Obstruction
- Fistulae
90
What cancer targeted therapies can be used for incurable or recurrent endometrial cancer?
- Radiotherapy
- Surgical resection
- Palliative chemotherapy
- Hormonal therapy with progesterone or aromatase inhibitors
91
What is the overall 20 year survival for endometrial cancer?
80%
92
What does prognosis of endometrial cancer depend on?
Type and stage of tumour
93
What are some poor prognostic indicators for endometrial cancer?
- Older age
- Advanced stage
- High-grade tumours
- Adenosquamous histology
- Obesity
94
Where is recurrence of endometrial cancer post-surgery most common?
The vaginal vault
95
When does recurrent endometrial cancer most commonly present?
2-3 years after primary treatment
