Background

Question 1

What is the incidence of Endometrial Cancer?

Answer 1

• Most Common GYN malignancy
• 2nd most common cause of gyn deaths
• 4th most common malignancy in Women
• 54,870 new cases
• 7% of Cancer in Women
• 7th most common cause of cancer death
• 10,170 Deaths
• 4% of Cancer Deaths in Women

Question 2

Risk Factors for Endometrial Cancer?

Answer 2

Estrogen, nulliparity, obesity, tamoxifen

1. Exogenous unopposed estrogen (RR 5)
2. Endogenous estrogen

• obesity (RR=3, increases to 10 if >50 lb Overweight),
• Nulliparity (RR 2-3)
• Menopause after 52 yrs (RR 2)
• DM (RR 3)
• functional ovarian tumors, chronic anovulation/ polycystic ovarian syndrome

3. Tamoxifen (RR 7.5, Annual risk 1/100)
4. Advancing age (75% postmenopausal)
5. Hereditary (HNPCC)
6. Family Hx
7. HTN

Question 3

What are protective factors for endometrial cancer?

Answer 3

1. combination oral contraceptives
2. Aromatase inhibitors
3. physical activity.

Question 4

What are the different histologies of Endometrial cancer?

Answer 4

1. Type I: endometrioid, 70%– 80% of cases, estrogen related
2. Type II: nonendometrioid, typically papillary serous or clear cell, high grade, not estrogen related, aggressive clinical course

Question 5

What determines the grade of endometrial tumors?

Answer 5

The grade of endometrial tumors depends on the glandular component:

Grade I: ≤ 5% nonsquamous solid growth pattern

Grade II: 6%– 50% nonsquamous solid growth pattern

Grade III: > 50% nonsquamous solid growth pattern

Question 6

What is the risk of simple hyperplasia becoming cancer? how about complex hyperplasia? Genetics of Lynch Syndrome?

Answer 6

Simple hyperplasia→cancer (<2%)
Complex hyperplasia→cancer (40%)
Lynch Syndrome: microsat instability, uterine + colon ca

Question 7

What % of postmenopausal women with abnl vaginal bleeding have endometrial cancer?

What is the most common clinical presentation of endometrial cancer?

Answer 7

Only 5%– 20% of postmenopausal women with abnl vaginal bleeding have endometrial cancer.

All postmenopausal bleeding needs biopsy

Endometrial cancer presents with abnl vaginal bleeding in 90% cases.

Question 8

Endometrial Ultrasound

Answer 8

Endometrial US shows strip

Question 9

Layers of uterus

Answer 9

Uterus- pelvic organ bordered anteriorly by the bladder and posteriorly by the rectum. It is covered by peritoneal reflections and is divided into the fundus, isthmus, and cervix.

The uterine wall consists of an outer smooth muscle layer (the myometrium) and an inner layer of glandular epithe- lium (endometrium).

The uterus is supported by five ligaments: broad, round, cardinal, uterosacral, and vesicouterine.

The uterus is attached at the cervix to the lateral pelvic wall by a pair of ligaments at the base of the broad ligament referred to as the cardinal ligaments which contain arteries, veins, and lymphatics. The uterine arteries pass over the ureters on each side in close proximity to the cervix.

Question 10

What is the primary lymphatic drainage of the uterus?

Answer 10

The primary lymphatic drainage of the cervix and lower uterine segment is to the pelvic LNs (parametrial, internal and external iliacs, obturator, common iliac, presacral). The fundus has direct drainage to the para-aortic (P-A) nodes. The round ligament can drain directly to the inguinal nodes.

Question 11

What % of endometrial cancer pts with positive pelvic LNs will also harbor Dz in the P-A LNs? What is the chance of P-A nodal involvement if pelvic nodes are negative?

Answer 11

33%– 50% of pts with pelvic LN involvement also have involvement of the P-A nodes. Isolated P-A nodal involvement with negative pelvic LNs is detected in ~ 1% of surgically staged cases, though the rate may be higher when dissection is extended above the IMA to the perirenal nodes, especially on the left where direct route of spread might occur.

Question 12

What is the risk of LN involvement by DOI and grade per Gynecologic Oncology Group’s GOG 33?

Answer 12

According to GOG 33, the risk of LN involvement is < 5% for tumors limited to the endometrium (all grades) and 5%– 10% for tumors invading the inner and middle 3rd of the myometrium (all grades). For tumors invading the outer 3rd of the myometrium, the risk is ∼ 10% for grade 1, ∼ 20% for grade 2, and ∼ 35% for grade 3. (Creasman WT et al., Cancer 1987)

Question 13

What are the most aggressive histologies?

Answer 13

papillary serous, clear cell, and pure squamous cell.

Question 14

What % of endometrial cancers are adenocarcinoma?

Answer 14

75%– 80% of endometrial cancers are adenocarcinomas.

Question 15

According to the American College of Obstetricians and Gynecologists (ACOG), how should women be screened for endometrial cancer?

Answer 15

No appropriate cost effective strategy