Clinical Conference of the Uterus Flashcards
What tends to be the presentation of endometrial cancer?
PMB
Spotting red blood/dark brown blood
Elderly woman (post-menopausal)
What are the risk factors for endometrial cancer?
Nulliparity Late menopause/early menarche PCOS Unopposed oestrogen Tamoxifen Lynch syndrome Metabolic syndrome
What factors are protective for endometrial cancer?
Smoking
OCP
Multiparity
Exercise
How should you Ix PMB?
Pelvic & speculum examination (rule out cervical, vulval cancer etc.)
Transvaginal USS to measure endometrial thickness
What would you expect endometrial thickness to be in a postmenopausal woman?
Very thin
An endometrial thickness of what suggests abnormal tissue?
> 4cm or irregular lining may suggest cancer or polyp
Take a biopsy over this
How can you take an endometrial biopsy?
Pipelle
Warn patient of pain/discomfort
Aside from pelvic bimanual/speculum/transvaginal USS & biopsy what over Ix can you do if you suspect endometrial cancer?
Hysteroscopy (fibreoptic endoscope passed transcervically to view uterine cavity) under LA
Use if can’t use pipelle
What is atrophic endometrium?
What you’d expect from normal post-menopausal woman
Histology of biopsy should show little tissue, stroma & few RBCs
What will histology of endometrial adenocarcinoma show?
Lots of tissue & cells
Cribrinforming (=pierced with small holes, typical of malignant tissue)
Back to back glands
Enlarged, atypical nuclei
How do you treat endometrial adenocarcinoma?
Total abdominal hysterectomy (TAH) & bilateral salphinoophorectomy (BSO) & peritoneal washings
Can be performed laparoscopically
These are then sent to pathology
What are the pathological prognostic features?
Histological type Histological grade (more solid = higher grade, how aggressive it is/deviated from normal cells) Stage - how far it has extended throughout body (imaging) LVSI = lymph-vascular space invasion (buds/tubes of tumour cells in blood/lymph tissue, poor prognostic factor)
What are the two ways you can stage endometrial cancer?
Surgical/pathological (post biopsy)
MRI - depth of myometrial invasion, cervical involvement, LN involvement
What are the FIGO stages of endometrial cancer?
1A - inner half of myometrium 1B outer half of myometrium 2 - invades cervix 3A - serosa/adnexa 3B - vagina/parametrium 3C - pelvic/para-aortic nodes 4 - bladder/bowel/intra-abdominal/inguinal nodes
Endometrial cancer is split into two distinct groups. What is type 1?
Endometrial adenocarcinoma (commonest)
What are the risk factors for endometrial adenocarcinoma?
HRT with unopposed oestrogen
Obesity (greater oestrogen production)
What comes before endometrial adenocarcinoma?
Hyperplasia with atypical precursor lesion (gland forming, abnormal nuclei, overcrowding of glands)
Endometrial cancer is split into two distinct groups. What is type 2?
Uterine serous and clear cell carcinoma
High grade, more aggressive, worse prognosis
Who tends to get type 2 endometrial cancers?
Older ladies
What is the precursor to type 2 endometrial cancers?
Intraepithelial carcinoma precursor
What does adenocarcinoma mean?
Adeno = come from glandular tissue
Carcinoma means the cancer has started in a surface/inner lining of cells
What are the three types of endometrial cancer?
Endometroid adenocarcinomas - usually diagnosed early & treated successfully
Uterine serous carcinoma - fast growing/more likely to recur
Clear cell carcinoma - v. rare
How do you treat endometrial cancer?
Early - TAH/BSO/washings - maj done laparoscopically
+/- radiotherapy
High risk histology - chemo
Advanced stage - radio/palliation (if spread outwith uterus/patient not fit for surgery due obesity/comorbs) - progesterone
What are the ways of giving radiotherapy?
External beam Caesium insertion (intra-cavity/vault)
Most woman req. radio after surgery (internal & external)
What are the endometrial cancer cure rates?
Stage 1B - 85% –> stage 4 - 21%
What is the aetiology of endometrial cancer?
HIGH CIRCULATING OESTROGEN
Obesity Unopposed E2 therapy/tamoxifen PCOS Nulliparity Atypical endometrial hyperplasia HNPCC/Lynch type II familial cancer syndrome
Why is obesity a RF for endometrial cancer?
Fat cells convert hormones into a type of oestrogen
The more fat you have the more you build up the lining of the woman and the more risk there is for one of the cells to become cancerous
Why is tamoxifen a RF for endometrial cancer?
Tamoxifen is a hormonal therapy for some types of breast cancer
Thought to have similar effect as oestrogen on woman
Who gets unopposed oestrogen HRT?
Only those without a womb now as those with a womb need progesterone to protect against endometrial cancer
Why is PCOS a risk factor for endometrial cancer?
May be linked to hormone imbalance (also assoc. w insulin resistance, being overweight, DM which are all RFs for endometrial cancer)
Why is nulliparity a RF for endometrial cancer?
This along with late menopause/early menarche are prolonging the stimulation of the endometrium
What is lynch syndrome?
A hereditary cancer syndrome caused by mutation in the MMR genes
Those with lynch syndrome are at higher risk of developing what cancers?
Colorectal, gastric & endometrial
What are the symptoms of endometrial cancer?
Abnormal vaginal bleeding (heavy, prolonged, abnormal bleeding between periods)
PMB
What % of woman with PMB will have endometrial cancer?
8%
What else can cause OMB?
HRT Perimenopausal bleeding Atrophic vaginitis Polyps of cervix/endometrium Other cancers, e.g. cervix, vulva, bladder, anal
What is the prognosis of endometrial cancer for all stages?
78% 5ys
What stage do most woman with endometrial cancer present?
Stage 1
