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Gynaeoncology > Endometrial > Flashcards

Endometrial Flashcards

1
Q

Postmenopausal bleeding aetiology

A 
Most common cause is atrophy 60-80%
Exogenous oestrogen 15-25%
Endometrial hyperplasia 10%
Endometrial cancer 10%
Cervical/Endometrial polyps 2-12%
Cervical cancer 1%
Other
	Vaginal trauma
	Anticoagulants
	Bleeding from non-gynae sites
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2
Q

Incidence PMB

A

5% of gynae OPC presentation

4-11% of postmenopausal women will experience bleeding

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3
Q

Investigations PMB

A

TVUSS
Endometrial biopsy
- pipelle50% of endometrium, 99% sensitive hyperplasia , 81% Ca
- hyst D&C sample 70% cavity

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4
Q

Management atrophy

A

top estrogen daily 2 weeks, twice weekly thereafter

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5
Q

Endometrial hyperplasia in postmenopausal women

A

Progesterones or hysterectomy

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6
Q

Lymphatic drainage endometrial ca

A

Lymphatic drainage

- Infundibulopelvic (uteroovarian)
- Parametrial
- Presacral

	○ They collectively drain into the internal iliac --> external iliac --> common iliac --> presacral --> para-aortic
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7
Q

Metastastatic sites

A

Ovary
Vagina
Lungs

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8
Q

FIGO Staging

A 
1 - Confined to the uterus
	1A <50%myometrial invasion
	1B >50% myometrial invasion
2 - Tumour invades cervical stroma, but does not extend beyond the uterus
3 - Local/Regional spread
	3A Serosal +/- adnexae invasion
	3B Vagina/parametrium invasion
	3C Pelvic or para-aortic lymph nodes
4 - Distant invasion
	4A Bladder/bowel
	4B Distant metastases (abdominal organs, inguinal nodes)
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9
Q

Stage 1

A

1 - Confined to the uterus
1A <50%myometrial invasion
1B >50% myometrial invasion

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10
Q

Stage 2

A

2 - Tumour invades cervical stroma, but does not extend beyond the uterus

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11
Q

Stage 3

A

3 - Local/Regional spread
3A Serosal +/- adnexae invasion
3B Vagina/parametrium invasion
3C Pelvic or para-aortic lymph nodes

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12
Q

Stage 4

A

4 - Distant invasion
4A Bladder/bowel
4B Distant metastases (abdominal organs, inguinal nodes)

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13
Q

Lifetime risk endometrial Ca

A

1:45

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14
Q

Cumulative risk endometrial Ca

A

1.6%

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15
Q

Histopathological types

A 
- Endometrioid carcinoma
		○ Adenocarcinoma and variants
	- Mucinous adenocarcinoma
	- Serous adenocarcinoma
	- Clear cell adenocarcinoma
	- Undifferentiated adenocarcinoma
	- Neuroendocrine tumours
	- Mixed carcinoma
	- Mixed epithelial and mesenchymal tumours - 
		○ Adenomyoma
		○ Adenofibroma
		○ Adenosarcoma
Carcinosarcomas malignant and aggressive
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16
Q

Histological Grading

A

GX: Grade cannot be assessed.
G1: Well differentiated.
G2: Moderately differentiated.
G3: Poorly or undifferentiated.

17
Q

Stage 1 A (Grade 1-2)

A

Hysterectomy + BSO

no adjuvant therapy required and survival rate 96% at 5years

18
Q

Stage 1-2 with Grade 3 disease

A

Hysterectomy + BSO

Radiotherapy reduces pelvic recurrence with no change in survival (vaginal brachytherapy)

19
Q

Stage 3

A

Hysterectomy +BSO
Radiotherapy +/- chemotherapy
If not surgically resectable, then primary radiotherapy +/- chemotherapy +/- delayed surgical resection of residual disease

20
Q

Stage 4

A 
Hysterectomy +BSO
Neoadjuvent chemo (platinum based)
		Doxorubicin (most toxic), cisplatin, carboplatin, paclitaxel (various combinations)
21
Q

Recurrence

A
  • 75% recurrence is in the vaginal vault.
    • 75% recurrence is symptomatic
    • Radiotherapy - brachytherapy has replaced external beam radiation as less adverse effects and similar survival
    • Usual reason for inoperable is morbid obesity or severe cardiopulmonary disease
      ○ Uterine brachytherapy in these women can achieve cure in 70%
      Chemotherapy is used for serous cancers
22
Q

Indications for radiotherapy

A
  • To reduce local recurrence after surgical resection
    • Neoadjuvant treatment in non-surgically resectable disease
    • Palliative treatment - symptomatic control of bleeding
    • Treatment of recurrence
23
Q

Follow up

A
  • Physical examination 3-6monthly for 2-3 years
    • CA125 optional
    • Imaging as clinically indicated
    • Patient information - symptoms of recurrence, sexual health
      Treatment of recurrence - MDT
24
Q

Definition of endometrial hyperplasia

A

irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio when compared with proliferative endometrium

Endometrial cell growth is stimulated by binding to estrogen receptors in the nuclei of endometrial cells

25
Q

Risk factors hyperplasia

A
  • AGE!
    • Unopposed estrogen
      ○ Obesity
      ○ PCOS
      ○ HRT (estrogen only) or tamoxifen
      ○ Perimenopause (anovulation like PCOS)
      ○ Oestrogen secreting ovarian tumours (granulosa cell)
    • Nulliparity
    • Early menarche and late menopause
    • T2DM
    • Hypertension
    • Lynch Syndrome (HNPCC)
26
Q

Protective factors endometrial hyperplasia

A

-higher age at last birth
- Smoking
- Contraceptive (COC or POP)
- Breastfeeding
- Exercise
Coffee and tea

27
Q

Investigation TV USS hyperplasia

A

TV USS thickness <7mm in premenopausal woman- very unlikely hyperplasia
<4mm PMB unlikely hyperplasia (<1%)

28
Q

Endometrial hyperplasia risk of progression to Ca

A

<5% over 20 years

29
Q

Endometrial hyperplasia WITH ATYPIA % risks

A

43% already concurrent cancer
29% progress to cancer <19years
8% progress to cancer <8years
4% risk concurrent ovarian ca

30
Q

Management hyperplasia without atypia

A
  1. Progesterone
    Higher regression rates 89-96% cf observation
    i. Mirena – 1st line
    ii. Continuous PO progesterone e.g. medroxyprogesterone 10-20mg/day or norethisterone 10/15mg/day
  2. Address risk factors
  3. Observation with endometrial biopsy surveillance
    Regression rate 74.2 – 81%
31
Q

Management hyperplasia with atypia

A

Hysterectomy

BSO / BS depending on risk and menopausal status

32
Q

If atypia and fertility desired

A

Counsel RE risk of progression to endometrial cancer
Investigations to rule out invasive endometrial Ca or co existing ovarian Ca
Review in MDM
1. Mirena – 1st line
2. PO Progesterone
2. 3 monthly biopsy, once 2x negative then 6-12 monthly until hysterectomy once fertility no longer required

Gynaeoncology (7 decks)

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