Endometrial cancer Flashcards
List the causes of PMB
vaginal atrophy (60%) hormonal effect endometrial polyp endometrial hyperplasia endometrial cancer cervical cancer
For a woman presenting with PMB what is her risk of cancer?
3-20%
For a woman presenting with PMB what is her risk for endometrial hyperplasia?
5-15%
What would you tell a woman presenting with PMB regarding management?
Most likely benign cause 3-20% risk of cancer 5-15% risk of endometrial hyperplasia Modifiable risk factors should be modified Advise about the steps in investigation
In pre- menopausal bleeding what is the normal ET on TV USS?
<7mm is normal
TV USS useful to review structural anomalies
what is the ET cut off for TV USS in investigation of PMB?
3-4mm
Risk of cancer is <1% if the ET is less than cut off
What is the role of TVUSS in women on tamoxifen?
Women on Tamoxifen should only have TVUSS for investigation if they are symptomatic i.e. with PMB/PCB
Tamoxifen can cause thickened/cystic stripes
No cut off for TV USS - all symptoms should be investigated
What are the three principles for the management of hyperplasia?
Is there presence of atypia?
What are the women’ fertility wishes
What is the women’ suitability for surgery
For endometrial hyperplasia without atypia, what are the conservative management options used?
Weight loss Metformin LNG-IUD/Mirena Oral contraceptives cyclical progesterone
How would you justify conservative management of Endometrial hyperplasia without atypia?
Risk of progression to cancer is <5% in 20 years
Most regress spontaneously
Can just watch and wait
However much quicker regression if use progesterone treatment
What is the lifetime risk of uterine cancer?
1:45
What is the mainstay of management for uterine cancer?
Surgical resection
Radiation treatment reduces local recurrence but does not impact on survival
What are the risk factors of endometrial cancer?
Endometrial hyperplasia Obesity T2DM Hypertension Nulliparity Early menopause PCOS Tamoxifen treatment Familial syndromes (Lynch, Cowden) estrogen secreting tumours
What management steps would you take for a patient with endometrial cancer (lets say pipelle or D&C comes back with finding of invasive cancer)
Ca125 - high preoperative Ca125 associated with advanced disease
CT CAP (in Auckland we do MRI pelvis + CXR unless high grade known)
MDT
Confirmation of pathology
What are the intra-operative principles of staging an endometrial cancer?
Hysterectomy BSO (risk reduction ovarian ca)
+/- peritoneal washings (optional)
+/- pelvic +/- para-aortic lymph nodes
Minimally invasive surgery is an option
What are the management options for a confirmed endometrial cancer?
Surgical (first line) Conservative - for the surgically unfit - for women desiring fertility retention Medical - up front Chemo/Rad therapy in some scenarios Palliative
With regards to endometrial cancer, what is the current thoughts on lymphadenectomy?
Previously pelvic and para-aortic lymphadenectomy completed as standard
Now controversial - no survival benefit
apparent early endometrial cancer only associated with 19% LN positive
morbidity from lymphadenectomy ++
what are the complications associated with lymphadenectomy?
Intra-operative - vessel injury - nerve damage - VTE Post operative - Lymphocele (20%) - lymphoedema (1.5-28%) 60% report affect on ADLs - infection
During pelvic lymphadenectomy for endometrial cancer which nerves can be damaged?
Obturator
genitofemoral
What are the non surgical management options for endometrial cancer?
Rationale - only if cannot perform surgery or fertility preserving
Progestin therapy - LNG-IUD + oral progestin
repeat endometrial biopsies (3-6 monthly)
optimise medical problems (pre-operatively)
consider bariatric surgery
List 8 poor prognostic factors associated with endometrial cancer
Increasing age (>65) Stage (>1B) Increasing myoinvasion vascular invasion Tumour extension beyond fundus Grade 3 Histological subtypes (clear cell, serous, adenosquamous) tumour >2cm
Briefly describe LYNCH syndrome
most common form of hereditary colon cancer (1:1000 individuals)
Defect in DNA MMR genes (mismatch repair genes)
increased endometrial, ovarian, stomach, small intestine, hepatobiliary, ureter, brain and skin
50% present with Gynae cancer as their sentinel cancer
22% >stage 2
Briefly describe the Cowden syndrome
autosomal dominant mutation of PTEN
PTEN - tumour supressor gene
loss of function of PTEN contributes to oncogenesis
What are the key points for radiation treatment in endometrial cancer?
- Vaginal brachytherapy can be used to reduce the risk of local recurrence following surgical resection
- radiation therapy can be used for non surgically resectable disease
- used in palliative treatment to control symptom of bleeding
- used to treat recurrence
in what scenario would you consider radiation therapy for stage 1 endometrial cancer?
If >2 poor prognostic factors could consider vaginal brachytherapy
- if age >65
- deep myometrial invasion
- grade 3 disease
- serous or clear cell histology
- LVSI (lymph vascular space invasion)
what did the SEER study show with regard to stage 2 endometrial cancer and radiation therapy?
For patient with clinically overt and surgically resectable stage 2 disease the SEER study showed that when adjuvant radiotherapy was used for these patients there was an improved survival (post both simple and radical hysterectomy)
For stage 2 endometrial cancer when is radiation therapy considered appropriate?
- Could argue that following SEER study then all surgical resectable overt stage 2 disease would benefit
- if surgery is not considered feasible then full pelvic radiation therapy with intracavity brachytherapy may be employed
What are the short term side effects of Radiation therapy? ‘itis’
urinary - radiation cystitis
GI - enteritis, colitis, proctitis
Vaginal - ulceration, erythema, discharge, infection
Skin - erythema, moist desquamation
What follow up should women with endometrial cancer have?
NCCN guidelines:
physical exam every 3-6 months for 2-3 years, then 6-12 months
imaging as clinically indicated
patient education regarding symptoms or recurrence and sexual health
Ca 125 optional
Treatment of recurrence - MDT
How does recurrence of endometrial cancer present?
5-15% of patients with early stage disease with have a recurrence
75% of recurrence will occur in the vagina and present with bleeding
What are the long term side effects on the urinary tract of radiation therapy?
Urinary:
- bladder fibrosis
- haematuria
- ulceration
- pain
- UV and VV fistula
What are the long term side effects of radiation therapy on the Gut?
GI:
- chronic enteropathy (chronic diarrhoea and malabsorption)
- fibrosis - dysmotility or obstructive/ileus
- ulcerations
what are the vaginal side effects of radiation treatment long term?
- sexual dysfunction
- stenosis
- vaginismus
- adhesions
what are the long term side effects of radiation treatment?
- urinary - fibrosis, ulceration, reduced capacity, haematuria, pain
- GI - chronic enteropathy - malabsorption, diarrhoea
- vagina - stenosis, sexual dysfunction, ulceration
- ovaries - premature menopause
- bone - insufficiency fractures
- skin - hyperpigmentation, talangiectasia, fibrosis
What is the risk of malignancy in hyperplasia with atypia?
43% of cases showed invasive disease when hysterectomy performed
progression with atypia is quoted as 8% in 4yrs, 12% in 9 yrs nearly 30% after 19 yrs
What is the risk of malignancy in hyperplasia with atypia?
43% of cases showed invasive disease when hysterectomy performed
progression with atypia is quoted as 8% in 4yrs, 12% in 9 yrs nearly 30% after 19 yrs
