Endometrial Cancer

Question 1

The histologic feature of endometrial hyperplasia that is associated with the greatest risk of progression to invasive cancer is?

Answer 1

Nuclear Atypia

Question 2

What precent of Endometrial Cancer is Stage I at diagnosis?

Answer 2

70% of cases

Question 3

Treatment for Endometrial Hyperplasia?

Answer 3

Regression of hyperplasia has been observed in 80-90% of individuals receiving Medroxyprogesterone acetate (10 mg daily for 12-14 days/month) or micronized progesterone vaginal cream (100 mg for 12-14 days/month) when treated for 3 months

Question 4

Risk of co-existing low grade endometrial carcinoma with EIN?

Answer 4

30-50% of cases

most minimally invasive Grade 1

Question 5

Treatment for EIN?

Answer 5

Total Hysterectomy (w/ or w/out BSO)- provides definitive assessment of a possible concurrent carcinoma and effectively treats pre-malignant lesions

SUPRACERVICAL HYST IS UNACCEPTABLE

Question 6

Risk of concurrent endometrial carcinoma in women with EIN?

Answer 6

30-50%

(PPALND as a routine part of treatment for EIN would result in a large majority of patients being subjected unnecessarily to the risks associated with comprehensive surgical staging)

Question 7

Protective Factors for Type 1 Em Ca?

Answer 7

Smoking
Breastfeeding
Increasing parity
Progestin contraceptives

Question 8

What does grade indicate for Em Ca?

Answer 8

how much solid component does it have (would expect most of it to be glandular)

Grade 1 → < 5% solid component
Grade 2 → 6-50% solid component
Grade 3 → > 50% solid component

Question 9

Treatment of Em Ca?

Answer 9

Everyone gets surgery!

Removal of uterus, cervix, adnexa, PPALND, washings

Question 10

FIGO Em Ca Stage I

Answer 10

Confined to Uterus

IA: < 50% myometrial invasion

IB: > 50% myometrial

Question 11

FIGO Em Ca Stage II

Answer 11

Invades cervical STROMA (not glands)

Question 12

FIGO Em Ca Stage III

Answer 12

Local/regional spread

3A: Serosa or adnexa
3B: Vaginal or parametrial involvement
3C: PPALN
3C1 -pelvic
3C2 - paraaortic

Question 13

FIGO Em Ca Stage IV

Answer 13

4A: Bladder/Bowel invasion
4B: Distant Mets

Question 14

Which Em Ca patients should receive radiation after surgery?

Answer 14

Stage I w/

• Grade 2
• Grade 3
• Depth of invasion to outer third
• LVSI

Question 15

Most common type of uterine sarcoma?

Answer 15

Uterine leiomyosarcoma

Question 16

EIN diagnosed on in office biopsy…. what to do next?

Answer 16

Rule out concurrent Em Ca w/ hysteroscopy

Prevent progression to Em Ca

Refer to Gyn Onc for surgical management (preferred)

Surgery for EIN by Generalist:
- TLH w/ or w/out BSO, peritoneal washings
- NO SUPRACERVICAL
- NO MORECELLATION
- Counsel patient on need for additional surgery if endometrial cancer diagnosed

Question 17

Surgical treatment for EIN?

Answer 17

Preferably TLH by Onc

If done by generalist:
- Get washings
- Take cervix
- Don’t morcellate
- Counsel on possible additional procedures

Question 18

Medical treatment for benign hyperplasia?

Answer 18

Medroxyprogesterone 20 mg daily

Micronized progesterone 200 mg daily

LNG 52 mg IUD

Combo OCPs

**Continue to sample Q3-6 months until normal

**If risk factors remain can continue indefinitely

Question 19

Medical management of EIN(AEH)?

Answer 19

Optimal dose, treatment duration, and length of follow-up has not been determined!!

MUST do hysteroscopic sampling to r/o Em Ca

Megace 40-200 mg/d
LNG 52 mg IUD (highest rate of regression)
Medroxyprogesterone 20 mg daily
DMPA 150 mg q 3 months
Micronized progesterone 200 mg/daily

Question 20

Highest rate of regression with medical management of EIN(AEH)?

Answer 20

LNG 52 mg IUD

Question 21

When would GYN onc consider medical therapy for Em Ca?

Answer 21

Desire to preserve fertility or poor surgical candidate

pre menopausal

Stage I well differentiated (no myometrial invasion), Grade 1 endometrioid adenocarcinoma

IUD, Megace, Provera for 6 months

When done child bearing- then hyst!

Question 22

Post treatment follow up for Em Ca?

Answer 22

H&P + recto/vaginal exam

Every 3 months for 2 years
Every 6 months for 3 years
Annually

Pelvic exam to identify local recurrence