Endometrial cancer

Question 1

What are 3 cancers that can arise in the uterus?

Answer 1

Endometrial (most)
Sarcoma
Leiomyosarcoma

Question 2

What is the risk of endometrial hyperplasia without atypia progressing to endometrial cancer? How should these patients be managed?

Answer 2

<5% over 20y
Majority regress spontaneously
LNG IUS/ Progesterone

6 monthly repeat EB
x 2 -ve: discharge (high risk do yearly EB)
Still bleeding/ no regression: TLH/ TAH +/- BSO

Question 3

What is the risk of endometrial hyperplasia with atypia progressing? How should these patients be managed?

Answer 3

23-48%
Offer TLH/ TAH +/- BSO

If wanting to conceive, regression should be achieved on at least 1 EB before attempting

Question 4

What is endometrial hyperplasia?

Answer 4

proliferation of endometrial glands resulting in a greater gland-to-stroma ratio than in normal endometrium.
a/w progression to adenocarcinoma

Question 5

What stimulates endometrial hyperplasia?

Answer 5

Oestrogen when unopposed by progesterone, binding to oestrogen receptors in nuclei of endometrial cells

Question 6

How does high BMI contribute to endometrial hyperplasia?

Answer 6

Excess peripheral conversion of androgens to oestrogen

Question 7

What are 7 risk factors for endometrial cancer?

Answer 7

Metabolic syndrome:
Overweight + obesity
PCOS (anovulation)
DM/ Insulin resistance

Excess oestrogen:
Nulliparity
Early menarche
Late menopause
Unopposed oestrogen HRT

Age >50 years

Endometrial hyperplasia

Tamoxifen

FH of endometrial/ breast/ ovarian cancer

Hereditary non-polyposis colorectal cancer

Question 8

Give 3 protective factors against endometrial cancer

Answer 8

Multiparity
COCP
Smoking

Question 9

Summarise the epidemiology of endometrial cancer.

Answer 9

Most common gynae tumour in developed world.

6th most common cancer overall in women.

Question 10

What is the classic symptom of endometrial cancer?

Answer 10

PMB
Usually slight + intermittent before getting heavier

Question 11

How may a pre-menopausal woman present with endometrial cancer?

Answer 11

Menorrhagia
IMB

Question 12

What does endometrial cancer RARELY present with?

Answer 12

Pain- signifies extensive disease

Question 13

What does endometrial cancer present with on physical examination?

Answer 13

Uterine mass, fixed uterus, or adnexal mass indicating extra-uterine disease

Question 14

What are the investigations for endometrial cancer?

Answer 14

TVUSS
Hysteroscopy with endometrial biopsy + histopathology
MRI/ CTCAP with contrast
FBC: anaemia/ coagulation disorders
Discussion in MDT

Question 15

What action needs to be taken depending on TVUSS findings?

Answer 15

Postmenopausal endometrial thickness
>4mm: Endometrial biopsy
<4mm: biopsy not routine, consider for persistent/ recurrent Sx

Question 16

Give 3 indications for endometrial biopsy in postmenopausal women

Answer 16

Endometrial lining >4mm
Endometrial lining cannot be adequately visualised
Endometrial lining <4mm but clinical features of cancer persist

Question 17

Give 3 indications for endometrial biopsy in premenopausal women

Answer 17

> 45y
Persistent/ recurrent AUB despite Tx
Hx of unopposed oestrogen exposure

Question 18

What investigations would be performed to exclude differentials in endometrial cancer?

Answer 18

TVUSS: endometriosis, endometrial polyp
EB: endometrial hyperplasia
Smear: cervical cancer

Question 19

What therapy may be used for frail elderly women with endometrial cancer?

Answer 19

Progestogen therapy

Question 20

What staging system is used for endometrial cancer?

Answer 20

FIGO
I: limited to body of uterus
II: cervical involvement
III: spread within pelvis
IV: involvement of rectum/ bladder/ distant mets

Question 21

How does treatment vary for each stage of endometrial cancer?

Answer 21

I: TAH +BSO or LNG-IUS
II: Radical hysterectomy + LN assessment
III: max. debulking surgery + chemo + radio
IV: max. debulking surgery / palliative approach- radio/ progesterone

Question 22

Summarise the prognosis for patients with endometrial cancer.

Answer 22

5y survival rate for endometrial cancer by stage at dx is:

• Localised (confined to uterus): 95%
• Regional (disease spread regional LN): 69.4%
• Distant (metastatic disease): 17.3%
• Unstaged: 53.2%.

Question 23

Identify 7 possible complications of endometrial cancer and its management.

Answer 23

Menopausal Sx: if pre-menopausal BSO

Bladder instability following surgery: pain, incontinence

Vaginal stenosis, atrophy, + fibrosis following radiotherapy

Long-term sexual dysfunction following tx

Local or distant spread

Lymphoedema

Toxicity a/w chemotherapy