endometrial cancer

Question 1

endometrial (uterine) cancer

Answer 1

80% are adenocarcinoma
oestrogen dependent cancer

50-60yrs, uncommon under 40 - in younger consider PCOS or Lynch syndrome
key RF = obesity + siabetes

Question 2

types of endometrial cancer

Answer 2

type 1 (80%) -> endometriod + mucinous carcinoma

type 2 (20%) -> serous + clear cell carcinoma

Question 3

type 1 endometrial cancer

Answer 3

endometriod + mucinous carcinoma
- atypical hyperplasia is precursor - related to unopposed oestrogen (dependent)
- often diagnosed at an early stage
- microstatellite instability - germline mutation of mismatch repair genes (Lynch syndrome)

Question 4

type 2 endometrial cancer

Answer 4

serous + clear cell
- serous intraepithelial carcinoma i precursor - NOT assoc with unopposed oestrogen
- effects elderly post-menopausal women
- *TP53 mutation + over expression
- spreads along fallopian tube mucosa + peritoneal surfaces - can present with extrauterine disease

-> more aggressive - more extensive surgery + adjuvant chemo/radio

Question 5

endometrial hyperplasia

Answer 5

a precancerous condition involving thickening of endometrium
- most return to normal over time - <5% become cancer
- px = abnormal bleeding
- also occurs with high oestrogen levels

3 types
- simple
- complex
- atypical hyperplasia

on histology = “cystic glandular hyperplasia” with or without atypia

Question 6

management of endometrial hyperplasia

Answer 6

progesterones
- IUS - mirena coil
- continuous oral progesterones

monitor for progression to atypia/malignancy

Question 7

risk factors for endometrial cancer

Answer 7

exposure to unopposed oestrogen (without progesterone)
- increased age, nulliparity, early menarche, late menopause
- oestrogen only HRT
- obesity - contains aromatase which converts androgens to oestrogen
- PCOS - lack of ovulation
- *tamoxifen - anti-oestrogenic effect on breast tissue but oestrogenic effect on endometrium

not assoc with oestrogen
- T2DM - increase insulin stimulating endometrial cells, PCOS also assoc with insulin resistance
- hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch

Question 8

protective factors for endometrial cancer

Answer 8

COCP
mirena coil
increased pregnancies
smoking - not protective in other oestrogen dependent cancers such as breast

Question 9

referral criteria for endometrial cancer

Answer 9

Postmenopausal bleeding (>12 months after last menstrual period)
o 2 week urgent referral

> =55 with unexplained vaginal discharge, visible haematuria and raised platelets, anaemia or elevated glucose levels
o Transvaginal US

Question 10

endometrial cancer investigation

Answer 10

1st = trans-vaginal US
o For endometrial thickness, normal = <4mm post menopause
o >4mm -> biopsy

• Pipelle biopsy
• Hysteroscopy with endometrial biopsy – gold standard

Suspect underlying Lynch
o Immunohistochemistry staining of tumour for mismatch repair proteins
o Test cancer tissue for microsatellite instability (MSI)

Question 11

staging endometrial cancer

Answer 11

• Stage 1 – confined to uterus
• Stage 2 – invades cervix
• Stage 3 – invades ovaries, fallopian tubes, vagina or lymph nodes
• Stage 4 – invades bladder, rectum or beyond pelvis

Question 12

management of endometrial cancer

Answer 12

• Localised – total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO)
• High risk – + post operative radiotherapy
• Radical hysterectomy – pelvic lymph nodes, surrounding tissues + top of vagina
• Frail women, unsuitable for surgery – progestogen therapy

Depends on stage, histological grade, and depth of myometrial invasion:
* Stage I - total hysterectomy and bilateral salpingo-oophorectomy
* Stage II - radical hysterectomy, may be offered adjuvant radiotherapy
* Stage III - maximal de-bulking surgery, additional chemotherapy is usually given prior to radiotherapy
* Stage IV - maximal de-bulking surgery, palliative approach is preferred (e.g. low dose radiotherapy)
* Type 2 tumours usually involve more extensive surgery and adjuvant chemo/radiotherapy is used more frequently

Question 13

Smooth muscle tumours

Answer 13

Leiomyoma (fibroid)
- Common
- Menorrhagia + infertility

Leiomyosarcoma
- Rare + poor prognosis
- Women >50
- Px = abnormal vaginal bleeding, palpable pelvic mass + pelvic pain

Question 14

cervical cancer

Answer 14

tends to affect younger women
- 80% squamous cell carcinoma, adenocarcinoma, small cell

strong assoc with HPV - 16+18 (responsible for 70%)

Question 15

risk factors of cervical cancer

Answer 15

risk of catching HPV - early sexual activity, increased number, not using condoms
non-engagement with cervical screening
*smoking
HIV
*COCP - poss due to decrease use of barrier
increased number of full term pregnancies
fam history

Question 16

CIN vs CGIN

Answer 16

CIN = preinvasive phase of squamous cervical carcinoma (70%)

CGIN = preinvasive phase of endocervical adenocarcinoma – harder to diagnose

Question 17

presentation of cervical cancer

Answer 17

lots asymptomatic
abnormal vaginal bleeding - intermenstrual, postcoital, postmenopausal
vaginal discharge
pelvic pain
dyspareunia

Question 18

cervical smear screening

Answer 18

o Every 5yrs
o Tested for high risk HPV – if negative, cells are not examined, considered neg
o Examined under microscope for dyskaryosis

o HPV neg – routine screening
o HPV pos with normal cytology – repeated HPV after 12 months
o HPV pos with abnormal cytology – colposcopy referral

Question 19

colposcopy

Answer 19

if HPV pos with abnormal cytology
o magnifies cervix

acetic acid stain – causes abnormal cells to appear white, occurs in cells with increased nuclear: cytoplasmic ratio

iodine test – healthy cells will go brown, abnormal cells will not stain

punch biopsy or LLETZ of transitional zone can be performed during colposcopy

o Ulceration, inflammation, bleeding, visible tumour
o Screened 6 months later for test of cure

Question 20

cervical cancer grading

Answer 20

cervical intraepithelial neoplasia (CIN)
- Grading for level of dysplasia of cells on cervix

• CIN I: mild dysplasia, affecting 1/3 of epithelial layer, likely to return to normal without treatment
• CIN II: moderate dysplasia, affecting 2/3 the thickness of epithelial layer, likely to progress to cancer if untreated
• CIN III: severe dysplasia, very likely to progress to cancer if untreated

Question 21

management of cervical cancer

Answer 21

<=stage 1a2
- preserve fertility –> LLETZ/cone biopsy
- family complete –> hysterectomy

stage 1b
- preserve fertility -> trachelectomy
- family complete -> trachelectomy

> 1b –> chemoradiotherapy

Question 22

LLETZ

Answer 22

LLETZ - Large loop excision of transformation Zone
o Can be performed with local anaesthetic during a loop colposcopy
o Loop of wire with diathermy to remove epithelial tissue of cervix

Question 23

trachelectomy

Answer 23

removal of
- cervix
- PM - parametrium
- cuff of vagina

(top of vagina + bottom of cervix)

Question 24

cervical cancer on microscopy

Answer 24

big rasionoid nucleus

Question 25

appearance of endometrioma on USS

Answer 25

ground glass echogenicity