endometrial cancer Flashcards
endometrial (uterine) cancer
80% are adenocarcinoma
oestrogen dependent cancer
50-60yrs, uncommon under 40 - in younger consider PCOS or Lynch syndrome
key RF = obesity + siabetes
types of endometrial cancer
type 1 (80%) -> endometriod + mucinous carcinoma
type 2 (20%) -> serous + clear cell carcinoma
type 1 endometrial cancer
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)
type 2 endometrial cancer
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
endometrial hyperplasia
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
management of endometrial hyperplasia
progesterones
- IUS - mirena coil
- continuous oral progesterones
monitor for progression to atypia/malignancy
risk factors for endometrial cancer
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
protective factors for endometrial cancer
COCP
mirena coil
increased pregnancies
smoking - not protective in other oestrogen dependent cancers such as breast
referral criteria for endometrial cancer
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
endometrial cancer investigation
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)
staging endometrial cancer
- 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
management of endometrial cancer
- 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
Smooth muscle tumours
Leiomyoma (fibroid)
- Common
- Menorrhagia + infertility
Leiomyosarcoma
- Rare + poor prognosis
- Women >50
- Px = abnormal vaginal bleeding, palpable pelvic mass + pelvic pain
cervical cancer
tends to affect younger women
- 80% squamous cell carcinoma, adenocarcinoma, small cell
strong assoc with HPV - 16+18 (responsible for 70%)
risk factors of cervical cancer
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
CIN vs CGIN
CIN = preinvasive phase of squamous cervical carcinoma (70%)
CGIN = preinvasive phase of endocervical adenocarcinoma – harder to diagnose
presentation of cervical cancer
lots asymptomatic
abnormal vaginal bleeding - intermenstrual, postcoital, postmenopausal
vaginal discharge
pelvic pain
dyspareunia
cervical smear screening
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
colposcopy
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
cervical cancer grading
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
management of cervical cancer
<=stage 1a2
- preserve fertility –> LLETZ/cone biopsy
- family complete –> hysterectomy
stage 1b
- preserve fertility -> trachelectomy
- family complete -> trachelectomy
> 1b –> chemoradiotherapy
LLETZ
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
trachelectomy
removal of
- cervix
- PM - parametrium
- cuff of vagina
(top of vagina + bottom of cervix)
cervical cancer on microscopy
big rasionoid nucleus
appearance of endometrioma on USS
ground glass echogenicity
