Endometrial Cancer

Question 1

Endometrial cancer is a disease in which malignant (cancer) cells form in the tissues of the endometrium. What is the incidence of endometrial cancer?

1 - 3000 cases per 100,000
2 - 300 cases per 100,000
3 - 30 cases per 100,000
4 - 3 cases per 100,000

Answer 1

3 - 30 cases per 100,000

Question 2

Endometrial cancer is a disease in which malignant (cancer) cells form in the tissues of the endometrium. What age does the incidence of endometrial cancer peak?

1 - 70-80
2 - 60-70
3 - 50-60
4 - 4050

Answer 2

2 - 60-70

Question 3

What is the definition of post-menopausal?

1 - women who is amenorrhea and >50
2 - women with amenorrhea for >1 year
3 - women with amenorrhea for >2 years
4 - women with amenorrhea and >45

Answer 3

2 - women with amenorrhea for >1 year
- can occur between 45-55 years old
- average age is 51

Question 4

Post-menopausal bleeding (PMB) is defined as uterine bleeding occurring after at least one year of amenorrhea, without any contributory factor for amenorrhea. How common is endometrial cancer in patients with PMB?

1 - 1-2%
2 - 1-14%
3 - 15-35%
4 - >35%

Answer 4

2 - 1-14%

Question 5

Post-menopausal bleeding (PMB) is defined as uterine bleeding occurring after at least one year of amenorrhea, without any contributory factor for amenorrhea. Which of the following are common causes of PMB that are not due to endometrial cancer?

1 - genital tract atrophy
2 - endometrial polyps
3 - postmenopausal hormone therapy (HRT)
4 - all of the above

Answer 5

4 - all of the above

• genital tract atrophy is by far the most common

Question 6

Which of the following are risk factors for endometrial cancer?

1 - tamoxifen
2 - estrogen only contraception
3 - obesity
4 - age
5 - annovulation or lots of periods
6 - nulliparity
7 - hereditary non-polyposis colorectal cancer syndrome (Lynch syndrome)
8 - unopposed oestrogen stimulation (PCOS)
9 - all of the above

Answer 6

9 - all of the above

Unopposed estrogen is by far the biggest stimulator of hyperplasia of uterus

• tamoxifen stimulates oestrogen receptors in uterus
• fat converts adrenal precursors into sex hormones such as oestrogen

Question 7

A patient comes to the clinic and you suspect endometrial cancer based on the patients history. Which of the following should be the 1st line?

1 - transvaginal ultrasonography
2 - pelvic examination
3 - hysteroscopy
4 - pipelle endometrial biopsy
5 - laperoscopy

Answer 7

2 - pelvic examination
- includes visual, bimanual and speculum examination

all of the others would still occur depending on the findings

Question 8

Which of the following is NOT a protective factor that reduces the risk of endometrial cancer?

1 - multiparity
2 - combined oral contraceptive pill
3 - smoking
4 - breastfeeding
5 - lots of periods
6 - regular exercise

Answer 8

5 - lots of periods
- can actually increase risk of endometrial cancer as would result in lots of endometrial hyperplasia

COC is protective because it has progesterone as well as oestrogen

Question 9

Patients with endometrial cancer may present with a history of all the following, EXCEPT which one?

1 - post-menopausal bleeding (up to 90%)
2 - bleeding 12 months after menstruation has stopped as a result of menopause
3 - recent onset menorrhagia (particularly in women >45 years old.)
4 - boggy uterus
5 - irregular or inter menstrual bleeding in premenopausal women.

Answer 9

4 - boggy uterus

Common in fibroids

Question 10

If you suspect a patient has endometrial cancer, a bimanual examination should be performed. Which of the following would NOT commonly be found?

1 - uterine mass or enlarged uterus
2 - fixed uterus
3- adnexal masses
4 - strawberry cervix

Answer 10

4 - strawberry cervix

Common in the protozoan Trichomonas vaginalis (T. vaginalis).

Adnexal mass suggest extra-uterine disease

Question 11

If a patient presents to the GP with symptoms suggestive of endometrial cancer, which of the following patients should be referred on a 2-week wait according to NICE guidelines?

1 - peri-menopausal with spotting
2 - post-menopausal aged >55, unexplained vaginal bleeding for >12 months
3 - 45 year old women with intermenstrual bleeding
4 - all of the above

Answer 11

2 - post-menopausal aged >55, unexplained vaginal bleeding for >12 months

Question 12

According to NICE guidelines, in addition to 12 months of unexplained vaginal bleeding in women >55, which of the following symptoms should prompt a 2 week referral in a post-menopausal bleeding?

1 - vaginal discharge with 1st VTE
2 - vaginal discharge with thrombocytosis for the 1st time
3 - vagainal discharge with visble haematuria, low Hb and high blood glucose
4 - all of the above

Answer 12

4 - all of the above

Low Hb is blood loss
Thrombocytosis can be due to malignancy

Question 13

A women presents to the gynaecologist and they suspect endometrial cancer. Order the following in order of investigations that would typically be performed?

1 - transvaginal ultrasonography
2 - pelvic examination
3 - hysteroscopy
4 - pipelle endometrial biopsy
5 - CT scan

Answer 13

2 - pelvic examination
4 - pipelle endometrial biopsy
1 - transvaginal ultrasonography
3 - hysteroscopy
5 - CT scan

• for ultrasound and pipelle, patients typically would have an endometrial thickness >5mm

Question 14

An endometrial cancer greater than what is 96% probability of endometrial cancer?

1 - >2mm
2 - >5mm
3 - >10mm
4 - >20mm

Answer 14

2 - >5mm

Question 15

Which of the following is the gold standard reference for the for the evaluation of the endometrial cavity that would be used if a patient >55 has vaginal bleeding and a suspected endometrial thickness >5mm?

1 - transvaginal ultrasonography
2 - pelvic examination
3 - hysteroscopy
4 - pipelle endometrial biopsy
5 - CT scan

Answer 15

3 - hysteroscopy

• diagnostic and therapeutic through dilatation and curettage (may need general anaesthesia if pain is too much)

CT chest, abdomen and pelvis: useful for staging if significant, advanced disease is suspected.

Question 16

What is the most common gynaecological cancer in the UK?

1 - breast
2 - cervical
3 - ovarian
4 - endometrial

Answer 16

4 - endometrial
- around 34% incidence

Question 17

What is a pre-invasive lesion of the endometrium?

1 - growth of a fibroid on endometrium
2 - growth of a polyp on endometrium
3 - histological and molecular alterations of the endometrium
4 - post menopausal bleeding with pain

Answer 17

3 - histological and molecular alterations of the endometrium
- related to high-risk of uterine carcinoma development

Question 18

What is endometrial hyperplasia?

1 - thinning of the endometrium
2 - thickening of the endometrium
3 - abnormal cells develop on the endometrium

Answer 18

2 - thickening of the endometrium
- hyperplasia means to increase cell number

Question 19

Endometrial hyperplasia is thickening of the endometrium. When unopposed, which hormone drives endometrial hyperplasia?

1 - estrogen
2 - progesterone
3 - human chorionic gonadotrophin hormone
4 - testosterone

Answer 19

1 - estrogen
- unopposed continues secretion

Question 20

Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed estrogen. There are 2 types of endometrium hyperplasia, what are they?

1 - simple hyperplasia
2 - mixed hyperplasia
3 - complex hyperplasia
4 - combined hyperplasia

Answer 20

1 - simple hyperplasia
- proliferative lesion of glands of irregular size and shape and increases gland:stroma ratio

3 - complex hyperplasia
- proliferative lesion of glands with severe glandular complexity and crowding as well as minimal stroma between glands

Question 21

Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed secretion of estrogen. Would the combined pill cause endometrial hyperplasia?

Answer 21

• no
• estrogen is not unopposed as there is progesterone as well

Question 22

Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed secretion of estrogen. There are 2 types of endometrial hyperplasia:

1 - simple hyperplasia = proliferative lesion of glands of irregular size and shape and increases gland:stroma ratio

2 - complex hyperplasia = proliferative lesion of glands with severe glandular complexity and crowding as well as minimal stroma between glands. This can include atypical and complex, with the latter being cancerous.

If a patient has simple non-atypical endometrial hyperplasia, which has a progression rate of 1–3%, what treatment could you provide?

1 - estrogen
2 - GnRH
3 - high dose progesterone
4 - high dose androgens

Answer 22

3 - high dose progesterone

• clinically Intrauterine system, which secretes progesterone only would preferably be implanted for 5 years and then removed

Question 23

Why is obesity associated with endometrial hyperplasia?

1 - total cholesterol contributes to cell hyperplasia
2 - insulin like growth factor is raised in obesity and causes hyperplasia
3 - increased gluconeogenesis occurs in obesity and is linked with cellular hyperplasia
4 - adipocytes convert the precursor of estrogen, esteron into estrogen

Answer 23

4 - adipocytes convert the precursor of estrogen, esteron into estrogen
- adipose tissue converts estrone sulfate to estrone, and estrone to estradiol
- essentially too much estrogen again

Question 24

A pre-invasive lesion of the endometrium is a histopathological and molecular alteration to the endometrium, which is related to high-risk of uterine carcinoma development. Does the gland to stroma ratio in the endometrium increase or decrease? (normal endometrium can be seen in the image below)

Answer 24

• gland:ratio increases
• it is endometrial glands that are associated with endometrial cancer

Question 25

Endometrial hyperplasia is thickening of the endometrium, driven primarily by estrogen. There are 2 types of endometrium hyperplasia:

1 - simple hyperplasia = proliferative lesion of glands of irregular size and shape and increases gland:stroma ratio

2 - complex hyperplasia = proliferative lesion of glands with severe glandular complexity and crowding as well as minimal stroma between glands

What is the single most important prognostic factor for progression to carcinoma?

1 - cytology looking for aytipia (abnormal cells)
2 - blood sample
3 - colposcopy
4 - muscle biopsy

Answer 25

1 - cytology looking for aytipia (abnormal cells)
- most important prognostic factor for progression to carcinoma

Question 26

How is polycystic ovary syndrome (PCOS) associated with endometrial hyperplasia?

1 - increase LH, increased androstenedione converted into estrogen
2 - insulin like growth factor is raised in obesity and causes hyperplasia
3 - increased gluconeogenesis occurs in obesity and is linked with cellular hyperplasia
4 - adipocytes convert excess

Answer 26

1 - increase LH, increased androstenedione converted into estrogen

• PCOS associated with low FSH and increased LH
• increased LH causes theca cells to express too much androstenedione
• androstenedione moves into adipocytes and is converted to estrone and then estradiol
• excessive unopposed estrogen increases the risk of endometrial hyperplasia

Question 27

In addition to the common pelvic examination, pipelle endometrial biopsy, transvaginal ultrasonography, hysteroscopy and CT scan, which of the following can also be used if a patient has suspected endometrial cancer?

1 - CT of chest, abdomen, and pelvis
2 - MRI pelvis and abdomen
3 - PET Scan
4 - all of the above

Answer 27

4 - all of the above
- all are used to stage cancer incase of metastasis

Question 28

Based on the International Federation of Gynaecology and Obstetrics (FIGO) what is stage 1 endometrial cancer?

1 - Tumour with Local and regional spread of Tumour
2 - Tumour invades cervical stroma but does not extend beyond uterus
3 - Tumour confined to the corpus uterus
4 - Tumour invades the bladder/bowel mucosa/distant metastasis

Answer 28

Tumour confined to the corpus uterus
- IA: No/ <50% myometrial invasion
- IB: ≥50% myometrial invasion

Question 29

Based on the International Federation of Gynaecology and Obstetrics (FIGO) what is stage 2 endometrial cancer?

1 - Tumour with Local and regional spread of Tumour
2 - Tumour invades cervical stroma but does not extend beyond uterus
3 - Tumour confined to the corpus uterus
4 - Tumour invades the bladder/bowel mucosa/distant metastasis

Answer 29

2 - Tumour invades cervical stroma but does not extend beyond uterus

Question 30

Based on the International Federation of Gynaecology and Obstetrics (FIGO) what is stage 3 endometrial cancer?

1 - Tumour with Local and regional spread of Tumour
2 - Tumour invades cervical stroma but does not extend beyond uterus
3 - Tumour confined to the corpus uterus
4 - Tumour invades the bladder/bowel mucosa/distant metastasis

Answer 30

1 - Tumour with Local and regional spread of Tumour

• IIIA: Involvement of serosa of uterus
• IIIB: Involvement of vagina and/or parametrium
• IIIC: Metastasis to pelvic and/or para-aortic lymph node

Question 31

Based on the International Federation of Gynaecology and Obstetrics (FIGO) what is stage 4 endometrial cancer?

1 - Tumour with Local and regional spread of Tumour
2 - Tumour invades cervical stroma but does not extend beyond uterus
3 - Tumour confined to the corpus uterus
4 - Tumour invades the bladder/bowel mucosa/distant metastasis

Answer 31

4 - Tumour invades the bladder/bowel mucosa/distant metastasis

• IVA: Tumour invasion of the bladder and or bowel mucosa
• IVB: distant metastasis which includes intra-abdominal metastases and or inguinal lymph nodes

Question 32

In all stages of endometrial cancer, what is the primary treatment of choice?

1 - surgery
2 - chemotherapy
3 - radiotherapy
4 - hormonal therapy

Answer 32

1 - surgery
- used for staging and curative purposes
- only curable if detected early

• therapy is typically a combination of all 4 of these

Question 33

If surgery is performed, all of the following are options, depending on the severity:

• total abdominal hysterectomy+ Bilateral salpingo-oophorectomy
• peritoneal cytology
• omental biopsy
• pelvic node dissection (lymphadenectomy) and/or sentinel lymph node mapping for surgical staging in uterine-confined disease
• para-aortic nodal evaluation for staging of select high-risk tumour
• removal of intraperitoneal disease if found at the time of surgery

Answer 33

The non-pelvic tissues are common locations for metastatic disease

Question 34

A 70 year old woman with a BMI of 30 attends ambulatory care with 1/52 of a painful and swollen R calf
o/e tender, swollen R calf 3cm larger than the L leg with pitting odema, no signs of infection. No hx of cancers, flights, immobility, recent surgery or previous blood clots. 2-level Wells score gives the patient a score of 2 and d-dimer is raised. Which 2 of the following should be performedf?

1 - calf ultrasound and repear d-dimer
2 - calf ultrasound and CTPA
3 - begin DOAC and ultrasound calf
4 - repeat d-dimer and begin DOAC

Answer 34

3 - begin DOAC and ultrasound calf

This is defined as an unprovoked DVT.

Question 35

If a 70 year old patient has an unprovoked DVT, they need to be investigated. The patient tells you she had some intermittent vaginal bleeding, is diabetic and has a BMI of 30. She also has the following:

• microcytic anaemia
• thickened endometrium following transvaginal ultrasound

Which of the following is the most likley diagnosis?

1 - cervical cancer
2 - endometriosis
3 - ovarian cancer
4 - endometrial cancer

Answer 35

4 - endometrial cancer

She has lots of risk factors

Endometrial cancer can be confirmed using hysteroscopy and a sample taken for histology confirms the diagnosis

Question 36

A 70 year old female has been confirmed as having the following:

• imaging confirms no distant metastases - malignancy in endometrium and in the right fallopian tube

What stage of endometrial cancer is this?

1 - stage I
2 - stage II
3 - stage III
4 - stage IV

Answer 36

3 - stage III

Question 37

If a patient has chemotherapy, they may be at increased risk of neutropenic sepsis. Which of the following is NOT one of the sepsis 6?

1 - take blood sample
2 - take lactate sample
3 - measure urine output
4 - take lumbar puncture sample
5 - give antibiotics
6 - give oxygen
7 - give fluid challenge

Answer 37

4 - take lumbar puncture sample

Question 38

If someone is suspected of having neutropenic sepsis, how quickly should the sepsis 6 be completed?

1 - <30 mins
2 - <60 mins
3 - <120 mins
4 - <360 mins

Answer 38

2 - <60 mins

If suspect sepsis do not hold back on any of the sepsis 6, even if patient appears well

Question 39

If a patient has neutropenic sepsis, what treatment can be given in an attempt to raise the neutrophil count?

1 - Granulocyte colony stimulating factor (GCSF)
2 - Erythropoietin
3 - Anti-diuretic hormone
4 - All of the above

Answer 39

1 - Granulocyte colony stimulating factor (GCSF)

MUST STOP ONCE NEUTROPHIL COUNT IS >1