Endometrial cancer Flashcards
What are the types of endometrial cancer?
Type 1: endometrioid: most common, 75% of endometrial cancers. associated w/ EIN precursor. global process, unopposed estrogen, better prognosis.
Type 2: clear cell/papillary serous (high grade)
- poorer prognosis, more focal in origin. EIN also a precursor.
What are the types of endometrial hyperplasia?
Simple hyperplasia without atypia (aka benign hyperplasia): 1% malignancy risk
Complex hyperplasia without atypia (aka benign hyperplasia): 3% malignancy risk
Simple hyperplasia with atypia (endometrial intraepithelial neoplasia/EIN - premalignant): 10% malignancy risk
Complex hyperplasia with atypia (endometrial intraepithelial neoplasia/EIN - premalignant): 30% malignancy risk
What is the treatment for EIN?
surgery w/ total hysterectomy preferred. NO supracervical hyst
Medical management if hyst not feasible (poor candidate or desires future fertility):
- progesterone IUD (best regression rate)
- Oral progestin therapy: megace 40-200mg/day - hormonal medication (megestrol acetate) similar to progesterone.
- provera 10-20mg/day or cyclic 12-14d/month
- depo provera 150mg IM q3 mo
- micronized vaginal progesterone 100-200 mg/day.
Need serial endometrial sampling q3-6mo. regression in 80-90%.
If on repeat EMB, unchanged, hyst OR repeat progesterone therapy for 3mo.
If resolution not seen in 1 year, surgery strongly recommended
Once medical therapy stopped for EIN, 50% will have recurrence.
What is uterine cancer staging?
Stage 1A < 1/2 myometrium
Stage 1B > or = 1/2 of myometrium
Stage 2: cervical stroll involvement (NOT endocervical glands), doesn’t extend beyond uterus
Stage 3: local/regional spread
Stage 3A: uterine serial or adnexal involvement
Stage 3B: vaginal or parametrical involvement
Stage 3C: positive nodes (3C1 pelvic nodes, 3C2 para-aortic nodes)
Stage 4A: bladder or bowel mucosa
Stage 4B: distant mets (inter-abdominal mets or inguinal LN)
What is involved in surgical staging for endometrial cancer?
Abdominal exploration
Pelvic washings
TAH/BSO
Omentectomy
Pelvic and paraaortic Lymphadenectomy
- minimally invasive (LSC/robotic) approach is standard
- supracervical hyst not recommended
- most important prognostic factors is presence of extrauterine disease. do not need pre-op assessemtnw tie imaging
KEY: nodal dissection and peritoneal cytology should be considered at time of hyst for pre-op diagnosis of EIN. 30-50% chance of underlying endometrial cancer.
What is the medical management of endometrial cancer?
Patient selection:
- premenopausal w/ desire for future fertility (need well-differentiated grade 1 endometrioid tumor verified by hysteroscopy d&C), no myometrial invasion (MRI), no extrauterine involvement.
- poor surgical candidate 2/2 medical co-morbidities.
Medical options: medroxyprogesterone (Provera) or Megestrol (megace), progesterone IUD, need EMB q3 mo while on tx. recurrence occurs in up to 50% once treatment id discontinued.
What is the surveillance after surgery for endometrial cancer?
H&P (pelvic, vaginal and rectal exam): q3-6mo x 2years then q6 mo x 3 years then annual.
- no pap/vaginal smears
- no annual CXR
- CT/PET of C/A/P ONLY to evaluate recurrence suspicion.
What is tamoxifen?
used for adjuvant breast cancer treatment, metastatic breast cancer tx, reduce breast cancer risk in high-risk women.
- associated w/ endometrial proliferation, hyperplasia, polyp formation, invasive carcinoma, uterine sarcoma.
- risk of malignancy is DOSE and TIME dependent.
- prenopausal women have no increased risk of uterine cancer and don’t need any additional monitoring beyond routine gyn care.
- post-menopausal women: can get pre-screening for endometrial polyp
What is raloxifene?
not indicated for pre-menopausal
- NO increased risk of uterine cancer or uterine bleeding.
- reduce breast cancer risk in high-risk postmenopausal women.
- adjuvant breast cancer treatment.
- prevent/tx osteoporosis in women at high risk breast cancer and low risk for VTE, vasomotor sx.
What are some risk factors for endometrial cancer?
HONDA
Hypertension
Obesity
Nulliparity
Diabetes
Anovulation
what preoperative and intraoperative factors would influence your decision to proceed with a staging procedure at the time of hysterectomy for complex hyperplasia w/ atypia?
Pre Op
- Comfort in performing LND or availability of a capable surgeon (gyn, oncologist, GNS)
- Obvious advanced disease (ascites, lymphadenopathy, distant metastasis)
Intra Op
- Gross inspection of greater than 50% myometrial invasion
- Grade 3 lesions pre-op or frozen section
- Grade 3 lesions > 2cm pre-op or frozen section
- Nonendometrioid histologies (clear cell or papillary serous) pre-op or frozen section
How would you evaluate 22y/o w/ Lynch syndrome?
How would you counsel? When would you start screening?
Offer testing (AD inheritance) if fam hx lynch-associated cancer, uterine cancer before age 50, fam hx lynch syndrome.
Colonoscopies q1-2yr at age 20-25 or 2 yrs before youngest family member, yearly EMB at age 30-35, no screening for ovarian cancer, rR hyst/bso before age 45
Use progesterone contraception before hyst.
68 y/o on tamoxifen for breast cancer has new PMB. How do you manage?
If sampling reveals grade 2 endometrial cancer, what do you do?
She needs endometrial sampling with either office EMB or hysteroscopic D&C.
An ultrasound for endometrial stripe is not reassuring, given her risk factors of Tamoxifen use, obesity, and diabetes.
- Workup and Refer to gyn onc.
Workup: LFTs (liver mets), CXR (r/o mets), CT/MRI to asses depth of invasion/node enlargement.
What prognostic factors influence survival for pt w/ endometrial cancer?
Stage
Grade/histologic type
Depth of invasion
Peritoneal cytology
Receptor status
Age
Vascular space invasion
Comorbidities
What is a proper evaluation for PMB?
H&P w/ pelvic exam, bimanual exam for masses
- Pap smear w/ ECC, colpo of lesions
- endometrial sampling
- US
- consider vaginal atrophy!
