Endometrial cancer

Question 1

Paths of endometrial cancer

Answer 1

80% Type I estrogen-dependent, 20% Type II estrogen independent

Question 2

Characteristics of Type I?

Answer 2

Well-diferentiated (endometrioid type), lower grade, better prognosis, atypical hyperplasia

Question 3

Characteristics of Type II?

Answer 3

High grade nuclear atypic
Serous or clear cell histology
p53 mutation more likely

Question 4

Important for staging and prognosis?

Answer 4

#1 FACTOR IS Histologic grade (degree of differentiation), how solid it is (greater area of solid growth pattern is higher grade) 
***#1 for OVARIAN is STAGE

Myometrial invasion, age, histologic type, surgical stage, peritoneal cytology, tumor size, lymph invasion, pelvic LN mets

Question 5

Routes of spread

Answer 5

• Direct extension- down to cervix, out to endometrium
• Lymphatic spread- para-aortic and pelvic LNs
• Hematogenous spread- liver lungs bone

Question 6

Types of endometrial cancer and prevalence

Answer 6

• Endometrioid adenocarcinoma- 75-80%
• Mucinous 5%
• Clear cell 5%
• Papillary serous 4%
• Squamous 1%

Question 7

Ages for endometrial cancer? Average age of diagnosis?

Answer 7

25% premenopausal, 75% postmenopausal

61 yo

Question 8

Risk factors

Answer 8

>50 lb overweight 10% risk
Unopposed estrogen therapy 2-10%
Tamoxifen use 3-8%
Diabetes 2-8%
PCOS 3%
Nulliparity
Late menopause
21-50lb overweight
HYPERTENSION
BREAST CANCER
CANCER BREAST, OVARY OR COLON (family hx of Lynch II syndrome aka HNPCC)
FAMILY HX OF ENDOMETRAL (first degree relative)

Question 9

Does BRCA1 play a role?

Answer 9

This is UNCLEAR

Question 10

Endometrial hyperplasia degree of risk?

Answer 10

Depends on the type (penny nickel dime quarter)

Question 11

Screening for endometrial cancer

Answer 11

NONE. Good news is it presents early with bleeding as sign.

Question 12

Protective?

Answer 12

For TYPE I:
OCPs, progestin contraceptives, HRT, high parity, pregnancy, physical activity

SMOKING b/c it increases hepatic metabolism of estrogen

THERE ARE NO IDENTIFIABLE RISK FACTORS FOR TYPE II.

Question 13

Presentation?

Answer 13

Some form of bleeding: menorrhagia, postcoital spotting, intermenstrual bleeding, POSTMENOPAUSAL esp

10% with nonbloody vaginal discharge

Question 14

Physical exam?

Answer 14

NORMAL pelvic exam

Question 15

Differential diagnosis of postmenopausal bleeding and %’s?

Answer 15

Endometrial atrophy 60-80%
Exogenous estrogens/HRT 15-25%
Endometrial cancer 10-15%
Endometrial or cervical polyps 2-12%
Endometrial hyperplasia 5-10%

Question 16

Differential diagnosis of premenopausal bleeding?

Answer 16

Fibroids, endometrial polyps, adenomyosis, endometrial hyperplasia, ovarian cysts, thyroid dysfunction

Question 17

Diagnosis? Good rule out?

Answer 17

EMB is NEW gold standard, not D&C

Do a transvaginal u/s and if endometrial stripe is less than 4 mm it’s super low risk. These would only need an EMB if the bleeding is persistent and they’re at high risk anyway

Question 18

When WOULD you do D&C to diagnose?

Answer 18

cervical stenosis, insufficient tissue sample, patient discomfort

Question 19

What other important workup during diagnosis?

Answer 19

TSH, prolactin level (if oligomenorrheic), FSH and estradiol (if you need to know if she’s postmenopausal)
CBC to r/o anemia
Pelvic u/s to r/o fibroids, polyps, adenomyosis, may also be able to see endometrial hyperplasia.

Question 20

What clues can you get from the pap smear?

Answer 20

Only 30-40% with endometrial cancer have an abnormal pap smear.
But if it shows endometrial cells in a woman over 40 you should prob do an EMB.
It’s especially concerning to see atypical endometrial cells.

Question 21

How often do women at risk for Lynch II syndrome develop endometrial or ovarian cancer BEFORE developing colon cancer?

Answer 21

Like 50%!!

Question 22

Staging?

Answer 22

SURGICALLY

Ia- no myometrial
Ib- 50% of myometrium

IIa- endocervical gland pread
IIb- cervical stroma invasion

IIIa- Serosa and/or peritoneum
IIIb- vaginal or parametrial mets
IIIc- pelvic and/or para-aortic LNs

IVa- distant mets bladder and/or bowel mucosa
IVb- intra-abdominal or ingunial LNs

Question 23

Treatment of Stage I and II?

Exceptions?

Answer 23

TAH-BSO, pelvic washings, pelvic and para-aortic LN resection, complete resection of all visible tumor

Exception is a young woman with grade I endometrioid carcinoma who desires future fertility (or someone who’s at high risk for undergoing surgery)

RADIATION THERAPY MAY ALSO BE REQUIRED (esp for III and IV…after serosal invasion; and for high risk types like papillary serous or clear cell)
***OVARIAN REQS CHEMOTHERAPY

Question 24

5 year survival

Answer 24

65%

Note: 85-100% of recurrences occur in the 3 year period after treatment

Question 25

Treatment options for recurrent disease?

Answer 25

Chemo, high-dose progestin therapy, try radiation if they didn’t get it before