Endometrial cancer

Question 1

Endometrial cancer incidence

Answer 1

4th most common cancer in females
most common gynecological cancer
5 year survival ~70%

Question 2

Oncogenesis of endometrial cancer

Answer 2

unopposed estrogen leading to hyperplasia, then ca

Question 3

Natural history of endometrial cancer

Answer 3

extension through uterus

spread into lymph nodes and blood

Question 4

Risk factors of endometrial cancer

Answer 4

unopposed estrogen (exogenous hormones, obesity, anovulation)
obesity: 3-10x
Lynch syndrome (lifetime risk 40-60%)
HTN
diabetes: 2-3x
irregular menstruation
nulliparity

Question 5

Prevention of endometrial cancer

Answer 5

decrease BMI

Question 6

Pre-cancerous stage of endometrial cancer

Answer 6

endometrial hyperplasia

Question 7

Spread of endometrial cancer

Answer 7

Local: uterus, cervix, colon, bladder
Lymph: para-aortic nodes or pelvic nodes
Blood: uncommon, metastasis to lungs, liver, bone

Question 8

SSx of endometrial cancer

Answer 8

Postmenopausal bleeding

abnormal vaginal bleeding

Question 9

Diagnosis of endometrial cancer

Answer 9

biopsy
D&C if biopsy not enough
US can give suspicion but not diagnosis

Use IHC for all endometrial ca to screen for Lynch syndrome

Question 10

Staging of endometrial cancer

Answer 10

surgical
I: confined to uterus (majority of patients present here)
II: cervix
III: adnexae
IV: bowel, bladder, distant metastasis (rare)

Question 11

Tx of endometrial cancer

Answer 11

1) Surgery!
Hysterectomy + bilateral salpingo-oophorectomy +/- lymmphadenectomy

Adjuvant:
depending on stage and risk of recurrence
Pelvic radiation - local
Chemo - distant
Hormone therapy - advanced stage, well-differnetiated (grade 1)

Question 12

Followup of endometrial cancer

Answer 12

For recurrence:

• Pelvic exam q6/12 for 2-3 y, then annually
• Screening tests are NOT USEFUL
• most are symptomatic (vaginal bleeding)
• majority recur in pelvis

To maximize survivorship:

• reduces risk of other cancers
• QOL

Question 13

Type I endometrial ca

Answer 13

“low risk”
more common
Age ~62 (20%

Question 14

Type I endometrial ca risk factors

Answer 14

Estrogen-related (E>P)
obesity: conversion of androstenediol –> estrogen
PCOS
T2DM: hyperinsulinemia
Tamoxifen: selective estrogen receptor modulator - used to treat breast ca, but increases endometrial hyperplasia

Question 15

Type II endometrial ca

Answer 15

high risk
rare
age ~70
almost always postmenopausal
NOT estrogen related, more likely to have normal BMI
non-endometriod: serous, clear cell, malignant mixed mullerian tumour (carcinosarcoma)
All high grade (grade 3)

Question 16

Prognostic factors in endometrial cancer

Answer 16

Grade
Depth of myometrial invasion
Cervical stroma involvement

Question 17

other cancer risks after endometrial cancer

Answer 17

breast: 2x higher, estrogen, 1-2% in 5 y

Colorectal: 3-7x, obesity, radiotherapy, Lynch syndrome; 1-2% in 5 year

Question 18

Lynch syndrome

Answer 18

hereditary non-polyposis colorectal cancer (HNPCC)
inherited mutation in DNA mismatch repair MMR gene
High lifetime risks of cancer
- Colorectal 60%
- endometrial 60%
- ovarian 10%
- gastric 10%

Question 19

Screening to reduce cancer risk in Lynch syndrome

Answer 19

CRC: biannual colonoscopy from 25 y, then annual from 40
Endometrial/ovarian:
- annual endometrial biopsy and US from age 25-35 (not proven to be effective)
- prophylactic surgery

Question 20

How to counsel on prophylactic surgery for ca

Answer 20

Early (age 30) vs later (early 40s)
hormone replacement therapy afterwards

Progestins as alternative to surgery for young women

• grade 1 endometriod tumours, no myometrial invasion
• adverse effects
• response rate 60-70%; need regular surveillance
• keep fertility!

Question 21

Amsterdam II criteria

Answer 21

3-2-1 rule
3 family members
2 generations
1 under age 50
but family history not enough

Question 22

Lynch syndrome Dx

Answer 22

Amsterdam II criteria

Immunohistochemistry to detect 4 MMR proteins

Question 23

IHC algorithm for endometrial ca

Answer 23

Test all endometrial ca patients for 4 MMR proteins
Normal 80%
Abnormal 20% –> refer to hereditary cancer program
- Mutation 10%; no mutation 90%

Question 24

Indications for bilateral salpingo-oophorectomy in endomterial ca

Answer 24

Concurrent ovarian pathology
synchronous ovarian primary (low grade endometriod tumour), up to 25% (good prognosis)
Ovarian metastases less likely ~3%

Question 25

CI for bilateral salpingo-oophorectomy in endometrial ca

Answer 25

morbidity/mortality from early BSO

osteoporosis, CHD, lung and CRC

Question 26

HT after endometrial ca

Answer 26

Stage I/II/III: no increased risk with HRT

benefits > risks

Question 27

Protective factors for endometrial ca

Answer 27

Multiparity (>3): 0.3 RR
OCP (5 y): 0.5
Exercise (2.5 h/week): 0.5
Smoking (current vs never): 0.7
Coffee (per cup): 0.9

Question 28

Immediate precursor to endometrial ca

Answer 28

Complex Atypical Hyperplasia