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Obstetrics and Gynecology > Endometrial cancer > Flashcards

Endometrial cancer Flashcards

1
Q

what is the fourth most common cancer among american women

A

endometrial (breast, bowel and lung are ahead)

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2
Q

what is the most commonly encountered gynecological malignancy in the US

A

endometrial

favorable survival profile because majority are dx early

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3
Q

what % of women with endometrial cancer are diagnosed at stage I

A

72%–surgical staging is thus usually curative

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4
Q

why are most endometrial cancers caught early

A

early symptoms and accurate diagnosis modalities

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5
Q

what are the risk factors for endometrial cancer

A 
obesity
chronic anovulation
nulliparity
late menopause
unopposed estrogen use
hypertension
DM
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6
Q

what are the two distinct pathogenic etiologies of endometrial cancer

A

Type I–> most common (80%); occurs in women with history of chronic estrogen exposure unopposed by progestin (estrogen dependent neoplasms); more favorable prognosis

Type II–> (20%); estrogen independent; not related to unopposed estrogen stimulation or endometrial hyperplasia; often occur within a background of ATROPHIC endometrium or polyps; often have high grade nuclear atypia with SEROUS or CLEAR CELL histology; many assoc with p53

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7
Q

how do type I endometrial cancers start

A

as atypical endometrial hyperplasia and progress to carcinomas

tend to be well differentiated (endometroid type) with lower grade nuclei and usually more favorable prognosis

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8
Q

what type of histology is associated with type II

A

clear cell or serous

many associated with p53 tumor suppressor gene

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9
Q

what is an important component of staging and prognosis of endometrial cancer

A

depth of myometrial invasion

prognosis worsened when cancer has invaded more than one half of the thickness of the myometrium

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10
Q

what are the 4 primary routes of spread of endometrial cancer

A

direct extension–most common
–towards cervix or outward through the myometrium and serosa

lymphatic–when there is significant myometrial penetration, spread to pelvic or para-aortic lymph nodes

transtubally–via exfoliated cells, to the ovaries, parietal peritoneum, and omentum

hematogenous–less frequent, can result in mets to liver, lungs, bones

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11
Q

what is the most common type of endometrial cancer

A

endometroid adenocarcinoma (75-80%)

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12
Q

what are the other (non endometroid) types of endometrial cancer

A

mucinous carcinoma (5%)

clear cell carcinoma (5%)

papillary serous carcinomas (4%)

squamous carcinomas (1%)

these types tend to be more aggressive

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13
Q

what does invasive adenocarcinoma usually result from

A

proliferation of the glandular cells of the endometrium in a back-to-back fashion without intervening stroma

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14
Q

what is the most important prognostic factor for endometrial carcinoma

A

histologic grade

poorly differentiated tumours have a higher grade and a higher percentage of solid (non glandular) growth –> have a poorer prognosis due to likelihood of proliferation outside of the uterus

histologic type of the carcinoma also affects prognosis

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15
Q

define grade 1 endometrial cancer

A

5% or less of the tumour shows a solid growth pattern –> highly differentiated

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16
Q

define grade 2 endometrial cancer

A

6-50% of the tumour shows solid growth pattern–> moderately differentiated

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17
Q

define grade 3 endometrial cancer

A

more than 50% of the tumour shows a solid growth pattern–> poorly differentiated

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18
Q

list the major independent risk factors for endometrial cancer

A 
age
depth of myometrial invasion 
histologic grade
histologic type
surgical stage
peritoneal cytology
tumour size
lymphovascular invasion
pelvic lymph node mets
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19
Q

what age group is most likely to get endometrial cancer

A

post menopausal women (75% versus 25% in premenopausal)

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20
Q

what is the average age of dx of endometrial cancer

A

61–largest affected group is between 50-59

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21
Q

what % of women who receive estrogen replacement therapy without progesterone will develop endometrial hyperplasia within a year?

A

20-50%

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22
Q

what is tamoxifen

A

a selective estrogen receptor modulator (SERM)–can act as a source of exogenous estrogen

works to block estrogen stimulation of breast tissue in women with estrogen-progesterone sensitive breast cancer

BUT in endometrium, it acts as a partial agonist/weak estrogen to stimulate endometrial proliferation

23
Q

why is obesity a risk factor for endometrial cancer

A

increased endogenous estrogen due to peripheral conversion of androgens to estrone and estradiol in adipocytes

also have lower sex hormone binding globulin levels

many are anovulatory

24
Q

why do women with PCOS have higher risk for endometrial cancer

A

chronic anovulation/PCOS typically have more central obesity and therefore more estrogens

also have relative lack of progesterone in luteal phase due to anovulatory cycles

(may also explain higher rates of endometrial cancer in nulliparous women)

25
Q

why are DM and HTN independent risk factors for endometrial cancer

A

possible the presence of hyperinsulinemia, insulin resistance and insulin-like growth factors may lead to abnormal endometrial proliferation

26
Q

what is a syndrome that is assoc with increased risk of endometrial cancer

A

lynch II syndrome in the family

27
Q

what is Lynch II syndrome

A

herediatary nonpolyposis colorectal cancer (HNPCC)

genetic predisposition to breast, ovarian, colon and endometrial cancers

specific germline gene mutations are responsible for the cancers in the majority of these women

28
Q

what is the risk of endometrial cancer in simple endometrial hyperplasia without atypia

A

1% if untreated

29
Q

what is the risk of endometrial cancer in complex endometrial hyperplasia with atypia

A

29% if untreated

30
Q

are there any effective screening mechanisms for endometrial cancer

A

no

31
Q

what are some protective factors for endometrial cancer

A

those that decrease lifetime estrogen exposure

combined OCPs
progestin containing contraceptives
combo estrogen-progesteron hormone replacement
high parity
pregnancy
physical activity
smoking (increased hepatic metabolism of estrogen)

32
Q

is smoking a risk factor for endometrial cancer

A

no its actually protective as it increases hepatic metabolism of estrogen

33
Q

how protective is exercise for endometrial cancer

A

women who exercise have a one half risk of endometrial cancer compared to those who dont

34
Q

are there any identifiable risk factors for type II endometrial cancer

A

no

35
Q

classic history for endometrial cancer

A

90% have either postmenopausal vaginal bleeding or some form of abnormal vaginal bleeding (menorrhagia, postcoital spotting, intermenstrual bleeding)

10% may present with bloody vaginal discharge

these are EARLY symptoms

pelvic pain, mass and weight loss are seen in women with more advanced disease

36
Q

classic physical exam for endometrial cancer

A 
obesity
acanthosis nigricans
HTN
stigmata of DM (pleural effusion, ascites, hepatosplenomegaly, general LAD, abdo masses)
typically normal pelvic exam

in more advanced stages, cervical os may be patulous, cervix may be firm and expanded

uterus may be or normal size or enlarged

adnexae should be carefully examined for evidence of extrauterine mets

37
Q

ddx for premenopausal abnormal uterine bleeding

A 
uterine fibroids
endometrial polyps
adenomyosis
endometrial hyperplasia
ovarian cysts
thyroid dysfunction
(endometrial cancer)
38
Q

ddx for postmenopausal abnormal uterine bleeding

A

endometrial atrophy (60-80%)

exogenous estrogens/HRT (15-25%)

endometrial cancer (10-15%) –> the older the patient and the more years since menopause, the higher the likelihood of malignancy (amount of bleeding does not correlate with risk of malignancy)

endometrial or cervical polyps (2-12%)

endometrial hyperplasia (5-10%)

other (10%)

39
Q

what is the diagnostic method of choice for evaluating irregular bleeding

A

office endometrial biopsy (EMB)–> has an accuracy of 90-98% without the need for anesthesia and operative time (was previously D&C)

40
Q

what test can you use to evaluate postmenopausal bleeding

A

transvaginal US–> can distinguish between suspicious lesions and atrophy (most common source of bleeding)

41
Q

what endometrial thickness is suggestive of low risk of malignancy

A

4mm or less–> do not require EMB unless bleeding is persistent ot recurrent or they are at high risk for malignancy

42
Q

what do you do if there are suspicious findings on EMB

A

D&C

43
Q

what is the initial workup for a patient with abnormal bleeding beyond biopsy?

A

TSH
prolactin level (if oligomenorrheic)
FSH and estradiol (to see if menopausal)
CBC (rule out anemia preop)
CA-125 level–> if very high, suggestive of spread beyond uterus–> can follow post op to assess success of tx
up to date pap
pelvic US to look for polyps, fibroids, adenomyosis, endometrial hyperplasia

44
Q

what % of women with HNPCC will develop endometrial cancer before colon cancer

A

50%–thus should have yearly EMB beginning at age 35

45
Q

what is the treatment for stage I and II endometrial cancer

A

total abdominal hysterectomy and bilateral salpingo-oophrectomy (TAH-BSO), pelvic washings, pelvic and para-aortic lymph node resection and complete resection of visible tumour for all stages –> “complete surgical staging”

exceptions: young women with grade 1 endometroid ca who desire future fertility or women with high mortality risk with surgery

may require radiation therapy in addition if there are poor prognostic factors

46
Q

treatment for stage III and IV endometrial cancer

A

when has spread to uterine serosa or beyond, patients also require pelvic radiation

47
Q

define stage I endometrial cancer

A

Ia–> Ic ranges from limited to endometrium with no myometrial involvement to invasion greater than one half of myometrium

48
Q

define stage II endometrial cancer

A

IIa–> spread to endocervical glands only

IIb–> spread to cervical stroma

49
Q

define stage III endometrial cancer

A

ranges from tumor invades serosa and/or positive peritoneal cytology to positive para-aortic/pelvic nodes

50
Q

define stage IV endometrial cancer

A

tumor invasion of bladder or bowel mucosa//distant mets

51
Q

what is the overall 5 year survival of endometrial cancer

A

65%

87% stage 1–> 18% stage IV

52
Q

what are the high risk features for endometrial cancer

A

more than 50% myometrial involvement

papillary serous or clear cell

grade 3

large (over 2 cm or filling cavity)

spread beyond uterine fundus

lymph involvement

53
Q

follow up for endometrial cancer

A

physical (rectovaginal and speculum) every three months for three years followd by biannual for subsequent 2 years—annually after that if all normal

risk of recurrence greatest in first three years

54
Q

treatment for recurrent endometrial cancer

A

radiation

chemo

high grade progestin therapy

Obstetrics and Gynecology (21 decks)

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