Endometrial Cancer

Question 1

What cancers affect the endometrium

Answer 1

Adenocarcinoma (most common)
- type 1: oestrogen excess (endometrioid commonest)
- type 2: non oestrogen excess (papillary serous or clear cell)
Sarcoma
- derived from muscle layer
- leiomyosarcoma most common
Uterine carcinosarcoma

Question 2

Incidence and age of endometrial cancer

Answer 2

Peak incidence 70-74 years
58% of cases in over 65s
Most common gynecological cancer in the UK
- 13th most common cancer in UK
65% increase in incidence since 1970s

Question 3

Presentation of endometrial cancer

Answer 3

Postmenopausal bleeding (PMB)
Post-coital bleeding 
Intermenstrual bleeding 
Altered menstrual pattern 
Persistent vaginal discharge

Question 4

What is endometrial hyperplasia

Answer 4

Overgrowth of endometrial cells caused by excess unopposed oestrogen
- shares aetiology with endometrial cancer
Presents with irregular periods of PMB
Simple hyperplasia (1-3% malignant potential)
Complex hyperplasia (3-4% malignant potential)
Atypical hyperplasia (23% malignant potential)

Question 5

Risk factors for endometrial cancer

Answer 5

Obesity (34% of cases)
Physical inactivity 
Oestrogen only HRT
Type 2 Diabetes Mellitus 
Metabolic syndrome 
Oestrogen producing tumour
PCOS
Tamoxifen - oestrogen agonist in endometrial tissue 
Nulliparity
Longer menstrual lifespan (late menopause)
Genetics (HNPCC)
Breast cancer or bowel cancer

Question 6

Describe the association between endometrial cancer and genetics

Answer 6

Cancer due to
- chance (sporadic cases - p53 mutations)
- familial clustering
- hereditary cancer syndromes
Family history important
- look for multiple cases of same or related tumour in more than one generation
- younger onset than general population

Question 7

Protective factors in endometrial cancer

Answer 7

Parity (increased progesterone)

COCP - due to effect of progesterone

Question 8

Describe HNPCC - hereditary non-polyposis colorectal cancer

Answer 8

Lynch I syndrome
- site-specific colorectal cancer
Lynch II syndrome
- autosomal dominant
- predisposition to colorectal, endometrial, ovarian, stomach, hepatobiliary, brain, skin, upper urinary tract and small bowel cancers
Amsterdam Criteria (Lynch II diagnosed if)
- colorectal cancer in 3 or more relatives
- at least two generations involved
- one case <50 years
- familial polyposis excluded

Question 9

Incidence of ovarian cancer in Lynch II syndrome

Answer 9

30-40% risk of endometrial cancer by age 70
- compared to 3% in general population
Occur up to 15 years early than population peak
- 65 years old
Cumulative risk of ovarian cancer 9%
Cumulative risk of colorectal cancer (proximal to splenic flexure) is 70%

Question 10

WHat is the FIGO surgical staging in endometrial cancer

Answer 10

Stage 1 - tumour limited to uterine body
- 1A: <50% myometrial invasion
- 1B: >50% myometrial invasion
Stage 2 - tumour limited to uterine body and cervix
Stage 3 - tumour outside the uterus
- 3A: tumour invades serosa or adnexa
- 3B: vaginal and/or parenchymal involvement
- 3C1: pelvic node involvement
- 3C2: para-aortic involvement
Stage 4
- 4A: tumour invasion of the bladder and/or bowel mucosa
- 4B: distant mets including abdominal and/or inguinal lymph nodes

Question 11

Survival of endometrial cancer

Answer 11

All stages
- 90% one year
- 79% 5 years
- 78% 10 years
Depends on histological subtype, grade and comorbidities
Most women are diagnosed at an early stage
- only 25% present with stage 4 disease

Question 12

Investigations for ?endometrial cancer

Answer 12

Examination
- vulval, vaginal and speculum
- bimanual exam
Bloods - nil specific
- comorbidities 
Imaging
- TV USS to measure endometrial thickness
- MRI to assess for extra-uterine disease (not in grade 1 tumours)
- CT/PET CT (for staging and grading)
Biopsy
- pipelle
- hysteroscopy and biopsy

Question 13

What are the signs of endometrial cancer on TV USS

Answer 13

Biopsy if endometrial thickness >3mm
- non HRT
- continuous combined HRT
Biopsy is endometrial thickness >5mm
- sequential HRT users
Hysteroscopy and biopsy anyone who has ever used Tamoxifen

Question 14

How is early stage (stage 1 and 2) endometrial cancer managed

Answer 14

TAH + BSO + washings
- abdominal, laparoscopic or vaginal access
Examine all peritoneal surfaces
Lymphadenectomy shoes no benefit and has significant morbidity

Question 15

How is advanced endometrial cancer managed

Answer 15

Palliative chemo/surgery to relieve symptoms can be performed
Neoadjuvant chemotherapy, radiotherapy and hormonal therapy may be considered
- hormonal therapy involves high dose progesterone, helps with palliation of symptoms (e.g. bleeding)

Question 16

How is inoperable endometrial cancer managed

Answer 16

Oestrogen/progesterone receptor stats of the tumour is important
- chemo, radio and hormonal therapy can be considered
Palliative medicine gets an input
Single fraction of radiotherapy can help heavy bleeding

Question 17

Describe the use of radiotherapy in endometrial cancer

Answer 17

Post-op radiotherapy in high risk disease
- MDT decision
- guided by histopathological risk factors and performance status 
Types
- external beam
- brachytherapy (vault insertions)
Side effects
- proctitis
- cystitis
- lethargy
- skin changes

Question 18

Grading scale used in endometrial cancer

Answer 18

G1 - well differentiated
G2 - moderately differentiated
G3 - poorly differentiated or high levels of a risk cell type

Question 19

What are the histological subtypes of endometrial hyperplasia

Answer 19

Simple
- thickening of normal endometrial cells
Complex
- crowding of endometrial cells with budding of glands
Atypical
- appearance of individual glandular cells
- high glandular:stromal ratio

Question 20

Management of endometrial hyperplasia

Answer 20

Simple
- conservative (lifestyle changes, stop smoking, lose weight, exercise more, etc)
Complex
- conservative (POP and/or mirena)
Atypical
- TAH (+BSO if >45 years)
- mirena or POP (preserves fertility)