Endometrial Cancer Flashcards
What is the typical presentation of endometrial cancer?
What is the peak incidence age?
Post-menopausal bleeding
50-60 years
Though it is unlikely, how would an endometrial cancer present in a young, pre-menopausal woman?
What things might you want to consider if endometrial cancer did present in a younger woman (i.e. < 40)?
Heavy, prolonged or inter-menstrual bleeding
PCOS or Lynch Syndrome
What are the two types of endometrial cancer and what subtypes can be found within each type?
Type 1 - Endometrioid: contains endometrioid and mucinous
Type 2 - Non-Endometrioid: contains serous and clear cell
What is the most common form of endometrial cancer?
What type of carcinoma is this?
Endometrioid (80%)
Adenocarcinoma
What is the precursor lesion for each of the following:
A) Type 1 endometrial cancers?
B) Type 2 endometrial cancers?
A) Atypical endometrial hyperplasia
B) (Serous) intra-epithelial carcinoma
What is the main causative factor of each of the following:
A) Type 1 endometrial cancers?
B) Type 2 endometrial cancers?
A) Unopposed oestrogen exposure
B) TP53 mutations
What is the difference in differentiation/prognosis of type 1 and type 2 endometrial cancers?
Type 1 is usually well differentiated and has a good prognosis
Type 2 is usually poorly differentiated and has a bad prognosis
Type 1 endometrial cancers are mainly caused by obesity - why is this?
Who is this problematic in?
The aromatisation of androgens to oestrogens by adipose tissue creates a state of oestrogenic excess
This becomes problematic in people who are anovulatory due to PCOS or being post-menopausal since the oestrogen is ‘unopposed’ by progesterone
In obese women, what is the relevance of each of the following in terms of the pathophysiology of endometrial cancer:
A) Low sex hormone binding globulins?
B) High free insulin?
A) There will be more unbound oestrogen which is biologically active in the bloodstream
B) Exerts a proliferative effect on the endometrium
How is Lynch Syndrome inherited?
It is caused by a germline mutation in what?
If the second allele gets activated, what is the individual’s risk of endometrial cancer?
Autosomal dominant
One allele of a DNA mismatch repair gene
40-60%
Having Lynch Syndrome increases a person’s risk of developing what cancers?
What can be used to detect tumours due to this condition?
What do these tumours show, which is characteristic of defective DNA mismatch repair?
Endometrial and colorectal mainly, little bit ovarian
Immunohistochemistry
Microsatellite instability
What is the appearance of an endometrial cancer:
A) Macroscopically?
B) Microscopically?
A) Large uterus, polypoid appearance
B) Adenocarcinoma, well differentiated
What are some risk factors for endometrial cancer related to unopposed oestrogen?
Obesity
PCOS
Tamoxifen/HRT use
Early menarche/late menopause
Nulliparity
What are some risk factors for endometrial cancer related to insulin resistance?
Type 2 diabetes
Metabolic syndrome
What are some risk factors for endometrial cancer which are not related to unopposed oestrogen or insulin resistance?
Lynch Syndrome
Hypertension
Increasing age
What are some protective factors against endometrial cancer?
COCP use
Mirena coil
Pregnancy
Hysterectomy
Lifestyle choices to lose weight/exercise more
What does post-menopausal bleeding warrant in terms of referral?
What investigations are required?
Urgent referral to gynaecology
Transvaginal US
Hysteroscopy
Endometrial biopsy
A TVUS is used to measure endometrial thickness - what should this be in post-menopausal women?
What would be some abnormal findings on TVUS that would be suggestive of endometrial cancer?
< 4mm
Irregular/thickened endometrium or polypoid appearance
What investigation is needed for diagnosis and grading of endometrial cancer?
Endometrial biopsy
Describe what is meant by each of the following:
A) Grade 1, well differentiated endometrial cancer?
B) Grade 2, moderately differentiated endometrial cancer?
C) Grade 3, poorly differentiated endometrial cancer?
A) Up to 5% solid growth
B) 6-50% solid growth
C) > 50% solid growth
Which types of endometrial cancers are graded?
Type 1 only (endometrioid)
What type of staging is used for endometrial cancers?
Why is this important?
FIGO
It helps to determine the prognosis
Describe stage I of endometrial cancers?
The tumour is confined to the uterus.
IA = < 50% invasion of the myometrium
IB = > 50% invasion of the myometrium
Describe stage II endometrial cancers?
The tumour extends into the cervical stroma
Stage III of endometrial cancers is used to describe the local/regional tumour spread. What is meant by:
A) Stage IIIA?
B) Stage IIIB?
C) Stage IIIC?
A) Invades the serosa of the uterus and/or adnexae
B) Vaginal/parametrial involvement
C) Involvement of the pelvic or para-aortic lymph nodes
Stage IV of endometrial cancer is used to describe the distant tumour spread. What is meant by:
A) Stage IVA?
B) Stage IVB?
A) Invasion into the mucosa of the bowel or bladder
B) Distant metastases
There can be direct spread of endometrial cancers into where?
What other spread can there be?
Myometrium and cervix
Lymphatic and haematogenous
What is the standard management of endometrial cancer?
What can be given as adjuvant treatment?
Hysterectomy (ideally laparoscopically) with removal of both ovaries and both Fallopian tubes
Radiotherapy if intermediate risk, radiotherapy and chemotherapy if high risk
What are the alternative management options for endometrial cancer in women who are unable to or don’t want to undergo surgery, or women who want to maintain their fertility?
Is this curative?
Hormone therapy with progesterone (i.e. Mirena coil or progesterone tablets)
Radiotherapy
This is generally not curative
Overall, what is the prognosis of endometrial cancer?
If it presents at an early stage, confined to the uterus, it has an excellent 5 year prognosis
