Endometrial Cancer

Question 1

A big red flag

Cause

2 pre-malignant states

Answer 1

PMB

Oestrogen unopposed by progesterone

Endometrial hyperplasia and polyps

Question 2

Presentation:

Main symptom during menopause

Pre-menopausal symptoms - 2

What would palpation of an abdominal mass suggest?

Answer 2

PMB - only 10% end up having endometrial cancer

Persistent IMB bleeding
Menorrhagia

Abdominal mass

Question 3

Risk factors:

What type of HRT is used?

What is tamoxifen and tibolone?

Other risk factors

Answer 3

Oestrogen-only HRT

Oestrogen receptor agonists - block oestrogen

Obesity
Functional ovarian tumour
Nulliparity
Late menopause

Question 4

Other risk factors

Answer 4

PCOS
Pelvis irradiation
Common, chronic disease - DM, HTH, hypothyroidism
FH of breast, ovarian or colorectal cancer

Question 5

DDx of PMB

Answer 5

Endometrial cancer, hyperplasia and polyps

Submucous fibroids

Vaginal atrophy

Question 6

Investigations:

TVUS:

Over what endometrial thickness would be considered pathological in menopausal AND premenopausal women?

What is done if the endometrial is found to be thickened?

Answer 6

M - >4 mm
PM - >16 mm

Pipelle biopsy (plastic cannula with plunger) which takes tissue from all quadrants of uterus

Question 7

Investigations:

What is more sensitive for diagnosis?

Blood and why? - 1

Answer 7

Hysteroscopy and biopsy (curettage)

FBC - anaemia

Question 8

FIGO staging:

Stage 1, 2, 3 and 4

Answer 8

1 - Uterus
2 - Cervix
3 - Adnexa, vagina or pelvic or para-aortic nodes
4 - Bowel, bladder, or distant mets

Question 9

Management:

What is done for all stages?

What stages does pelvic lymph nodes need to be removed?

What stages need adjuvant radiotherapy?

What stages need adjuvant chemotherapy?

What is done for unresectable disease?

Answer 9

Open bilateral hystero-salpingo-oophorectomy

Stages 2-4

Stages 1-2

Stages 2-4

Palliative chemo and radiotherapy

Question 10

Endometrial Polyps:

Investigations - 2

Management - How is it removed? - Why is it removed?

Answer 10

TVUS 
Saline infusion (SIS) for improved visualisation 

Hysteroscopic polypectomy due to malignancy risk if:

• > 1 cm
• Post-menopausal
• Accompanied by abnormal bleeding

Question 11

Endometrial hyperplasia:

Imaging

Management:

• What is done for simple hyperplasia?
• What is done for complex hyperplasia?

Answer 11

TVUS - biopsy done if >4 mm or > 16 mm

Levonorgestrel IUS - Mierna

Hysterectomy or Mirena + biopsy if unsuitable for surgery