Endometrial Cancer Flashcards
Is endometrial cancer the most common gynaecological cancer in the UK?
Yes
The majority are diagnosed in what age group?
Peak incidence = 64-74
The majority 93% occur in women over 50
There is marked geographical variation. North American: Chinese =
7:1
Reflects the differences in risk factors
What risk factors are there?
Obesity DM, HTN Nulliparity Early menarche and late menopause Unapposed oestrogen Tamoxifen PCOS - anovulatory cycles, absence of corpus luteum and therefore progesterone PMH of breast or ovarian cancer BRCA1/2 gene mutation FH HNPCC (Lynch syndrome) - confers higher risk of breast, endometrial and ovarian cancers Endometrial polyps and hyperplasia Parkinson’s disease
What factors are protective?
COCP Continuous, combined HRT Parity Smoking Physical activity Coffee and tea
What is the most common type of endometrial cancer?
Type 1 = Adenocarcinoma (80%)
Type 2 = papillary serous, clear cell, carcinosarcoma (20%)
Sarcoma = very rare
What is the pre malignant condition?
Endometrial hyperplasia
How is endometrial hyperplasia classified?
Complex with or without atypica
With atypical cells: malignancy coexists in 25-50% and 20% will develop cancer in 10 years
How does it present?
Usually post menopausal bleeding
Usually little and occasional, then bleeding gets heavier and more frequent
Less commonly: blood stained, watery or purulent discharge
Premenopausal: Change in bleeding pattern Irregular bleeding Intermenstrual bleeding Heavier bleeding
What percentage risk of endometrial cancer does a woman have with PMB?
10%
What staging system is used?
FIGO staging
S1 - limited to myometrium
S2 - cervical spread
S3 - outside uterus but not pelvis e.g ovaries, tubes, vagina, pelvic, para-aortic LNs
S4 - bladder/ bowel involvement, distant metastases
What is the predicted 5 year survival for S1?
80%
What is the predicted 5 year survival for S2?
60%
What is the predicted 5 year survival for S3?
20%
What is the predicted 5 year survival for S4?
20%
Who should be referred using the suspected cancer 2 week pathway ?
Women 55 years old and over with PMB
Consider referral in under 55 y/o with PMB
What is the first line investigation?
Trans-vaginal US
A normal endometrial thickness (less than 4mm) has what negative predictive value of endometrial cancer?
96% - no require for biopsy unless symptoms recurrent
How is diagnosis confirmed?
Hysteroscopy with endometrial biopsy - pipelle or dilatation and curettage
What investigations/ imaging is done for staging?
FBC, U&E, LFTs
CT CAP
MRI pelvis
What factors influence treatment?
Stage
Age and fitness for surgery
Patient preference
80% have primary surgery…
Hysterectomy and bilateral salpingo-oophorectomy, peritoneal washing
- laparoscopic or open
When is adjuvant radiotherapy used?
Increased risk of recurrence
Low grade disease with deep myometrium invasion and high grade disease with superficial invasion
What type of adjuvant radiotherapy is done?
External beam or brachytherapy
What management can be done for advanced disease/ inoperable/ unfit for surgery?
Chemotherapy
RT
Hormones e.g aromatase inhibitors, progestogen therapy
Palliative care
Why is tamoxifen a risk factor?
It acts against the growth promoting effects of oestrogen in breast tissue, but it acts as an oestrogen in other tissues e.g uterus and bones
- helps preserve bone density
- increased risk of cancer in uterus (causes the endometrial lining to grow)
Why is endometrial cancer often diagnosed early?
They are picked up because of PMB or irregular vaginal bleeding
Irregular bleeding is a common symptoms of many other symptoms such as…
Endometriosis Fibroids Endometrial hyperplasia Polyps Dysfunctional uterine bleeding (no obvious underlying cause)
Why is obesity a risk factor?
The greater the amount of subcutaneous fat, the faster the rate of peripheral aromatisation of androgens to oestrogen
What examinations should be done?
Abdominal - for abdominal or pelvic masses
Speculum - evidence of vulval/ vaginal atrophy or cervical lesions
Bimanual - assess size and axis of uterus prior to sampling
How can hyperplasia without atypia be treated?
Progestogens e.g Mirena IUS
Surveillance biopsy
How should atypical hyperplasia be treated?
TAH + BSO
If contraindicated, regular surveillance biopsies
How is non malignant simple or complex hyperplasia without atypia treated?
With progestogens e.g mirena IUS
Surveillance biopsies to identify any progression to atypia of malignancy
How is atypical hyperplasia managed?
Highest rate of progression to malig, so should be treated with total abdominal hysterectomy + bilateral salpingo-oophorectomy
If contraindicated - reg surveillance performed
