Endometrial Cancer Flashcards
Epidemiology of Endometrial cancer?
Around 8000 new endometrial cancers are diagnosed each year in the UK
More common in post-menopausal women
What are the 2 distinct categories of Endometrial Cancer?
-
Type 1
- Endometrioid adenocarcinoma
- By far the commonest type
- Unopposed oestrogen - exposure to endogenous or exogenous oestrogen that is not opposed simultaneously by a progestagen
- Hyperplasia with atypia precursor
-
Type 2
- Uterine serous and clear cell carcinoma
- High grade, more aggressive, worse prognosis
- Generally older women
- Serous intraepithelial carcinoma precursor
What are the stages of Endometrial cancer?
Cure rates for Stage 1b = 85%
Cure rates for Stage 4 = 21%
What is the most common presenting symptom of endometrial cancer?
Abnormal vaginal bleeding
Mostly post-menopausal bleeding but it can affect a small number of younger women causing intermenstrual bleeding or heavy irregular bleeding
Risk factors for Endometrial cancer
- High levels of oestrogen in the body
- Obesity
- Contraception / Use of an intrauterine device (IUD)
- Age
- Diet and exercise.
- Type 2 diabetes.
- Family history
- FH of Lynch syndrome, also known as hereditary non-polyposis colorectal cancer (HNPCC)
- Previous breast or ovarian cancer
- Previous endometrial hyperplasia
- Previous radiation therapy to the pelvis to treat another cancer
What things can cause high levels of oestrogen in a female’s body?
- Obesity – peripheral conversion of androgens in body fat into weak oestrogens
- HRT – must use progesterone to protect the uterus
- Tamoxifen – although this is an anti-oestrogen in breast tissue it acts as an oestrogen in the uterus and it is associated with increased risk of endometrial hyperplasia, endometrial adenocarcinoma and endometrial sarcoma
- PCOS – don’t have normal cyclical activity and due to this there is a steady state in oestrogen instead of normal fluctuation. Although levels are not that high they are still damaging
What is Lynch syndrome / HNPCC?
- It is a type of inherited cancer syndrome associated with a genetic predisposition to different cancer types.
- People with Lynch syndrome have a higher risk of developing endometrial cancer
Excluding Endometrial cancer, what are some other possible causes of post-menopausal bleeding? (4)
- Peri-menopausal bleeding - may not have had a full year without periods and so they are actually in the transition stage
- Atrophic vaginitis - usually affects older women - low oestrogen levels in menopause mean that the cervical/vaginal/vulval mucosa is very thin and easily traumatised
- Cervical or endometrial polyps – benign
- Other cancers e.g cervical, vulval, bladder or anal - need to be investigated/excluded too
What investigation is done to look at the endometrial thickness and contour?
Transvaginal ultrasound scan
If the trans-vaginal USS detects changes in the thickness of the endometrium then what is done next?
Hysteroscopy + biopsy
How is endometrial cancer diagnosed?
Histology of the biopsy sample will give diagnosis
What is the main treatment for Endometrial Cancer?
Total Abdominal Hysterectomy with removal of fallopian tubes, ovaries and peritoneal washings
What is peritoneal washing?
- A procedure in which a salt-water solution is used to wash the peritoneal cavity and then is removed to check for cancer cells.
- Peritoneal washings are commonly done during surgery for cancer of the ovary and uterus, to see if cancer has spread to the peritoneal cavity.
How is each stage of endometrial cancer treated?
- Early stage – surgery / Total Abdominal Hysterectomy / bilateral salpingo-oophorectomy / peritoneal washings
- Think about preserving fertility / freezing eggs etc
- High risk histology – chemotherapy
- Advanced stage – radiotherapy
- Palliation – progesterone
A classic case study of Endometrial cancer patient
67 year old Female
PC:
- Vaginal bleeding
- 6 week history of spotting red blood/sometimes dark or brown
- No pain
- No urinary or bowel symptoms
- LMP at about age 53
- Menarche age 14 years
- Irregular cycle and primary infertility which was never investigated
- Never had any children
- Last cervical screen at age 64 years – negative
PMH:
- Type 2 diabetes controlled with diet and metformin
Social
- Non-smoker
- Occasional alcohol
- BMI of 41 (overweight)
Referred to Post Menopausal Bleeding (PMB) clinic
Examinations:
- Pelvic and speculum examination normal
Investigations:
- Transvaginal ultrasound scan to measure her endometrial thickness
- If endometrium is >4mm in a post-menopausal woman then this is considered irregular
- Endometrial biopsy
- Hysteroscopy – can be done in out-patient (local anaesthetic) or in-patient (general anaesthetic)
In this case the result of biopsy was adenocarcinoma
Management options discussed at MDT:
- Total laparoscopic hysterectomy
- Bilateral salpingoophorectomy
