Endometrial cancer (and hysteroscopy) Flashcards
Define endometrial cancer.
An epithelial malignancy of the uterine corpus mucosa, usually an adenocarcinoma.
How common is endometrial cancer?
- The most common gynaecological tumour in the developed world
- 6th most common cancer overall in women
- Incidence increasing which may be linked to obesity
- Median age at diagnosis is 63 years
What is the aetiology of endometrial cancer?
Chronic (unopposed by progesterone) oestrogen stimulation –> endometrial hyperplasia –> adenocarcinoma (endometrial cancer)
What is the stage between endometrial hyperplasia and endometrial cancer called?
Intra-epithelial endometrial neoplasia
What are some causes of unopposed oestrogen stimulation of the endometrium?
- Chronic anovulation e.g. in PCOS
- Post-menopause, obesity - androgens are aromatised into oestrogen in adipocytes
- Tumours of the ovary e.g. granulosa cell tumours producing oestrogen
Which familial cancer syndromes predispose to endometrial cancer?
- Lynch syndrome - HNPCC
- FH of endometrial, ovarian, breast or colon cancer
- Cowden syndrome - mutation in PTEN tumour suppressor gene
A 65-year-old woman with class III obesity (BMI 41) with hypertension and diabetes presents with post-menopausal vaginal bleeding, 12 years after the menopause. She has never been pregnant. She has a first-degree relative and a second-degree relative who have had endometrial cancer. Bleeding is scant but has persisted for more than 1 month. She has not recently used hormone replacement therapy and she had a normal Pap smear 6 months previously. Vaginal examination reveals evidence of recent bleeding.
What is the diagnosis?
Endometrial cancer -
- Most patients who present are post-menopause, or nulliparous and obese pre-menopausal women*
- Uncommonly, women with undiagnosed endometrial cancer are found to have atypical glandular cells of uncertain significance (AGUS) on routine Pap smear cytology*
What are the clinical features of endometrial cancer?
Post-menopausal vaginal bleeding - 5-10% will have endometrial cancer
Signs and symptoms of metastatic disease -
What are the risk factors for endometrial cancer?
- Overweight and obese
- Age >50yrs
- Endometrial hyperplasia
- Unopposed oestrogen
- Tamoxifen use
- Insulin resistance
- FH of EC or other syndromes
- PCOS
- Radiotherapy (rare)
Which 2 factors are protective against endometrial cancer?
combined oral contraceptive pill and smoking are protective
What investigations would you do for endometrial cancer?
Bloods:
- FBC - for anaemia
Imaging:
- TVUSS
- Endometrial biopsy and histopathology + hysteroscopy
- Hysteroscopy, dilation and curettage (D&C - shown below) - if outpatient biopsy is no feasilble or cannot be tolerated
What TVUSS finding is suggestive of endometrial cancer?
endometrial thickening (stripe) >5 mm
How can diagnostic accuracy of endometrial biopsy be improved?
By outpatient hysteroscopy
Why may Pap smears be sometimes useful in diagnosis of endometrial cancer?
Not a screening test for endometrial cancer but sometimes show atypical glandular cells on cervical cytology which should prompt immediate evaluation with endometrial sampling
What are some differentials for endometrial cancer?
- Endometrial hyperplasia
- Endometrial polyp - TVUSS may show thickened endometrial lining that is not uniform
- Endometriosis - although more common pre-menopause
- Cervical cancer - patinets typically younger, although PVB usually provoked e.g. post-coital
Summarise the FIGO classification for uterine cancers.
Stage I:limited to the corpus uteri
- IA: no or <50% myometrial invasion
- IB: ≥50% myometrial invasion.
Stage II: invades cervical stroma, but does not extend beyond the uterus. Endocervical glandular involvement only is stage I.
Stage III: local and regional spread
- IIIA: invades the serosa of the corpus uteri and/or adnexa
- IIIB: vaginal and/or parametrial involvement
- IIIC: metastases to pelvic and/or para-aortic lymph nodes
- IIIC1: positive pelvic nodes
- IIIC2: positive para-aortic lymph nodes +/- positive pelvic lymph nodes.
Stage IV: invades the bladder and/or bowel mucosa and/or distant metastases
- IVA: invasion of the bladder and/or bowel mucosa
- IVB: distant metastases
