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Gwen - Reproductive Medicine (Obs, Gyn, Breast) > Endometrial Cancer and Post-menopausal bleeding > Flashcards

Endometrial Cancer and Post-menopausal bleeding Flashcards

1
Q

What is endomtrial cancer?

A

Oestrogen-dependent malignant neoplasm arising from the endometrium of the uterus

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2
Q

What is uterine cancer?

A

Any malignant neoplasm arising from the tissues of the body of the uterus, including the endometrium, myometrium and connective tissues

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3
Q

What is post-menopausal bleeding?

A

Vaginal bleeding occurring after 12 months of amenorrhoea in a woman of menopausal age or who has experienced the menopause – this affects 4-11% of postmenopausal women and accounts for 5% of all gynaecology outpatient referrals

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4
Q

At what age does endometrial cancer most commonly affect women?

A

>50s - rare under the age of 40

(classically seen in post menopausal women byt around 35% occur before menopause)

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5
Q

What are risk factors for the development of endometrial cancer?

A
  • Endogenous oestrogen exposure
    • Early menarche/late menopause
    • Delayed childbearing/nulliparity
    • Obesity and associated conditions - DM, hypertension, hypothyroidism
    • PCOS
    • Anovulatory menstrual cycle
    • Oestrogen secreting tumours
    • Unopposed oestrogen (HRT)
  • Exogenous oestrogen - HRT, tamoxifen
  • Age
  • HNPCC/lynch type 2/familial cancer syndrome - FH of colon/ovarian/breast cancer
  • Breast cancer - tamoxifen use (anti-oestrogenic effects on breast but oestrogenic on uterus)
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6
Q

What is thought to be the pathophysiological basis for endometrial cancer development?

A

Excessive oestrogen exposure with unopposed progesterone

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7
Q

What are protective factors for endometrial cancer?

A
  • Parity
  • OCP use
  • Exercise
  • Smoking
  • Aspirin
  • Drinking coffee
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8
Q

What are the main histological types of endometrial cancer?

A
  • Endometroid (most common - 90%)
  • Non-endometroid - serous, clear cell, carcinosarcoma, sarcoma
  • Uterine sarcomas
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9
Q

What is the most common type of endometroid carcinoma?

A

Endometroid adenocarcinoma

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10
Q

What proportion of endometrial cancers occur in post-menopausal women?

A

91%

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11
Q

What are uterine sarcomas

A

Tumours arising from the myometrium and connective tissues of the uterus

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12
Q

What are the main types of uterine sarcomas?

A
  • Leiomyosarcoma
  • Carcinosarcoma
  • Endometrial stromal carcinoma
  • Fibrosarcoma
  • Adenosarcoma
  • Metastases
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13
Q

What are the main types of non-endometroid endometrial cancers?

A
  • Serous carcinoma
  • Clear cell carcinoma
  • Mixed adenocarcinoma
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14
Q

How does endometrial cancer tend to present symptomatically?

A
  • Post-menopausal bleeding - profuse and persistent
  • Pre-/perimenopausal - intermenstral bleeding/menorrhagia
  • Pyometra
  • Advanced disease - pelvic pain/mass, leg swelling, haematura, PR bleeding, weight loss, fatigue, symptoms of mets
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15
Q

What is pyometra?

A

Collection of pus in the uterine cavity

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16
Q

Typical presentation endometrial cancer

A

Abnormal PV bleeding, post menopausal is the classic symptom

May have lower abdo pain but this is unusual

Systemic symptoms - fatigue, weight loss, nausea

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17
Q

What signs might you see in someone with endometrial cancer?

A

Generally normal unless advanced:

  • Pelvic mass
  • Cancer in cervix - rare
  • Enlarged, immobile uterus
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18
Q

What would be your differential diagnosis for someone presenting with post-menopausal bleeding?

A
  • Trauma
  • Ovarian tumour
  • Endometrial causes - Endometrial atrophy, Endometritis/PID, endometrial polyps, endometrial hyperplasia, endometrial cancer
  • Cervical causes - cervicitis, cervical polyps, cervical cancer
  • Vulval causes - dermatitis, vulval dystrophy, cancer
  • Bleeding disorder
  • Metasatic cancer
  • GU/PR bleeding - rectal carcinoma, bladder cancer etc.
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19
Q

What is post-menopausal bleeding thought of as being due to until proven otherwise?

A

Endometrial cancer

20
Q

What investigations would you consider for suspected endometrial cancer (to diagnose it)?

A
  • Imaging - TVUSS - measure endomerial thickness (biopsy if >4mm)
  • Other - Endometrial biopsy/curettage (pipelle),
  • hysteroscopy and biopsy
21
Q

What investigations would you consider doing to stage endometrial cancer?

A
  • Bedside - ECG
  • Bloods - FBC, U+E’s, LFTs, group and save
  • Imaging - Consider MRI/CT abdo pelvis/PET scan
  • Other - Surgical staging
22
Q

What endometrial thickness on TVUSS would raise suspicion of endometrial cancer?

A

> 4mm

23
Q

What might histopathology of an endometrial cancer show?

A

Adenocarcinoma

24
Q

What is regarded as the gold standard for staging of endometrail cancer?

A

Surgical staging

25
Q

How is endometrial cancer graded?

A

FIGO grading system - based on pathological aggressiveness of disease

26
Q

What does G1 grading of endometrail cancer indicate?

A

5% or less of a non-squamous or non-morular solid growth pattern (good)

27
Q

What does G2 staging of endometrial cancer indicate?

A

6-50% of a non-squamous or non-morular solid growth pattern (OK)

28
Q

What does G3 staging of endometrial cancer indicate?

A

>50% of a non-squamous or non-morular solid growth pattern (bad)

29
Q

What does stage I endomtrial cancer mean?

A

Cancer limited to body of the uterus only

30
Q

What does stage II endometrial cancer mean?

A

Limited to body of uterus and cervix

31
Q

What does Stage III endometrial cancer mean?

A

Extenstion to uterine serosa, peritoneal cavity +/- lymph nodes

32
Q

What does stage IV endometrial cancer mean?

A

Extension to adjacent organs or beyond true pelvis

33
Q

How would you manage stage I endometrial cancer?

A

Total abdominal hysterectomy and bilateral salpingo-oophrectomy

34
Q

How would you manage stage II endometrial cancer?

A

Exploratory laparotomy and surgical staging with:

  • Radical hysterectomy,
  • Bilateral pelvic lymph node dissection (BPND) +/- para-aortic lymph node clearance
  • Pelvic and peritoneal washings for cytology
  • Omental sampling if indicated
35
Q

How would you manage stage III/IV endometrial cancer?

A
  • Exploratory laparotomy with maximal tumour debulking and full surgical staging
  • Consider chemotherapy
  • Consider radiotherapy
  • Progesterone
36
Q

How effective is chemotherapy in endometrial cancer?

A

Not very effective

37
Q

What are the main chemotherapeutic medications usedd when treating endometrial cancer?

A
  • Doxorubicin
  • Paclitaxel
  • Carboplatin/cisplatin
38
Q

What hormonal therapy is used for palliation of symptoms?

A

High-dose progesterone (acte like an anti-oetrogen, shrinking tumour)

39
Q

When is radiotherapy used in endometrial cancer?

A

Following surgery, reduces risk of local relaose but doesnt affect overall survival

40
Q

How does radiotherapy help in endometrial cancer?

A

Adjuvant radiotherapy reduces the risk of local pelvic recurrence, but confers no survival advantages to women with disease severity less than stage Ib grade 3

41
Q

What is the prognosis of stage IV endometrial cancer?

A

25%

42
Q

What are complications of endometrial cancer treatment?

A
  • Vaginal stenosis/atrophy/fibrosis - following radiotherapy
  • Bladder instability - following surgery
  • Sexual dysfunction - following treatment
  • Local/distant spread
  • Lymphoedema
  • Toxicity - associated with chemo
  • Bowel or bladder fistulae - following radiotherapy
43
Q

Endometrial cancer metastases sites

A

Vaginal vault (most common)

Lymph nodes

Omentum/peritoneum

Chest

44
Q

Recurrence risk endometrial cancer

A

30% recurrence risk - radiotherapy if confined to pelvis

45
Q

Prognosis endometrial cancer

A

BEST SURVIVAL RATE OFT HE GYNAECOLOGICAL CANCERS

Stage 1 - 85% 5 year survival rate

Stage 4 - 21% 5 year survival rate

Overall 75% 5 year survival rate

Gwen - Reproductive Medicine (Obs, Gyn, Breast) (49 decks)

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