Endometrial Cancer and Post-menopausal bleeding Flashcards
What is endomtrial cancer?
Oestrogen-dependent malignant neoplasm arising from the endometrium of the uterus
What is uterine cancer?
Any malignant neoplasm arising from the tissues of the body of the uterus, including the endometrium, myometrium and connective tissues
What is post-menopausal bleeding?
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
At what age does endometrial cancer most commonly affect women?
>50s - rare under the age of 40
(classically seen in post menopausal women byt around 35% occur before menopause)
What are risk factors for the development of endometrial cancer?
-
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)
What is thought to be the pathophysiological basis for endometrial cancer development?
Excessive oestrogen exposure with unopposed progesterone
What are protective factors for endometrial cancer?
- Parity
- OCP use
- Exercise
- Smoking
- Aspirin
- Drinking coffee
What are the main histological types of endometrial cancer?
- Endometroid (most common - 90%)
- Non-endometroid - serous, clear cell, carcinosarcoma, sarcoma
- Uterine sarcomas
What is the most common type of endometroid carcinoma?
Endometroid adenocarcinoma
What proportion of endometrial cancers occur in post-menopausal women?
91%
What are uterine sarcomas
Tumours arising from the myometrium and connective tissues of the uterus
What are the main types of uterine sarcomas?
- Leiomyosarcoma
- Carcinosarcoma
- Endometrial stromal carcinoma
- Fibrosarcoma
- Adenosarcoma
- Metastases
What are the main types of non-endometroid endometrial cancers?
- Serous carcinoma
- Clear cell carcinoma
- Mixed adenocarcinoma
How does endometrial cancer tend to present symptomatically?
- 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
What is pyometra?
Collection of pus in the uterine cavity
Typical presentation endometrial cancer
Abnormal PV bleeding, post menopausal is the classic symptom
May have lower abdo pain but this is unusual
Systemic symptoms - fatigue, weight loss, nausea
What signs might you see in someone with endometrial cancer?
Generally normal unless advanced:
- Pelvic mass
- Cancer in cervix - rare
- Enlarged, immobile uterus
What would be your differential diagnosis for someone presenting with post-menopausal bleeding?
- 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.
What is post-menopausal bleeding thought of as being due to until proven otherwise?
Endometrial cancer
What investigations would you consider for suspected endometrial cancer (to diagnose it)?
- Imaging - TVUSS - measure endomerial thickness (biopsy if >4mm)
- Other - Endometrial biopsy/curettage (pipelle),
- hysteroscopy and biopsy
What investigations would you consider doing to stage endometrial cancer?
- Bedside - ECG
- Bloods - FBC, U+E’s, LFTs, group and save
- Imaging - Consider MRI/CT abdo pelvis/PET scan
- Other - Surgical staging
What endometrial thickness on TVUSS would raise suspicion of endometrial cancer?
> 4mm
What might histopathology of an endometrial cancer show?
Adenocarcinoma
What is regarded as the gold standard for staging of endometrail cancer?
Surgical staging
How is endometrial cancer graded?
FIGO grading system - based on pathological aggressiveness of disease
What does G1 grading of endometrail cancer indicate?
5% or less of a non-squamous or non-morular solid growth pattern (good)
What does G2 staging of endometrial cancer indicate?
6-50% of a non-squamous or non-morular solid growth pattern (OK)
What does G3 staging of endometrial cancer indicate?
>50% of a non-squamous or non-morular solid growth pattern (bad)
What does stage I endomtrial cancer mean?
Cancer limited to body of the uterus only
What does stage II endometrial cancer mean?
Limited to body of uterus and cervix
What does Stage III endometrial cancer mean?
Extenstion to uterine serosa, peritoneal cavity +/- lymph nodes
What does stage IV endometrial cancer mean?
Extension to adjacent organs or beyond true pelvis
How would you manage stage I endometrial cancer?
Total abdominal hysterectomy and bilateral salpingo-oophrectomy
How would you manage stage II endometrial cancer?
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
How would you manage stage III/IV endometrial cancer?
- Exploratory laparotomy with maximal tumour debulking and full surgical staging
- Consider chemotherapy
- Consider radiotherapy
- Progesterone
How effective is chemotherapy in endometrial cancer?
Not very effective
What are the main chemotherapeutic medications usedd when treating endometrial cancer?
- Doxorubicin
- Paclitaxel
- Carboplatin/cisplatin
What hormonal therapy is used for palliation of symptoms?
High-dose progesterone (acte like an anti-oetrogen, shrinking tumour)
When is radiotherapy used in endometrial cancer?
Following surgery, reduces risk of local relaose but doesnt affect overall survival
How does radiotherapy help in endometrial cancer?
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
What is the prognosis of stage IV endometrial cancer?
25%
What are complications of endometrial cancer treatment?
- 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
Endometrial cancer metastases sites
Vaginal vault (most common)
Lymph nodes
Omentum/peritoneum
Chest
Recurrence risk endometrial cancer
30% recurrence risk - radiotherapy if confined to pelvis
Prognosis endometrial cancer
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
