Endometrial cancer (Complete)

Question 1

Definition endometrial cancer

Answer 1

Malignancy that originates from the endometrium, the inner lining of the uterus.

Question 2

What is the clinical significance of endometrial cancer?

Answer 2

6th most common cancer in woman

15th most common cancer worldwide

Question 3

What is the main aetiological cause of enodmetrial cancer?

Answer 3

Excess unoppososed oestrogen

(Increased proliferation of the glandular endometrial cells, –> greater gland:stroma ratio than is seen in normal endometrium)

Question 4

What risk factors are associated with endometrial cancer?

Answer 4

Factors which can increase endogenous or exogenous exposure to oestrogen such as:

Nulliparity (lack of pregnancy interruption)

Obesity and T2DM

Early menarche (Greater lifelong period of oestrogen)

Late menopause

PCOS (Increase in androgens which can be converted into oestrogen, persistent follicles also produce oestrogen, low progesterone which opposes oestrogen)

Oestrogen-only HRT

Tamoxine therapy (Breast cancer treatment)

Lynch syndrome (HNPCC)

Question 5

What are the three main ways PCOS can lead to increased oestrogen production?

Answer 5

Increased androgen production: Gets converted to oestrogen

Chronic annovulation: Ovarian follicles fail to mature and continuously releases oestrogen which doesnt follow hormonal cycle.

Imbalance in hormones: Decrease in progesterone which balanced oestrogen

Question 6

Why is obesity associated with endometrial cancer?

Answer 6

Fat cells contain enzyme aromatase

Aromatase synthesises extra-ovarian oestrogen

Question 7

Why are some breast cancer patients at risk of endometrial cancer?

Answer 7

Tamoxifen therapy is used in management of breast cancer and associated with endometrial cancer

Question 8

What GI condition is associated with increased risk of endometrial cancer?

Answer 8

Lynch syndrome (Hereditary non-polyposis colon cancer/HNPCC)

N.B. Up to 40% will go on to develop endometrial cancer

Question 9

What are some protective factors for endometrial cancer?

Answer 9

Multiparity

Combined oral contraceptive pill use

Regular exercise

Tobacco consumption (unclear as to why)

Question 10

What is the most common form of endometrial cancer?

Answer 10

Adenocarcinoma

Question 11

What are some of the main signs/symptoms of endometrial cancer?

Answer 11

Post-menopausal bleeding (90% cases)

Irregular or inter menstrual bleeding in premenopausal women.

Recent onset menorrhagia (heavy bleeding) especially in women >45 years of age

Abdominal discomfort/bloating

Anaemia

Weight loss

Question 12

What examination should be performed in patients suspected of endometrial cancer? What are the subsequent findings?

Answer 12

Bi-manual pelvic examination

Uterine mass or enlarged uterus

A fixed uterus

Adnexal mass indicating extra-uterine disease

Question 13

What examinations should be done for patients suspected of endometrial cancer?

Answer 13

Bedside:

Basic obs: Weight loss

Bloods:

FBC: Anaemia
Blood glucose: If patient obese/check for metabolic causes

Imaging:

Transvaginal ultrasound

Endometrial biopsy: Following suspicious ultrasound

CT chest abdomen and pelvis: If advanced disease suspected

Question 14

Which presentations warrant 2-week cancer referral?

Answer 14

Any woman over 55 with post menopausal bleeding

Question 15

What is the first-line investigation for endometrial cancer?

Answer 15

Transvaginal ultrasound

Question 16

What findings on transvaginal ultrasound are indicative of endometrial cancer?

Answer 16

Abnormal thickening of endometrium

(>5mm = 96% probability of endometrial cancer)

Question 17

Following transvaginal ultrasound findings, what investigation is diagnsotic for endometrial cancer?

Answer 17

Endometrial biopsy (Pipelle or hysteroscopy)

Question 18

What alternative is offered if pipelle endometrial biopsy is contraindicted?

Answer 18

Hyesteroscopy

Question 19

What is the management plan for patients diagnosed with endometrial cancer?

Answer 19

Surgery:

Total hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy.

Medicine:

Radiotherapy and chemotherapy: Used in adjunt with surgey in patients with advanced disease

Question 20

For elderly woman in which surgery is contraindicted, what alternative management options are available?

Answer 20

Progestogen therapy

Question 21

What are some complications of management for patients with endometrial cancer?

Answer 21

Lymphoedema

Bladder instability (Bladder denervation)

Bowel and bladder fistulae

Vaginal stenosis (sexual dysfunction and makes future pelvic examinations difficult)

Early menopause

Question 22

What differentials should be considered alongside endometrial cancer?

Answer 22

Uterine fibroids: Heavy menstrual bleeding, pelvic pressure or pain, frequent urination, constipation.

Endometrial polyps: Irregular menstrual bleeding, bleeding between menstrual periods, heavy menstrual periods, vaginal bleeding after menopause.

Cervical cancer: Abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.

Question 23

How does uterine fibroids differ to endometrial cancer?

Answer 23

Nature of bleeding:
Fibroids: Heavy irregular menstrual bleeding
Endometrial cancer: Post-menopausal bleeding

Pain: Uterine fibroids moresoe associated with pain and pressure whereas is a later presentation in endometrial cancer

Systemic symptoms: More common in endometrial cancer

Question 24

How does endometrial polyps differ to endometrial cancer?

Answer 24

Bleeding pattern: Endometrial cancer more peristent and severe

Pain: Usually does not occur with endometrial polyps

Systemic symptoms: Occurs in endometrial cancer

Question 25

How does cervical cancer differ to endometrial cancer?

Answer 25

Age: Endometrial more likely to affect middle-aged, post-menopausal woman

Bleeding pattern:
Endometrial: Post-menopausal bleeding
Cervical: Post-coital bleeding

Discharge: Cervical more associated with bloody, foul-smelling discharge

Pain: Cervical cancer moresoe dyspareunia and bladder symptoms