Endometrial Carcinoma Flashcards
What is endometrial carcinoma?
Cancer that arises from the endometrium (innermost lining of the uterus)
Epidemiology of endometrial carcinoma?
Peak incidence: 50-60 years, uncommon under 40
In young women, can be caused by certain underlying conditions I.e PCOS or lynch syndrome
Risk factors for endometrial cancer?
Prolonged period of anovulation e.g early menarche/late menopause.
Low parity (number of times a woman has given birth to a live neonate (any gestation) or at 24 weeks or more)
PCOS
Obesity - excess risk associated with the conversion of androgens in body to oestrogens. Obesity is the biggest risk of endometrial cancer
2 main types of endometrial carcinoma?
Endometrioid and mucinous carcinoma (type 1 tumours) - 80%
Serous and clear cell carcinoma (type 2 tumours) - 20%
Main pathophysiology of Endometrioid and mucinous carcinoma (type 1 tumours)
- Atypical hyperplasia is the precursor, related to unopposed oestrogen
- PTEN, KRAS, PIK3CA mutations
- Can occur in association with Lynch syndrome (defective
DNA mismatch repair gene)
Pathophysiology of Serous and clear cell carcinoma (type 2 tumours)
- Serous intraepithelial carcinoma is the precursor, not associated with unopposed oestrogen
- Affects elderly post-menopausal women
- TP53 mutation and overexpression
- Spreads along Fallopian tube mucosa and peritoneal surfaces so can present with extrauterine disease
- More aggressive than endometrioid/mucinous carcinoma
Spread of endometrial cancer?
Spread can be directly into the myometrium and cervix, through lymphatics, or haematogenous
Symptoms of endometrial cancer?
Generally presents with abnormal bleeding, most commonly postmenopausal bleeding
Examination findings of endometrial cancer?
- Abdominal examination- abdominal or pelvic masses
- Speculum examination- vulval/vaginal atrophy, or cervical lesions
- Bimanual examination - assess size and axis of the uterus prior to endometrial sampling
First line investigation for endometrial cancer?
Transvaginal ultrasound
Best method of establishing abnormally thickened endometrium in a post-menopausal patient with PMB (post-menstrual bleeding)
When should an endometrial biopsy be carried out?
If an endometrial thickness of >4mm in a postmenopausal woman is identified
If malignancy is confirmed, an MRI or CT scan may be used for staging. True/false?
True
Use of MRI and CT scans in endometrial cancer?
MRI scanning can be used to assess the degree of myometrial invasion
CT scanning is used to look for distant nodal metastases and pulmonary metastases
What criteria is used for staging of gynaecological cancers I.e. endometrial?
FIGO criteria
Stage 1 FIGO?
carcinoma confined to within uterine body
Stage 2 FIGO?
carcinoma may extend to cervix but is not beyond the uterus
Stage 3 FIGO?
carcinoma extends beyond uterus but is confined to the pelvis
Stage 4 FIGO?
carcinoma involves bladder or bowel, or has metastasised to distant sites
Management of endometrial cancer is dependant on the FIGO stage. True/false?
True
Treatment of different FIGO stages of endometrial cancer?
- Stage I- total hysterectomy and bilateral salpingo-oophorectomy
- Stage II- radical hysterectomy, may be offered adjuvant radiotherapy
- Stage III- maximal de-bulking surgery, additional chemotherapy is usually given prior to radiotherapy
- Stage IV - maximal de-bulking surgery, palliative approach is preferred (e.g. low dose radiotherapy)
Type 2 tumour treatment?
usually involve more extensive surgery and adjuvant chemo/radiotherapy is used more frequently
Common presentation of uterine (endometrial) cancer?
Presents with abnormal bleeding (dysfunctional uterine bleeding or postmenopausal bleeding)
Endometrial carcinoma macroscopic features?
Large uterus
Polypoid (related to/resembling a polyp)
Endometrial carcinoma microscopic features?
Most are adenocarcinomas
Most are well differentiated
Why is obesity a known risk factor for endometrial cancer?
This excess risk is associated with the endocrine and inflammatory effects of adipose tissue.
Adipocytes express aromatase that converts ovarian androgens into oestrogens, which induce endometrial proliferation.
Can weight loss reduce risk of endometrial cancer?
Yes
Weight loss (loss of adipose tissue) are associated with a reduction in risk.
What is lynch syndrome?
Lynch syndrome (Hereditary non-polyposis colorectal cancer) is a cancer predisposition syndrome - high risk of colorectal cancer.
High risk of endometrial cancer (lifetime risk 28%) and an increased probability of developingovarian cancer.
What causes lynch syndrome?
Due to the inheritance of a defective DNA mismatch repair gene.
Autosomal dominant inheritance.
A feature of Lynch syndrome?
Lynch syndrome tumours also show microsatellite instability (MSI), a characteristic of defective mismatchrepair.
Testing cancer tissue for MSI can be useful.
What lymph nodes may be removed as a result of endometrial cancer?
Pelvic (common, internal and external inguinal) lymph nodes
para-aortic lymph node
What is de-bulking surgery?
Debulking is the reduction of as much of the bulk of a tumour without the intention of a complete eradication.
Used in cases where the cancer has spread beyond the uterus and cervix towards the ovaries and fallopian tubes.
Eradicates majority of tumour before chemotherapy is carried out in an attempt to clear out the rest.
Endometrial cancer is mostly present in young women. true/false?
False
Cervical cancer mostly present in young women, diagnosed mainly between ages 35-44
How does early menarche or late menopause increase risk of endometrial cancer?
This is because both in cases of early menarche or late menopause. There is an increase in the period of time that the body is exposed to unopposed oestrogen.
Any factor that increases unopposed oestrogen in the body will increase risk of endometrial cancer.
Risk factors of endometrial cancer that result in unopposed oestrogen?
Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen
For endometrial protection, women with PCOS, what should women be given?
Should be given one of the following:
- The combined contraceptive pill
- An intrauterine system (e.g. Mirena coil)
- Cyclical progestogens to induce a withdrawal bleed.
Protective factors of endometrial cancer?
Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking
Key presenting feature of endometrial cancer?
Postmenopausal bleeding
Bleeding that is present >12 months after occurrence of menopause
Apart from postmenopausal bleeding, what else can endometrial cancer present with?
Postcoital bleeding
Intermenstrual bleeding (vaginal bleeding at any time within menstrual cycle other than in normal menstruation).
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
