Endometrial Carcinoma

Question 1

What is endometrial carcinoma?

Answer 1

Cancer that arises from the endometrium (innermost lining of the uterus)

Question 2

Epidemiology of endometrial carcinoma?

Answer 2

Peak incidence: 50-60 years, uncommon under 40

In young women, can be caused by certain underlying conditions I.e PCOS or lynch syndrome

Question 3

Risk factors for endometrial cancer?

Answer 3

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

Question 4

2 main types of endometrial carcinoma?

Answer 4

Endometrioid and mucinous carcinoma (type 1 tumours) - 80%

Serous and clear cell carcinoma (type 2 tumours) - 20%

Question 5

Main pathophysiology of Endometrioid and mucinous carcinoma (type 1 tumours)

Answer 5

• 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)

Question 6

Pathophysiology of Serous and clear cell carcinoma (type 2 tumours)

Answer 6

• 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

Question 7

Spread of endometrial cancer?

Answer 7

Spread can be directly into the myometrium and cervix, through lymphatics, or haematogenous

Question 8

Symptoms of endometrial cancer?

Answer 8

Generally presents with abnormal bleeding, most commonly postmenopausal bleeding

Question 9

Examination findings of endometrial cancer?

Answer 9

• 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

Question 10

First line investigation for endometrial cancer?

Answer 10

Transvaginal ultrasound

Best method of establishing abnormally thickened endometrium in a post-menopausal patient with PMB (post-menstrual bleeding)

Question 11

When should an endometrial biopsy be carried out?

Answer 11

If an endometrial thickness of >4mm in a postmenopausal woman is identified

Question 12

If malignancy is confirmed, an MRI or CT scan may be used for staging. True/false?

Answer 12

True

Question 13

Use of MRI and CT scans in endometrial cancer?

Answer 13

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

Question 14

What criteria is used for staging of gynaecological cancers I.e. endometrial?

Answer 14

FIGO criteria

Question 15

Stage 1 FIGO?

Answer 15

carcinoma confined to within uterine body

Question 16

Stage 2 FIGO?

Answer 16

carcinoma may extend to cervix but is not beyond the uterus

Question 17

Stage 3 FIGO?

Answer 17

carcinoma extends beyond uterus but is confined to the pelvis

Question 18

Stage 4 FIGO?

Answer 18

carcinoma involves bladder or bowel, or has metastasised to distant sites

Question 19

Management of endometrial cancer is dependant on the FIGO stage. True/false?

Answer 19

True

Question 20

Treatment of different FIGO stages of endometrial cancer?

Answer 20

• 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)

Question 21

Type 2 tumour treatment?

Answer 21

usually involve more extensive surgery and adjuvant chemo/radiotherapy is used more frequently

Question 22

Common presentation of uterine (endometrial) cancer?

Answer 22

Presents with abnormal bleeding (dysfunctional uterine bleeding or postmenopausal bleeding)

Question 23

Endometrial carcinoma macroscopic features?

Answer 23

Large uterus
Polypoid (related to/resembling a polyp)

Question 24

Endometrial carcinoma microscopic features?

Answer 24

Most are adenocarcinomas
Most are well differentiated

Question 25

Why is obesity a known risk factor for endometrial cancer?

Answer 25

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.

Question 26

Can weight loss reduce risk of endometrial cancer?

Answer 26

Yes
Weight loss (loss of adipose tissue) are associated with a reduction in risk.

Question 27

What is lynch syndrome?

Answer 27

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.

Question 28

What causes lynch syndrome?

Answer 28

Due to the inheritance of a defective DNA mismatch repair gene.

Autosomal dominant inheritance.

Question 29

A feature of Lynch syndrome?

Answer 29

Lynch syndrome tumours also show microsatellite instability (MSI), a characteristic of defective mismatchrepair.

Testing cancer tissue for MSI can be useful.

Question 30

What lymph nodes may be removed as a result of endometrial cancer?

Answer 30

Pelvic (common, internal and external inguinal) lymph nodes
para-aortic lymph node

Question 31

What is de-bulking surgery?

Answer 31

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.

Question 32

Endometrial cancer is mostly present in young women. true/false?

Answer 32

False

Cervical cancer mostly present in young women, diagnosed mainly between ages 35-44

Question 33

How does early menarche or late menopause increase risk of endometrial cancer?

Answer 33

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.

Question 34

Risk factors of endometrial cancer that result in unopposed oestrogen?

Answer 34

Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen

Question 35

For endometrial protection, women with PCOS, what should women be given?

Answer 35

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.

Question 36

Protective factors of endometrial cancer?

Answer 36

Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking

Question 37

Key presenting feature of endometrial cancer?

Answer 37

Postmenopausal bleeding

Bleeding that is present >12 months after occurrence of menopause

Question 38

Apart from postmenopausal bleeding, what else can endometrial cancer present with?

Answer 38

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