Endometrial Carcinoma

Question 1

EPIDEMIOLOGY:

Answer 1

• Most common genital tract cancer
• Highest prevalence at >60y
• 25% cases occur premenopausally
• Good prognosis due to early detection

Question 2

RISK FACTORS:

1. Endogenous oestrogen in excess;
2. Exogenous oestrogen in excess:
3. Miscellaneous:

*COCP is protective

Answer 2

1. PCOS, obesity, oestrogen-secreting tumours, nulliparity, late menopause, early menarche
2. Tamoxifen, unopposed oestrogen therapy(addition of progestogen is protective)
3. Hypertension and Diabetes(non-independent risk f), Lynch type II syndrome(familial non-polyposis colonic, ovarian and endometrial carcinoma)

Question 3

CLINICAL FEATURES:

Answer 3

1. Postmenopausal bleeding
   - PMB has 10% risk of carcinoma
2. Premenopausal presentations:
   - Intermenstrual bleeding
   - Irregular bleeding
   - Recent-onset menorrhagia
   - Cervical smear showing abnormal columnar cells consistent with CGIN
   - Pain and vaginal discharge(unusual presentations)
3. Pelvic examination often normal.

Question 4

FIGO STAGING OF ENDOMETRIAL CARCINOMA:

1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4

*Endocervical glandular involvement only shd be considered as stage 1

Answer 4

1. Lesions confined to uterus
   1A. <1/2 myometrial invasion
   1B. >1/2 myometrial invasion
2. Same as 1 with cervical stroma invasion but not beyond uterus.
3. Local and/or regional spread of tumour
   A. Invades serosa/adnexae
   B. Vaginal and/or parametrial involvement
   Ci. Pelvic node involvement
   Cii. Para-aortic involvement
4. Further spread:
   A. In bowel/bladder
   B. Distant metastases including intra-abdominal metastases and/or inguinal lymph nodes

Question 5

INVESTIGATIONS:

1. Investigate postmenopausal bleeding
2. Staging
3. Assess patient’s fitness

Answer 5

1. TVUS(endometrial thickness <4mm has high NPV) and/or endometrial biopsy with Pipelle/hysteroscopy
2. a) Only possible after hysterectomy
   b) MRI if spread suspected/high risk of spread from endometrial histology
   c) CXR to exclude pulmonary spread(rare)
3. FBC, renal function, glucose testing, ECG

Question 6

TREATMENT:

1. Surgery
2. Radiotherapy
3. Chemotherapy

Answer 6

1. Hysterectomy with bilateral salpingoophorectomy(BSO) abdominally/laparoscopically
   - in all early stage disease if patient is fit
   - staging done after surgery. if high-risk disease, may require post-op radiotherapy
2. • If proven extrauterine disease/high risk of extrauterine disease: eg deep myometrial invasion, poor tumour histology/grade, or cervical stroma involvement, recurrent disease
     a) External beam radiotherapy
     b) vaginal vault radiotherapy
3. High-risk early stage and advanced-stage disease.
   - Doxorubicin and cisplatin

Question 7

PROGNOSIS;

1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4
5. Overall

Poor prognostic features:

Answer 7

5-year survival rates:

1. 85%
2. 65%
3. 40%
4. 10%
5. 75%

Older age, advanced clinical stage, deep myometrial invasions, high tumour grade, adenosquamous histology.

Question 8

UTERINE SARCOMAS;

1. Leiomyosarcomas
2. Endometrial stromal tumours
3. Mixed mullerian tumours
4. Clinical features
5. Treatment
6. Prognosis

Answer 8

1. • Malignant fibroids
     - Rapid painful enlargement of fibroid
2. Most common in perimenopausal women
3. Common in old age
4. Irregular/postmenopausal bleeding
5. Hysterectomy. Possibly radio/chemotherapy
6. 5-year survival rate: 30%

Question 9

POST-MENOPAUSAL BLEEDING:

1. Definition
2. Causes
3. Investigations

Answer 9

1. Vaginal bleeding that occurs after 12 months of amenorrhoea in a woman of age when menopause can be expected.
2. a) Most common: Atrophic vaginitis, benign cervical polyp
   b) Other causes: HRT, Endometrial hyperplasia, Ovarian carcinoma, Cervical carcinoma, Vaginal carcinoma, Vulvar carcinoma, Uterine sarcoma, Trauma
3. a) TVUS
   - Cut-off 4mm for endometrial thickness
   - 3mm if on tamoxifen
   b) Endometrial biopsy
   c) Hysteroscopy