Endometrial carcinoma

Question 1

When do most cancers of the endometrium occur?

Answer 1

Postmenopausal, (>91%)

Question 2

What is the most common form of endometrial carcinoma?

Answer 2

Adenocarcinoma, related to excessive oestrogen exposure unopposed by progesterone

Question 3

What are the risk factors for endometrial carcinoma?

Answer 3

Endogenous oestrogen excess
-PCOS and other conditions causing anovulatory cycles
-Obesity
-Nulliparity, early menarche, late menopause
-Liver cirrhosis
Exogenous oestrogens
-Unopposed oestrogen therapy (oestrogen-only HRT)
-Tamoxifen therapy
Micellaneous
-Diabetes tpe 2
-Lynch II syndrome and genetic disposition
-HNT

Question 4

What factors are protective against endometrial carcinoma?

Answer 4

Parity

Use of COCP

Question 5

What premalignant condition may be associated with endometrial carcinoma?

Answer 5

Endometrial hyperplasia with atypia
Hyperplasia of endometrium secondary to unopposed oestrogen, causing changes to cellular/glandular architecture (atypical hyperplasia)
Premalignant, but still causes PMB/menstrual abnormalities
Uncommon in women of reproductive age

Question 6

How can endometrial hyperplasia with atypia be managed?

Answer 6

Hysterectomy should be discussed

If fertility needed - progesterones and 3-6m hysteroscopy and endometrial biopsy used + referral to fertility clinic

Question 7

What features would endometrial carcinoma present with?

Answer 7

PMB
Premenopausal - heavy/irregular periods, IMB
PV discharge/pyometra (50% with pyometra have underlying cancer)

Question 8

What features would be found on examination of a patient with endometrial carcinoma?

Answer 8

Normal pelvis

Atrophic vaginitis may coexist

Question 9

How is endometrial cancer diagnosed?

Answer 9

PMB
Endometrial thickening on USS (>4mm)
Biopsy (endometrial sampling with pappelle) or via hysteroscopy
CT/MRI used for staging
Histology to grade cancer
Assess patient fitness for surgery (FBC, renal function, glucose levels, ECG)

Question 10

What staging system is used for endometrial cancer?

Answer 10

FIGO staging system

Question 11

What is the FIGO staging system?

Answer 11

Staging of endometrial carcinoma
1 - Tumour confined to uterus corpus (body of uterus)
1a- no/<50% myometrial invasion
1b- >50% myometrial invasion

2 - Cervical stromal invasion, but not beyond uterus (uterus body and cervix only)

3 - Local and/or regional spread of tumour (advancing beyond uterus, but not beyond pelvis)
3a- Tumour invades to serosa or adnexa
3b- vaginal and/or parametrial involvement
3c1- pelvic node involvement
3c2- para-aortic node involvement

4 - Distant spread of tumour (extending outside the pelvis e.g. bladder, bowel)
4a- Tumour invasion bladder and/or bowel mucosa
4b- Distant metastases including abdominal metastases and/or inguinal lymph nodes

Question 12

What are the survival outcomes according to the FIGO criteria?

Answer 12

Stage I - 85%
Stage II - 75%
Stage III - 45%
Stage IV - 25%

Question 13

Where is endometrial cancer likely to metastasise to?

Answer 13

Vagina 5%

Any pelvic lymph nodes 7%

Question 14

What histological grading can be used for endometrial cancer?

Answer 14

G1-3 included for each stage of FIGO, G1 being a well differentiated tumour

Question 15

What treatment options are available for patients with endometrial cancers?

Answer 15

Surgical
-Total laparoscopic hysterectomy and bilateral salpingo-oopherectomy
-Lymphadenectomy of questionable benefit, but sentinel node staging may be very useful (inject dye and sample first node to light up)
-Surgery may just be used for staging
External beam radiotherapy
-Following hysterectomy in high risk patients
-High risk for extrauterine disease
-Proven extrauterine disease
-Inoperable/recurrent disease
-Palliation for symptoms e.g. bleeding
Vaginal vault radiotherapy
-Reduces local recurrence but does not prolong survival
Chemotherapy
Progestogens
-Rarely used, only for palliation