Endometrial Carcinoma (& Endometrial Hyperplasia)

Question 1

Outline the Epidemiology of Endometrial Carcinoma

Answer 1

• MOST COMMON genital tract cancer
• Prevalence highest at 60yrs
  
  • 15% premenopausally - <35yrs
  • Presents EARLY so often INCORRECTLY considered benign

Question 2

Outline the Pathology of Endometrial Carcinoma

Answer 2

• **ADENOCARCINOMA **(90%) of columnar endometrial gland cells
• Other rarer ones;
  
  • Adenosquamous carcinoma [contains malignant squamous and glandular tissue - poorer prognosis]

Question 3

Outline the Aetiology of Endometrial Carcinoma

Answer 3

• High ratio of Oestrogen/ Progestogen
• So malignancy is common when;
  
  • Oestrogen production is high
  • Oestrogen therapy unopposed by Progestogens

Question 4

Outline the Risk Factors for Endometrial Carcinoma

Answer 4

• Exogenous Oestrogens without progestogens (6x)
• Obesity - peripheral androgen to oestrogen conversion
• PCOS [higher oestrogen]
• Nulliparity [longer oestrogen]
• Late menopause [longer oestrogen]
• Ovarian granulosa cell tumours [oestrogen secreting]
• Tamoxifen [although antagonist to Oestrogen in breast, its agonist in postmenopausal Uteri]

Question 5

Outline Protective Factors for Endometrial Carcinoma

Answer 5

• COCP
• Pregnancy

Question 6

What is Endometrial Hyperplasia?

Outline the stages

Answer 6

• Abnormal proliferation of endometrial tissue due to unopposed Oestrogen
• Premalignant to Endometrial cancer

Stages;

1. Simple
2. Complex

• Cystic Hyperplasia

1. Simple Atypical
2. Complex Atypical

• Atypical Hyerplasia = Abnormal Cell

Question 7

When is Endometrial Hyperplasia with atypia usually found? Outline the treatment

Answer 7

• Normally women of reproductive age
• Present with abnormal vaginal bleeding
• Treatment;
  
  • Hysterectomy [absolute treatment]
  • Progestogens + 6monthly endometrial biopsy [maintain uterus]

Question 8

Outline the Clinical Features of Endometrial Carcinoma

Answer 8

• Postmenopausal bleeding [10% risk of Endometrial Carcinoma]
• Premenopausal = ‘change’
  
  • Irregular/ intermenstrual bleeding
  • Recent onset menorrhagia O/E normal

Question 9

Outline the Investigations for Endometrial Carcinoma

Answer 9

Post-Menopausal Bleeding

• Ultrasound scan
  
  • Endometrium >4mm
• or Multiple episodes
  
  • ⇒Biopsy by Pipelle or during Hysteroscopy

**Pre-Menopausal **‘change’

• Ultrasound scan abnormal
• ** ‘Change’** in periods & >40yrs
  
  • ⇒Biopsy

Smear: May show abnormal collumnar cells [cervical glandular intraepithelial neoplasia]

• Consider;
  
  • MRI [spread]
  • FBC
  • U&E
  • CXR [pulmonary spread]
  • Glucose
  • ECG

Question 10

Outline the Spread & Staging of Endometrial Carcinoma

Include 5 year survival rates

Answer 10

Tumour spread

• Direct: ⇒ Myometrium → Cervix → Vagina (+/- Ovaries)
• Lymph: ⇒ Pelvic →Para-aortic
• Blood: Occurs late

Staging [5yr survival]

• Surgical
  
  1. Lesion confined to Uterus [75%] [80]
     
     • A: <½
     • B: >½
  2. • Cervix [70]
  3. Invades through Uterus [50]
     
     • A: serosa/ adnexae
     • B: vaginal
     • Ci: pelvic lymph
     • Cii: para-aortic lymph
  4. Further spread [25]
     
     • A: bowel/bladder
     • B: distant mets

Question 11

Outline the management of Endometrial Carcinoma

Answer 11

Depends on stage;

1. Hysterectomy & bilat. salpingo-oophorectomy (BSO)
2. Radical Hysterectomy + Node clearance + Radiotherapy
3. & 4. Maximal Debulking Therapy
   
   • Surgery
   • Chemotherapy
   • Radiotherapy

• Radiotherapy types;
  
  • External beam radiotherapy
  • Vaginal vault radiotherapy

Question 12

What is the prognosis for Endometrial Carcinoma

Answer 12

• Recurrence most common at vaginal vault in <3yrs
• Poor prognostic features;
  
  • Elder age
  • Advanced stage/ high grade
  • Deep myometrial involvement in stage 1/2
  • Adenosquamous histology