Endometrial Hyperplasia and Cancer Flashcards
What is Endometrial Hyperplasia?
This is abnormal thickening of the uterine lining caused by proliferation of endometrial glands due to prolonged exposure to excess unopposed oxygen
Describe the pathogenesis of endometrial hyperplasia?
•Endometrial hyperplasia results from estrogen predominance and progesterone insufficiency.
•Estrogen stimulation of the endometrium causes proliferative glandular epithelial changes
How is endometrial hyperplasia classified according to WHO?
-Non-atypical hyperplasia (benign endometrial hyperplasia)
-Atypical hyperplasia (endometrial intraepithelial neoplasia
Describe the histological difference between benign endometrial hyperplasia and Endometrial intraepithelial neoplasia.
Benign endometrial hyperplasia
-Increased gland-stromal ratio.
-Glands show a variation in shape and size and may be dilated.
-Some intervening stroma present.
Endometrial intraepithelial neoplasia
-Increased gland- stromal ratio
-Glands show a variation in shape and size
-Complex patterns of proliferating glands displaying atypia.
-The cells display nuclear enlargement with or without prominent nucleoli.
What are the risk factors for Endometrial Hyperplasia?
Unopposed endogenous estrogen
Obesity
Nulliparity
Early menarche
Late menopause
Polycystic ovarian syndrome
Estrogen secreting tumors
Unopposed exogenous estrogen
Use of tamoxifen
Hormone replacement therapy
Genetics: Type 2 DM, family history, advanced age.
What are the protective factors of Endometrial hyperplasia?(4)
-Weight loss
-Multiparity
-COCs
-Progestin only pills
What are the clinical features of Endometrial Hyperplasia?
Abnormal uterine bleeding:
Postmenopausal: spotting
Premenopausal: heavy menstrual bleeding and inter menstrual bleeding.
What examination is done and what are the usual findings seen in the exam?
Pelvic examination usually normal
What investigations are done in Endometrial hyperplasia?
Laboratory results usually normal.
Transvaginal ultrasound:
To measure endometrial thickness.
To rule out structural causes of abnormal uterine bleeding.
Endometrial sampling:
Pipelle aspiration biopsy
Dilation and curettage
Hysteroscopy
What is the treatment for Benign Endometrial Hyperplasia?
1.Spontaneous regression without therapy
2.Low dose progestin therapy for 3-6months
-combined oral pills once daily
-medroxyprogesterone acetate 10-20mg 12-14days a month/ 10mg daily
-levonorgestrel IUD 20mcg per day.
3.Persistent disease: high dose MPA 40-100mg orally, Megestrol Acetate 160mg once daily, 80mg twice daily.
4.Refractory: hysterectomy
What is the treatment of Endometrial intraepithelial neoplasia?
1.Hysterectomy
2.High dose progestin therapy in premenopausal women with future fertility plans e.g. Megestrol Acetate 80mg twice daily.
If medical management was opted
Endometrial biopsy should be taken at least every 3months until 2 consecutive negative biopsies obtained.
What is endometrial cancer?
malignancy originating within the epithelial lining of the uterus
What is the most common endometrial cancer?
Endometroid Adenocarcinoma
-arises in the background of endometrial intraepithelial neoplasia.
How is endometrial cancer classified? And how do the two differ
TYPE 1 ENDOMETRIAL CANCER
-Endometroid adenocarcinoma (grade 1 and 2)
-Directly related to long term exposure to increased estrogen levels unopposed by progestin
-Referred to as estrogen-dependent neoplasms
-Most common type, making about 80% of all endometrial cancers
-These tumors usually begin as atypical endometrial hyperplasia/ endometrial intraepithelial neoplasia
-Some genetic mutation
TYPE 2 ENDOMETRIAL CANCER
-Endometriod adenocarcinoma (grade 3)
-Mostly estrogen independent
-Associated with endometrial atrophy (especially in -postmenopausal women) and polyps
-Genetic predisposition
Which genetic mutation is associated with Endometrial Cancer type 1?
PTEN genetic mutation
Which genetic mutation is associated with Endometrial cancer type 2?
p53 gene
What are the characteristics of patients who present with Endometrial cancer type 2?
-Vaginal Atrophy
-Thinner
-Older patients
-African Descent
What are the histological subtypes of Endometrial cancer(5) and describe them? Which one is associated with atrophic endometrium.
Endometroid adenocarcinoma: most common type
Serous carcinoma: highly aggressive and arise from atrophic endometrium.
Clear cell carcinoma: deeply invasive associated with poor prognosis.
Mucinous carcinoma: difficulty in differentiating with cervical adenocarcinoma.
Mixed and undifferentiated carcinoma.
What are the risk factors for type 2 Endometrial Cancer?
TYPE II
Low BMI
Black race
Older age
History of breast cancer.
What are the clinical features of Endometrial Cancer?
-Postmenopausal bleeding
-Abnormal vaginal discharge.
-Prolonged menses
-Heavy menstrual bleeds
-Intermenstrual bleeding
In Endometrial cancer type 2:
Abd pain, pelvic pressure and bloating.
What physical examinations are done in Endometrial Cancer and what are the findings?
Bimanual exam to assess size, shape and mobility of pelvic mass.
•Abdominal exam: ascites
•Palpation of lymph nodes
What is the tumor marker in Endometrial cancer?
CA125
What investigations are done to diagnose Endometrial Cancer diagnosed?
1.Bloods:
Full Blood Count
CA125
2.Imaging
Transvaginal ultrasound
•Incase of metastases:
1.CT: lymph node involvement or metastatic disease
2. MRI
Endometrial Biopsy
What condition is associated with endometrial Cancer
Lynch Syndrome
What is the treatment for Endometrial cancer ?
1.Surgical management
-Hysterectomy with bilateral salpingo-oophorectomy
-Lymphadenectomy or sentinel lymph node biopsy in high grade disease for staging.
-Extensive staging in high grade cancers: infracolic omentectomy, bilateral peritoneal biopsy
With adjuvant chemotherapy and Radiation therapy
2If the family has not been completed- Hormone Therapy - levonorgestrel-releasing IUD, Megestrol acetate 160mg once daily
3.Targeted therapy
4.For advanced or recurrent cases:
-Chemotherapy with carboplatin and paclitaxel.
-Surgical cytoreduction.
-Radiation
What drugs are used for chemotherapy ?
Carboplatin
Paclitaxel
How is Endometrial Cancer prevented?
Educating
Encouraging postmenopausal women to report any unexpected bleeding and spotting.
Weight loss
Endometrial biopsy every 1-2 years beginning at 30 to 35 years for women with Lynch syndrome
Prophylactic hysterectomy in women with Lynch syndrome.
