Endometrial Hyperplasia and Carcinoma Flashcards
Define Endometrial hyperplasia including pathophysiology of the disease
Thickening of the endometrial layer due to chronic unopposed oestrogen (reduced progesterone) which predisposes the endometrium to cytological atypia => pre-cancerous state
What are the different methods of obtaining an endometrial biopsy?
OPD:
Pipelle biopsy
Hysteroscopy + biopsy
Theatre under GA:
Hysteroscopy D&C
10-50% of endometrial hyperplasia will develop into cancer. What investigations would you perform?
Nothing would be found on examination
TVUS - Endometrial thickness >4mm
Hysteroscopy D&C - Biopsy
You perform a hysteroscopy Dilatation and curettage after confirming increased endometrial thickness >4mm. What are the possible pre-cancerous and cancerous results that you may obtain.
Give the treatment options for each
Pre-cancerous:
1) Simple Hyperplasia -> *Enlarged endometrial glands, no atypia
2) Complex Hyperplasia -> Enlarged and *proliferative endometrial glands with *architectural/structural complexity, no atypia
Conservative treatment:
a) Low risk = Cyclical, High risk Continuous progestogen (Levonorgestrel)
b) + Repeat biopsy in 6 months
3) Atypical Hyperplasia -> Enlarged, proliferative endometrial glands with *Atypical nuclei -> TAH + BSO
4) Endometrial Adenocarcinoma -> Irregular vascular appearance of endometrium. Undifferentiated cellular structure with complex architecture -> TAH + BSO + Peritoneal washings +/- Adjuvant therapy
Briefly explain what atypia is
cells show abnormal size, shape, and organization, significantly increasing the risk of progression to cancer.
What cancers are a part of lynch syndrome?
Give another name for lynch syndrome
AKA Hereditary non-polyposis colorectal cancers
1) Endometrial Ca
2) Breast Ca
3) Colorectal Ca
You perform a hysteroscopy Dilatation and curettage after confirming increased endometrial thickness >4mm. Complex hyperplasia was present with complex endometrial glandular structure with proliferation but no atypia. She is started on Levonorgestrel Mirena coil. She comes back 6 months later for her repeat biopsy with shows atypical nuclei. The patient is 81 years old and has a history of a stroke and a TIA, BMI 36. What is your management plan?
Surgery is clearly contraindicated in this patient. She will remain on Mirena coil.
The rule is. If TAH + BSO is contraindicated, Mirena coil is the best bet
Endometrial carcinoma:
What is the pathophysiology?
What is the most common type of adenocarcinoma? State the other 2 main types.
What are the RFs of Endometrial carcinoma?
Same as hyperplasia, unopposed oestrogen
Most common type = 95% Adenocarcinoma. Others: Papillary serous, clear cell
Recall: Progesterone is produced by the corpus luteum after ovulation => Anovulation is a major risk factor => extremes of reproductive age (early menarche, late menopause, PCOS)
+ Subcutaneous fat also produces oestrogen Post-menopausally => Aromatization of adrenal steroids => obesity is another RF
1) Anovulation + increased exposure to oestrogen (Early menarche + Late menopause + PCOS + Nulliparity)
2) Obesity (Aromatization)
3) Exogenous HRT (especially if given oestrogen-only)
4) Tamoxifen (oestrogen receptor agonist)
5) Lynch Syndrome/Hereditary Non-polyposis Colorectal Cancers ( endometrial breast colorectal)
What would be important to elicit in a history of post-men bleed?
I) Anorexia, weight loss
II) Irregular bleeding including IMB
III) Go over RFs:
1) Anovulation + increased exposure to oestrogen (Early menarche + Late menopause + PCOS + Nulliparity)
2) Obesity (Aromatization)
3) Exogenous HRT (especially if given oestrogen-only)
4) Tamoxifen (oestrogen receptor agonist)
5) Lynch Syndrome/Hereditary Non-polyposis Colorectal Cancers ( endometrial breast colorectal)
What is the chemoradiotherapy used in endometrial cancer
Platinum + external beam pelvic radiation
Endometrial cancer is treated with TAH + BSO + Peritoneal washings
State the FIGO staging for endometrial cancer.
Include the equivalent Histological grading
Include the relevant Adjuvant therapy
Stage I - Confined to Uterus
a) Endometrium, no myometrial invasion = <5% solid -> No adjuvant
b) <50% myometrial invasion = 6-50% solid -> No adjuvant
c) > 50% myometrial invasion = >50% solid -> Radiotherapy + Vault Brachytherapy
Stage II - Confined to uterus + Cervix -> Radiotherapy + Vault Brachytherapy
Stage III - Outside uterus but within the true pelvis +/- Paraaortic LN -> Chemoradiotherapy (Platinum + external beam pelvic radiation)
Stage IV - Local (bladder/rectum) or Distant (lung/liver) metastasis -> Palliative care
What is involved in palliative care of endometrial cancer?
1) Progesterone
2) Low dose radiotherapy to prevent bleeding
3) Chemotherapy to prevent pain
You perform a TVUS on a patient with post-menopausal bleed. What findings would support the diagnosis of endometrial cancer?
Endometrial thickness >4mm
Fluid in endometrial cavity (blood)
+/- Endometrial polyps
What is the followup protocol for endometrial carcinoma management?
6 weeks post-op
4 monthly for 2 years
yearly until 5 years
Give your full management plan (including investigations) for a patient with confirmed biopsy with cells show abnormal size, shape, and organization, significantly increasing the risk of progression to cancer and an irregular vascular pattern
Investigations:
1) Routine bloods
2) TVUS showing thickness, fluid in endometrial cavity, endometrial polyps)
3) MRI pelvis/CTTAP -> Assess invasion and lymphadenopathy
4) Biopsy via pipelle, Hysteroscopy + biopsy, Hysterocopy D&C
Management:
1) MDT + Referral to gynaecological oncology specialist centre
2) TAH + BSO + Peritoneal washings
3) Adjuvant therapy: External beam radio, platinum chemo, vault brachytherapy
4) Followup 6 weeks, 4 monthly for 2 years, yearly until 5 years
