Endometrial Pathology CPC Flashcards
_____ ______ of endometrium persists throghout the endometrial cycle
basal layer
Case:
67 year old retired teacher presents with vaginal bleeding
- 6 week history of spotting red blood/sometimes dark or brown
- No pain and no urinary or bowel symptoms
- LMP at about age 53 (first bleed since then)
- Menarche age 14 years
- Irregular cycle and primary infertility which was never investigated
- Last cervical screen at age 64 years negative
- Non smoker and occasional alcohol
- She has a BMI of 41
- She had type 2 diabetes controlled with diet and metformin
- Appendectomy at age 11 years
- Family history of ischaemic heart disease
Referred to PMB clinic - what is done?
(typical postmenopausual cervix, bleeding due to examination, small cervical os, considered normal of a women this age)
- GP refers patient for investigation of Post Menopausal Bleeding (PMB)
- Pelvic and speculum examination normal
- Transvaginal ultrasound scan to measure her endometrial thickness (endometirum is thin and regular and can be reassured that their cause of bleeding is not due to endometrial cancer)
Post-menopausal bleeding - what is done for this and how is it investgated?
• Trans-vaginal ultrasound scan:
- measure endometrial thickness
- Looks at the endometrial contour
- biopsy if >4mm or irregular
• Endometrial Biopsy - e.g. Pipelle
if it is not possible to undertake a pipelle endometrial biopsy or if there is a susicious of a localised pathology, you. may want to do what?
• Hysteroscopy
- Out patient with local anaesthetic
- In patient with general anaesthetic
what is shown here?
looking up into the uterus
distended using saline normally
can see when the flalopian tubes join the canal and this is the ostea
uterine fundus up at the top
right picture shows an endometril polyp filling the cavity - could be removed in hysteroscopy
if thickened endometrium then you can take a biopsy
Discussed results at MDT
what is recommened to do next?
TLH (total laparoscopic hysterectomy) and BSO (bilateral salpingoophorectomy)
plus peritoneal washings
picture shwoing cancer in endometrium
what are the Pathological Prognostic Features of endometrial cancer?
- Histological type
- Histological grade
- Stage
- Lymphovascular space invasion (LVSI)
Pathological Prognostic Features:
- Histological type - how do you investigate this?
Based on microscopy +/- ancillary tests
Pathological Prognostic Features:
- Histological grade - how do you investigate this?
Microscopy
Pathological Prognostic Features:
- Stage - how do you investigate this?
How far tumour has spread, based on surgical resection with assessment of entire uterus and adjacent organs
Pathological Prognostic Features:
- Lymphovascular space invasion (LVSI)
Microscopy of resection specimen
Classification: Two Distinct Categories of Endometrial Cancer
what are the categories?
type 1
type 2
what is type 1 endometrial cancer?
- Endometrioid adenocarcinoma
- By far the commonest
- Unopposed oestrogen
- Hyperplasia with atypia precursor
Type 1 cancers are the most common type. They are usually endometrioid adenocarcinomas, and are linked to excess oestrogen in the body. They are generally slow growing and less likely to spread
what is type 2 endometrial cancer?
- Uterine serous & clear cell carcinoma
- High grade, more aggressive, worse prognosis
- Generally older women
- Serous intraepithelial carcinoma precursor
Type 2 cancers include uterine serous carcinomas and clear cell carcinomas. These cancers are not linked to excess oestrogen. They are generally faster growing and more likely to spread
how is the classification of endometrial cancer made?
- The classification is changing
- In the future is likely to be based on molecular findings
- Pathologists will perform molecular testing on tumour tissue to look for certain mutations and genetic aberrations - E.g. P53 mutation, microsatellite instability
Endometrial Cancer Staging - how is it done?
- Surgical/Pathological
- MRI:
- depth of myometrial invasion
- cervical involvement
- lymph node involvement
what are the different stages of endometrial cancer?
Endometrial Cancer
Staging (FIGO 2009)
Grading is a way of dividing cancer cells into groups depending on how much the cells look like normal cells. This gives your doctor an idea of how quickly or slowly the cancer might grow and whether it is likely to spread.
Grade 1 - The cells look very like normal cells. They are also called low grade or well differentiated. They tend to be slow growing and are less likely to spread than higher grade cancer cells.
Grade 2 - The cells look more abnormal and are more likely to spread. This grade is also called moderately differentiated or moderate grade.
Grade 3 - The cells look very abnormal and not like normal cells. They tend to grow quickly and are more likely to spread. They are called poorly differentiated or high grade.
Diagnosis: Endometrioid endometrial adenocarcinoma, FIGO stage IA
what is the treatment of endometrial cancer?
- Early Stage - Surgery TAH (total abdominal hysterctomy done laproscopically)/BSO/washings
- High risk histology - Chemotherapy
- Advanced Stage - Radiotherapy
- Palliation - Progesterone
what are the endometrial cancer cure rates?
1B 85%
11A 75%
11B 60%
111B 30%
1V 21%
Why did this patient develop endometrial cancer/what are the risk factors?
- Post-menopausal women
- (Associated with) High circulating oestrogen levels:
- obesity
- unopposed E2 therapy/Tamoxifen (must combine with progesterone if the patient has a uterus)
- Polycystic ovarian syndrome (PCOS) (don’t get regular cycles)
- early menarche/late menopause
- Endometrial hyperplasia with atypia
- HNPCC/Lynch type II familial cancer syndrome
is uterine and ovarian cancer common?
how has the rates of uterine cancer changed?
19% increase
can be releated to - obesity, longitivity in age
there is a small reduction in ovarian cancer
does deprivation affect uterine cancer?
what are the symptoms of endometrial cancer?
- Abnormal vaginal bleeding
- Post menopausal bleeding (PMB)
Post-menopausal bleeding:
•8% of women with PMB will have endometrial cancer
what are some other causes of PMB?
- Hormone Replacement Therapy (HRT)
- Peri-menopausal bleeding
- Atrophic vaginitis
- Polyps cervical/endometrial
- Other cancer eg cervix, vulva, bladder,anal
uterine cancer statistics
a disease we associate with post-menopausal women
rising obesity rates = increase circulating oestogen rates = reason for increasing cases
Endometrial cancer:
- Red flag symptom = * _______________
- _________ scan to look at endometrial _______ and contour
- Diagnosis by ________ of endometrium
- Main treatment is _____________________ (done laproscopically) with removal of tubes and ovaries and peritoneal washings
Post-menopausal bleeding
Trans-vaginal
thickness
histology
Total Abdominal Hysterectomy
