Endometrial_Cancer_Flashcards
What is endometrial cancer and when does it typically occur?
Endometrial cancer is a type of cancer primarily seen in post-menopausal women, though about 25% of cases occur before menopause. It often has a good prognosis due to early detection.
Outline the grading and staging used for endometrial cancer
Grading (UK Guidance):
Grade 1 (Well-differentiated): Less than 5% of tumor is solid growth.
Grade 2 (Moderately differentiated): 5% to 50% of tumor is solid growth.
Grade 3 (Poorly differentiated): More than 50% of tumor is solid growth.
Staging (FIGO Staging System for Endometrial Cancer):
Stage 1: Cancer is confined to the uterus.
1A: Cancer is limited to the endometrium or invades less than half of the myometrium.
1B: Cancer invades one-half or more of the myometrium.
Stage 2: Cancer has spread to the cervix but not outside the uterus.
2A: Endocervical glandular involvement only.
2B: Invasion of the cervical stroma but not beyond the uterus.
Stage 3: Cancer has spread beyond the uterus, but is still within the pelvic area.
3A: Cancer involves the serosa of the uterus and/or adnexa.
3B: Vaginal and/or parametrial involvement.
3C: Metastases to pelvic and/or para-aortic lymph nodes.
3C1: Positive pelvic lymph nodes.
3C2: Positive para-aortic lymph nodes with or without positive pelvic lymph nodes.
Stage 4: Cancer has spread to the bladder, bowel mucosa, or distant metastasis.
4A: Invasion of bladder and/or bowel mucosa.
4B: Distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes.
What are the risk factors for endometrial cancer?
Risk factors include excess estrogen, nulliparity, early menarche, late menopause, metabolic syndrome, obesity, diabetes, PCOS, and use of tamoxifen. Hereditary factors like non-polyposis colorectal carcinoma also play a role.
What are protective factors against endometrial cancer?
Protective factors include multiparity, use of combined oral contraceptive pills, and paradoxically, smoking.
What are the classic symptoms of endometrial cancer?
The classic symptom is postmenopausal bleeding, which is usually slight and intermittent initially, but may become heavier. Premenopausal women may experience menorrhagia or intermenstrual bleeding.
What are the first-line investigations for endometrial cancer?
Women aged 55 or older with postmenopausal bleeding should be referred for suspected cancer, with transvaginal ultrasound as the first-line investigation. Hysteroscopy with endometrial biopsy is also used.
What is the mainstay of management for endometrial cancer?
The primary treatment for localized endometrial cancer is total abdominal hysterectomy with bilateral salpingo-oophorectomy. High-risk patients may receive postoperative radiotherapy.
How is endometrial cancer managed in frail elderly women?
In frail elderly women not suitable for surgery, progestogen therapy is sometimes used.
summarise endometrial cancer
Endometrial cancer
Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection
Aetiology
Risk factors
excess oestrogen
nulliparity
early menarche
late menopause
unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
metabolic syndrome
obesity
diabetes mellitus
polycystic ovarian syndrome
tamoxifen
hereditary non-polyposis colorectal carcinoma
Protective factors
multiparity
combined oral contraceptive pill
smoking (the reasons for this are unclear)
Features
The classic symptom is postmenopausal bleeding
usually slight and intermittent initially before becoming heavier
Other features
premenopausal women may develop menorrhagia or intermenstrual bleeding
pain is not common and typically signifies extensive disease
vaginal discharge is unusual
Investigations
All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
hysteroscopy with endometrial biopsy
Management
The mainstay of management for endometrial cancer is surgery.
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
patients with high-risk disease may have postoperative radiotherapy
Progestogen therapy is sometimes used in frail elderly women not considered suitable for surgery.
A 48-year-old woman presents to her general practitioner with several weeks of intermittent vaginal bleeding. She experienced menopause at the age of 38 and had not had any vaginal bleeding until now. Her past medical history includes starting periods at the age of 17. She has given birth to 2 children. She has been using combined hormone replacement therapy (HRT) for several years.
Physical examination is unremarkable; she has a BMI of 32 kg/m 2. She is urgently referred for further investigations, with a suspicion of endometrial cancer.
What is the most significant risk factor from her history?
Continuous use of combined HRT
Early menopause
Late menarche
Multiparity
Obesity
Obesity
Obesity is a significant risk factor for endometrial cancer
Important for meLess important
Excess (unopposed) oestrogen and metabolic syndrome syndrome are essentially the two overarching factors that increase the risk of developing endometrial cancer. Of the options listed, the only factor that fits this description is obesity, as part of metabolic syndrome. As such, type 2 diabetes mellitus and polycystic ovarian syndrome are also recognised to increase the risk of endometrial cancer.
Continuous use of combined HRT is incorrect. Although oestrogen-only HRT increases the risk of endometrial cancer, the presence of a continuous progestogen essentially eliminates this risk.
Early menopause is incorrect. This indicates that she has had less overall exposure to oestrogen in her lifetime. Late menopause would instead be a risk factor.
Late menarche is incorrect. As such, she will have had less oestrogen exposure overall during her lifetime. Early menarche would instead be a risk factor.
Multiparity is incorrect. Nulliparous, rather than multiparous, women are at increased risk of endometrial cancer, as they have not had times of reduced oestrogen synthesis (i.e. pregnancy).
buzz words
post menopausal vaginal bleedinv
late menopause
nulliparity
oestrogen only pill
obesity - high bmi
A 62-year-old woman presents with post-menopausal bleeding. Which one of the following is not a risk factor for endometrial cancer?
Diabetes mellitus
Late menopause
Obesity
Past history of combined oral contraceptive pill use
Nulliparity
Past history of combined oral contraceptive pill use
The combined oral contraceptive pill is a protective factor for endometrial cancer
The correct answer is Past history of combined oral contraceptive pill use. The Combined Oral Contraceptive (COC) pill has been shown to reduce the risk of endometrial cancer. It provides a protective effect that persists for many years after discontinuing its use. This is due to the progestogen component of the COC pill which counteracts the proliferative effect of oestrogen on the endometrium, thus reducing the risk of endometrial hyperplasia and subsequent malignancy.
Diabetes mellitus is a well-established risk factor for endometrial cancer. Insulin resistance and hyperinsulinaemia, common in type 2 diabetes, can lead to increased levels of circulating oestrogens which stimulate endometrial proliferation.
Similarly, Late menopause increases exposure to oestrogens without corresponding progesterone, leading to unopposed stimulation of the endometrium and increasing the risk of developing endometrial cancer.
Obesity also contributes significantly to the development of endometrial cancer. Adipose tissue can convert androstenedione into estrone, a potent oestrogen. In post-menopausal women who have no natural progesterone production from ovaries, this leads to unopposed oestrogenic stimulation of the endometrium.
Finally, nulliparity, or never having given birth, increases a woman’s risk for developing endometrial cancer. Pregnancy results in long periods without ovulation and therefore less exposure to cyclical oestrogens. Furthermore, full-term pregnancy appears to have a direct protective effect on the morphology and biological behaviour of endometrial cells.
Which of these is correct in regards to the management of endometrial cancer?
Most patients present with stage 1 disease, and are therefore amenable to surgery alone
Endometrial biopsy is not required for diagnosis
Chemotherapy is used more extensively in treatment than radiotherapy
Lymphadenectomy in early stage disease is usually beneficial
Progestogens are often used in treatment
Most patients present with stage 1 disease, and are therefore amenable to surgery alone
1: Correct, 75% of patients present with stage 1 disease, which is generally treated with a hysterectomy and bilateral salpingo-oophorectomy.
2: Endometrial biopsy is required for diagnosis.
3: Radiotherapy is used more often than chemotherapy, particularly in treating high-risk patients post-hysterectomy or in pelvic recurrence.
4. Routine lymphadenectomy is not usually beneficial.
5. Progestogens are now seldom used in treatment.
A 76-year-old woman presents with post-menopausal bleeding for the past 4 months. She is diagnosed with well-differentiated adenocarcinoma (stage II) on endometrial biopsy. There is no evidence of metastatic disease. Which is the most appropriate treatment?
Transcervical endometrial resection
Total abdominal hysterectomy
Provera (medroxyprogesterone acetate)
Wertheim’s radical hysterectomy
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the treatment of choice for stage I and II endometrial carcinoma. Provera is a progesterone used as a hormonal treatment for endometrial carcinoma - it acts by slowing the growth of malignant cells in the endometrium. Wertheim’s radical hysterectomy includes removal of lymph nodes and is used to treat stage IIB endometrial carcinoma.
A 62-year-old woman presents to her GP complaining of recurrent vaginal bleeding. The symptoms started six months ago, they get worse following sexual intercourse but she never experiences pain during it. She has never been pregnant and she took the combined pill for fifteen years, which she recently stopped due to menopause. Her smears are up to date are normal. On examination, she appears obese. There are no sores or lesions in the external genitalia area. The cervix appears normal and there are no masses in the vaginal canal. The uterus is normal in size.
What is the most likely cause of her presentation?
Cervical cancer
Cervical ectropion
Endometrial cancer
Ovarian cancer
Uterine fibroids
Endometrial cancer
A 60-year-old obese, nulliparous woman presents with vaginal bleeding - endometrial cancer
The correct answer is endometrial cancer. This patient is presenting with post-menopausal bleeding which is worse following intercourse but is never accompanied by pain. On examination, the cervix appears normal, there are no masses in the vaginal canal, and the uterus is of normal size. These symptoms, in a woman of her age who is obese, should warrant immediate referral for suspected endometrial cancer.
This malignancy is characteristic of women who are older than 60 years old, and obese patients are at particular risk, as increased levels of peripheral fat increase aromatase activity, which leads to the conversion of androgens to oestrogens, which directly promotes endometrial proliferation. Additionally, the fact that the bleeding is worse following sexual intercourse but the intercourse itself is not painful, points away from the other likely diagnosis of vaginal atrophy, making a diagnosis of endometrial cancer the most likely.
Cervical cancer is incorrect. This is a cause of postcoital bleeding, but in this case, the patient’s smears were all normal and the examination was normal, making this option unlikely.
Cervical ectropion is incorrect. This woman has risk factors for the development of this condition such as combined pill usage. In such cases, you would expect to see the columnar epithelium invading the ectocervix, but an examination is normal, making this option unlikely.
Ovarian cancer presents with vague symptoms such as bloating and weight loss and has not been associated with vaginal bleeding.
Uterine fibroids is an incorrect option. These are a common cause of pre-menopausal bleeding, but they tend to disappear following menopause, as they need the oestrogen to grow. After menopause, oestrogen levels decrease dramatically, which usually reduces the risk of developing fibroids and shrinks the pre-existing ones, causing fewer symptoms. Additionally, her uterus is normal on palpation, making this option unlikely.
