Endometrium Flashcards
Choose all correct answers:
a) transvaginal ultrasound for endometrial thickness is a useful screening test for endometrial hyperplasia and malignancy
b) endometrial biopsy is a useful screening test in postmenopausal women
c) An asymptomatic postmenopausal woman with an incidental finding of 8mm endometrial thickness should receive an endometrial biopsy as part of her work-up
d) yearly transvaginal ultrasound for endometrial thickness is indicated for women on tamoxifen
a) false
b) false -not screening -only symptomatic
c) false -no biopsy if no bleeding
d) false
Choose all correct answers regarding endometrial cancers:
a) 70% are stage 1 at diagnosis
b) 50-75% present with bleeding
c) for a woman presenting with PMB, the a priori risk of endometrial cancer is about 10%, 1% if on HRT
d) for women with Lynch syndrome, the incidence of endometrial cancer by age 70 is 20-60%
a) true
b) false 90%
c) true
d) true
List risk factors for endometrial cancer:
obesity, nulliparity, early menarche/late menopause, an ovulation (PCOS), tamoxifen, white race (though black women have increased mortality)
The reason endometrial thickness is not a good screening test for endometrial cancer is that:
a) the test is not sensitive
b) the test is not specific
c) endometrial cancer has a low population incidence
d) the cost is too high
b
Choose all correct answers:
a) current use of HRT is associated with increased endometrial thickness on ultrasound
b) women with bleeding on HRT should undergo hysteroscopy D and C only if endometrial thickening is > 10mm
c) in postmenopausal women, the chance of malignancy in a polyp is between 0.5 and 5%
d) tamoxifen is contraindicated in women with endometrial hyperplasia
e) the false negative rate of an endometrial bx is 5-15%
a) true
b) false -if >8mm
c) true
d) controversial but true as per ACOG
e) true
Which patients are candidates for surgical management of endometrial cancer without a lymph node dissection in a non-cancer centre?
Low risk disease = Figo grade 1 endometrial adenocarcinoma
F2-3 and all other histologies are high risk
Choose all correct answers regarding endometrial cancer:
a) pelvic lymphadenectomy confers a survival benefit
b) risk of pelvic lymph node involvement for Figo 1 is less than 1%
c) the discordance between pre-op and hysterectomy grading of endometrial cancer approaches 30%
d) MRI is the most sensitive imaging modality to estimate depth of invasion pre-op
a) false -directs adjuvant treatment
b) false 2.8%
c) true 15-30%
d) true
Choose all correct answers regarding endometrial cancer:
a) for patients with intermediate risk disease, external beam radiation is superior to vault brachytherapy in terms of recurrence risk
b) patients undergoing expectant management for intermediate risk disease have higher reported QOL than those receiving radiotherapy
c) the most common site of endometrial cancer recurrence is the vaginal vault
d) adjuvant chemotherapy is indicated for patients with low-risk disease
a) false equal
b) true
c) true
d) false
List 5 prognostic indicators for patients with endometrial cancer.
stage, grade, tumour type, lymphovascular space involvement, depth of invasion, age
Define low risk endometrial cancer:
What adjuvant treatment is recommended if any?
Stage 1A, Figo 1/2, endometriod type,
no further tx needed, recurrence risk 2-10%
Define intermediate risk endometrial cancer:
What adjuvant treatment is recommended if any?
Stage 1B, grade 1/2 endometriod OR grade 3 + LVSI, >60 years of age, recurrence risk 20-25%,
pelvic radiation or brachytherapy
Define high risk endometrial cancer. What adjuvant treatment is recommended if any?
Stage II-IV OR non endometriod (serous or clear cell)
recurrence risk is 30-65%
Chemorads
What follow-up would you recommend for a low risk endometrial cancer patient following surgery?
Counsel on signs/sx recurrence. F/U with pelvi-rectal exam q 6/12 for 2 years then annually for another 2 years
What follow-up would you recommend for a high risk endometrial cancer patient following surgery/adjuvant tx?
Counsel on signs/sx recurrence. F/u with pelvi-rectal exam q 3/12 x 3 years then q 6/12 x 2 years, then annual screening for life
What questions will you ask on history of a woman with PMB to assess for endometrial cancer risk factors?
hx anovulation, early menarche/late menopause, lack of parity, obesity, PCOS, long term unopposed estrogen therapy, tamoxifen use, family hx endometrial/ovarian Ca (Lynch)
A patient has a negative endometrial biopsy but persistent post-menopausal bleeding and thickened endometrium of 10mm on ultrasound. What is the next step in management?
a) repeat biopsy
b) expectant mgmt with repeat u/s
c) reassurance
d) hysteroscopy and sampling
e) hysterectomy
d
A patient with endometrial cancer invading the cervix. What is the stage?
a) 1B
b) 2
c) 3A
d) 3B
b
A patient with endometrial cancer and positive pelvic but not para-aortic nodes. What is the stage?
a) 2
b) 3A
c) 3B
d) 4A
b
What proportion of patients with endometrial cancer are pre-menopausal?
10-15% perimenopausal (2-3% under age 40)
What is the endometrial cancer screening recommendation for a patient with Lynch syndrome?
Yearly endometrial sampling starting age 30
Choose all correct answers regarding endometrial cancer:
a) 10% are hereditary
b) For pt with PMB after age 70, pre-test probability of cancer is 50%
c) tamoxifen increases the lifetime risk of endometrial cancer by 6-8X
d) soy protein (isoflavones) have been shown to decrease the lifetime risk of endometrial cancer in observational studies
all true
Of women with atypical endometrial hyperplasia on biopsy, what percentage will have endometrial cancer on hysterectomy pathology?
35-40% (15% have high risk features requiring staging)
Of women having hysterectomy for endometrial cancer, what percentage will be upgraded?
30%
What is the next mgmt step for a patient with PMB, insufficient tissue on endo bx and thickened EMT on u/s?
a) reassurance
b) re-biopsy
c) repeat u/s in 6/12
d) hysteroscopy D and C
d
For a woman with an endometrial biopsy showing Figo 1 endometrial cancer, what investigations should be ordered pre-op?
CBC, lytes, Cr, LFTs, INR/PTT, urinalysis, CXR, ECG
CT not routine
What are the top five causes of post-menopausal bleeding?
atrophy (30%), exogenous estrogens (30%), endometrial cancer (15%), polyp (10%), hyperplasia (5%)
What investigations would you order for a patient with an endometrial biopsy showing endometrial cancer (greater than FIGO 1) in whom you are planning surgery?
routine bloodwork, chest/abdo/pelvis CT, ?MRI (depth of invasion), ECC (r/o cervical extension), colonoscopy, ?CA-125
What does the histopathological grading in endometrial cancer refer to (What does each FIGO stage mean)?
FIGO 1 - 5% or less nonsquamous or nonmorular solid growth
FIGO 2 - 5-50% nonsquamous or nonmorular solid growth pattern
FIGO 3 - >50%
List 10 prognostic factors for an endometrial cancer.
stage (by far most important), grade, age, vascular space (lymph node) involvement, DNA ploidy, histologic cell type, nuclear grade, myometrial invasion, tumour size, peritoneal cytology, hormone receptor status, type of tx (initial tx with surgery better than rads alone)
For a patient with endometrial hyperplasia without atypia, what are the chances of regression with progestin therapy (e.g. mirena)?
96%
What is your mgmt for a woman with atypical hyperplasia wishing to avoid hysterectomy?
Progestin therapy trial:
Pre-menopause: provera 10-20mg/day for 14 days per month x 3 months then re-biopsy
Post-menopause: 10-20mg/day +/- mirena x 3/12 then re-biopsy
Both: if re-biopsy shows persistent hyperplasia then high dose 100-200mg provera daily x3/12 then re-bx. If still atypia –> hyst
What does surgical staging involve for endometrial cancer greater than Figo 2?
pelvic washings, hysterectomy/BSO, omental biopsy, pelvic and para-aortic nodes,
Choose all correct answers:
a) in a patient with Figo 2 endometriod tumour, stage 1, tumour size < 2cm, the chance of positive lymph nodes is greater than 10%?
b) a patient with grade 2 endometriod tumour, stage 2 has a chance of positive lymph nodes greater than 25%
c) Grade 2 endometriod with tumour <2cm and <50% myometrial invasion should have a lymphadenectomy
d) Grade 3 endometriod with <50% myometrial invasion and tumour <2cm should have a lymphadenectomy
a) false less than 1%
b) false less than 10%
c) false
d) true -all grade 3s should have nodes done
What is the purpose of performing a lymphadenectomy when staging endometrial cancer?
- to provide staging info
- to direct adjuvant treatment
- treat patients with positive nodes
therapeutic role of removing positive nodes is controversial
Which of the following is correct regarding adjuvant radiation therapy for endometrial cancer:
a) FIGO 2, stage 1A cancers do not require adjuvant rads
b) FIGO 2, stage 1B cancers should receive vault brachy
c) FIGO 3, positive pelvic lymph nodes in patients who do did not have para-aortics sampled should receive external beam radiation to pelvic nodes only
a) true
b) true -reduces recurrence
c) false -should receive extended field to include para-aortics (50% chance of positive para-aortic if positive pelvic)
Which of the following are correct regarding endometrial cancer?
a) More than 20% of patients with a recurrence die within 5 years
b) The vaginal vault is the most common site of recurrence
c) The primary treatment for a vault recurrence is surgical
d) A patient who had radiation as part of their initial treatment is likely to respond to a second radiation treatment for their recurrence
a) true 22%
b) true
c) false -radiation (vault brachy)
d) false -exenteration offers only possibility of cure
