Gynaecological cancers- Endometrial cancer

Question 1

endometrial cancer

Answer 1

cancer of the endometrium- lining of the uterus

80% are adenocarcinomas

it is an oestrogen dependent cancer (oestrogen stimulates the growth of the endometrium)

Question 2

postmenopausal bleeding

Answer 2

any woman presenting with postmenopausal bleeding has endometrial cancer until proven otherwise.

risk factors- obesity and diabetes

Question 3

endometrial hyperplasia

Answer 3

a precancerous condition
thickening of the endometrium

most cases return to normal and 5% go onto become endometrial cancer

• hyperplasia without atypia
• atypical hyperplasia

tx; progestogens with either mirena coil (intrauterine system) or continuous oral progestogens (medroxyprogesterone / levonorgestrel)

Question 4

risk factors for endometrial cancer

Answer 4

unopposed oestrogen exposure (without progesterone)

Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen (anti oestrogenic effect on breast tissue and oestrogenic effet on endometrium so is a risk factor)

type II diabetes
Hereditary nonpolyposis colorectal carcinoma (HNPCC) or Lynch syndrome

Question 5

PCOS and endometrial cancer

Answer 5

PCOS leads to exposure of unopposed oestrogen (lack of ovulation) *corpus luteum usually occurs in ovulation and produces progesterone.

women with PCOS should have:
The combined contraceptive pill
An intrauterine system (e.g. Mirena coil)
Cyclical progestogens to induce a withdrawal bleed.

Question 6

obesity and endometrial cancer

Answer 6

adipose tissue (fat) is a source of oestrogen. 
adipose tissue contains aromatase which is an enzyme that converts androgens like testosterone to oestrogen

bad if PCOS and post menopausal too as no unopposed progesterone

Question 7

type II diabetes and endometrial cancer

Answer 7

increased production of insulin can simulate endometrial cells- increase the risk of endometrial hyperplasia and cancer

PCOS- insulin resistance and increased insulin production

Question 8

what are some protective factors for endometrial cancer?

Answer 8

Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking
smoking (Anti oestrogenic but not protective agaisnt other like breast cancer)

Question 9

what is the presentation of endometrial cancer

Answer 9

*post menopausal bleeding
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count

Question 10

referral criteria for urgent 2 week wait

transvaginal ultrasuond

Answer 10

postmenopausal bleeding

transvaginal ultrasound in women >55 with unexplained vaginal discharge, visible haematuria (plus raised platelet, anaemia, elevated glucose levels0

Question 11

endometrial cancer investigations

Answer 11

Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)

Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
*can beb done in outpatient.
speculum with thin tube (pipelle) into cervix to get a sample of tissue for examinatoin.

Hysteroscopy with endometrial biops

Question 12

FIGO stages of endometrial cancer

Answer 12

The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage endometrial cancer:

Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis

Question 13

endometrial caner management

Answer 13

total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy, (BSO) (removal of cervix and adnexa)

A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer

Question 14

normal endometrium anatomy

Answer 14

Proliferative endometrium has tubular glands, columnar cells and dense stroma.

• Secretory endometrium has tortuous glands, oedematous stroma and subnuclear vacuolation.

menstrual endometrium shows fragmentation, stromal breakdown and blood and necoriss

Question 15

hyperplasia

Answer 15

increase in the amount of tissue due to prolfieration. pre-neoplastic and usually in reposnse to a stimulus.

non-atypical hyperplasia
complex atypical hyperplasia

Question 16

EIC endometrial intraepithelial carcinoma

Answer 16

Type 1 endometrial carcinoma arises
from hyperplasia secondary to
oestrogen exposure (early PTEN loss)

Type 2 endometrial carcinoma is
oestrogen-independent and arises on a
background of atrophy, which gives rise
to EIC (p53 mutation)

Question 17

endometrial type 1 and type 2

Answer 17

type 1: most common, well differentiated, arises from hyperplasia, oestrogen excess is a risk factor

type 2: older women, atrophic background, poorly differentiated, serous, p53
(subtypes: serous carcinoma, clear cell carcinoma, mucinous carcinoma, endometrioid carcinoma)

Question 18

carcinosarcoma

Answer 18

previously known as mullerian tumor

adenocarcinoma with a malignant mesenchyml component. rar but constitues half of all uterine sarcomas.