Uterine Cancer

Question 1

What are 3 types of endometrial hyperplasia and which is the precursor of adenocarcinoma?

Answer 1

Simple, complex or atypical - atypical is precursor

Question 2

How does endometrial hyperplasia present?

Answer 2

Abnormal bleeding - either dysfunctional uterine bleeding or postmenopausal bleeding

Question 3

Outline the distribution, component, glands and cytology of simple endometrial hyperplasia.

Answer 3

Distribution: general
Component: glands & stroma
Glands: dilated not crowded
Cytology: normal

Question 4

Outline the distribution, component, glands and cytology of complex endometrial hyperplasia

Answer 4

Distribution: focal
Component: glands
Glands: crowded
Cytology: normal

Question 5

Outline the distribution, component, glands and cytology of atypical endometrial hyperplasia.

Answer 5

Distribution: focal
Component: glands
Glands: crowded
Cytology: atypical

Question 6

What is the peak age group for endometrial carcinoma and under what age is it uncommon?

Answer 6

Peak age 50-60, uncommon <40

Question 7

What are 2 underlying syndromes you should consider in young women presenting with endometrial carcinoma?

Answer 7

PCOS or Lynch Syndrome

Question 8

The two main types of endometrial carcinoma are endometrioid carcinoma and the more aggressive serous carcinoma. What are their respective precursor lesions?

Answer 8

Endometrioid - atypical hyperplasia

Serous - serous intraepithelial carcinoma

Question 9

How does endometrial carcinoma present macroscopically?

Answer 9

Enlarged uterus and may be polypoid growth in cavity

Question 10

How do endometrial carcinomas spread? (3)

Answer 10

Directly into myometrium and cervix, lymphatic and haematogenous

Question 11

How are endometrioids graded?

Answer 11

Grade 1 - 3 based on how many glands are in it so is based on differentiation

Question 12

Type I tumours make up approx. 80% of endometrial adenocarcinomas. Which two phenotypes of endometrial carcinoma are type 1 tumours?

Answer 12

Mostly endometrioid and some mucinous

Question 13

What is thought to cause Type I endometrial carcinoma?

Answer 13

Unopposed oestrogen

Question 14

Type II tumours make up approx. 20% of endometrial adenocarcinomas. What are the 2 phenotypes for Type II?

Answer 14

Serous mostly and some clear cell

Question 15

Type II endometrial carcinomas are associated with unopposed oestrogen in elderly post-menopausal women. True/false?

Answer 15

False! Not associated with unopposed oestrogen but is in elderly post-menopausal women

Question 16

What 3 mutations are associated with Type I endometrial carcinomas?

Answer 16

PTEN, KRAS, PIK3CA

Question 17

What is the buzzoword for the histological appearance of endometrioid endometrial carcinomas

Answer 17

Sawtooth luminal appearance and glands packed in together

Question 18

Outline the link between obesity and endometrioid endometrial carcinoma in terms of adipocytes

Answer 18

Excess adipose tissue causes it because adipoctyes express aromatase that converts ovarian androgens into oestrogens

Question 19

Outline the link between obesity and endometrioid endometrial carcinoma in terms of SHBG

Answer 19

SHBG is lower in obese women so more unbound, biologically active oestrogen

Question 20

Outline the link between obesity and endometrioid endometrial carcinoma in terms of insulin

Answer 20

Lowered insulin action in obesity so insulin-binding globulins reduced and free insulin levels are elevated. Insulin/insulin-like growth factors (IGF) exert proliferative effect on endometrium

Question 21

What is the approximate lifetime risk of developing endometrial cancer in patient with Lynch syndrome? What other 2 cancers do they have increased probability of developing?

Answer 21

30%

High risk colorectal carcinoma and increased risk of ovarian

Question 22

Explain Lynch syndrome genetically

Answer 22

Autosomal dominant inheritance of a defective DNA mismatch repair gene

Question 23

What investigations are done on the tumour to help identify tumours due to Lynch syndrome?

Answer 23

Immunohistochemistry staining for mismatch repair proteins and testing for microsatellite instability

Question 24

What gene are Type II endometrial carcinomas associated with?

Answer 24

TP53 mutation and overexpression

Question 25

How do Type II tumours spread and how does this affect their presentation?

Answer 25

Spread along fallopian tube mucosa and peritoneal surfaces so can present with extrauterine disease

Question 26

Describe the histological appearance of serous carcinoma

Answer 26

Complex papillary and/or glandular architecture with diffuse nuclear pleomorphism, the serous carcinomas are surrounded by inflammatory cells

Question 27

What is buzzword for histological appearance of clear cell type II tumour?

Answer 27

Tubulocystic

Question 28

Outline parameters for endometrial cancer staging IA and IB

Answer 28

IA - tumour infiltrated inner half of myometrium and IIB - tumour infiltrated outer half

Question 29

What does the prognosis of endometrial carcinoma depend on? (3)

Answer 29

Stage (I-IV), histological grade and depth of myometrial invasion

Question 30

What are the treatments for endometrial carcinomas?

Answer 30

Hysterectomy; chemo/radiotherapy

Question 31

Outline parameters for grades 1-3 of endometrioid endometrial carcinomas

Answer 31

Grade 1: 5% or less solid growth Grade 2: 6-50% solid growth Grade 3: >50% solid growth

Question 32

Serous carcinoma and clear cell carcinoma are not formally graded. True/false?

Answer 32

True - automatically assumed high grade

Question 33

Outline parameter for endometrial cancer staging II

Answer 33

Tumour invades cervical stroma

Question 34

Outline parameters for endometrial cancer staging III, IIIA, IIIB, IIIC

Answer 34

III - local or regional tumour spread IIIA - invades serosa of uterus +/ adnexae IIIB - vaginal +/ parametrial involvement IIIC - metastases to pelvic +/ para-aortic lymph nodes

Question 35

Outline parameter for endometrial cancer staging IV, IVA and IVB

Answer 35

IV - Tumour invades bladder IVA - bowel mucosa IVB - distant mets

Question 36

What is the name of the quite rare tumours arising from the endometrial stroma?

Answer 36

Endometrial stromal sarcoma

Question 37

Where do endometrial stromal sarcomas infiltrate? (2)

Answer 37

Myometrium and lymphovascular spaces

Question 38

Prognosis of endometrial stromal sarcoma depends on staging. High grade more likely to die. How does endometrial stromal sarcoma sarcoma present?

Answer 38

Typically with AUB but initial presentation may be as metastasis, most commonly ovary or lung

Question 39

Carcinomasarcomas used to be known as malignant mixed Müllerian tumour. What are they?

Answer 39

Mixed tumour with malignant epithelial and stromal elemts

Question 40

Carcinosarcomas make up <5% of uterine malignancies and can be carcinomatous and sarcomatous. What 3 types of sarcomas can be seen and which indicated worst prognosis?

Answer 40

Rhabdomyosarcomatous (worst prognosis), chondrosarcoma and osteosarcoma

Question 41

Leiomyomata commonly develop into leiomyosarcomas. true/false?

Answer 41

False - rare, account for 1-2% of all uterine malignancies

Question 42

How do leiomyomas present histologically?

Answer 42

Swirling muscle tissues

Question 43

Leiomyosarcomas usually occur at what age?

Answer 43

women >50yrs

Question 44

What does leiomyosarcoma commonly display morpholigically?

Answer 44

Spindle cell morphology

Question 45

What are commonest symptoms of leiomyosarcoma? (3)

Answer 45

Abnormal vaginal bleeding, palpable pelvic mass and pelvic pain

Question 46

Leiomyosarcoma has poor prognosis even if confined to uterus, 5year survival rates 15-25%. True/false?

Answer 46

True