Uterine Cancer

Question 1

What percentage of endometrial cancers are secondary to lynch syndrome?

Answer 1

3%

Question 2

What measures should be taken to reduce the risk of uterine cancer in patients with Lynch?

Answer 2

Chemoprevention with OCP and risk reducing hysterectomy and BLSO, ideally before the age of 40. Surveillance with TVUS at age 35yrs.

Question 3

What percentage of endometrial cancer, cancers are MMRd?

Answer 3

25-30%

Question 4

In TCGA classification, name the four groups?

Answer 4

POLE (ultra-mutated), MSI high (hypermutated), Copy number low (endometriod), Copy number high (serous like p53 abnormal).

Question 5

When should SLNB be performed in early uterine cancer?

Answer 5

When myometrial invasion present in low risk or intermediate risk disease.

Question 6

If a patient is unfit for surgery then what should be considered?

Answer 6

Definitive RT with brachytherapy, EBRT or combination.

Question 7

Which method of adjuvant RT is generally preferred in high-intermediate risk disease following hysterectomy and BLSO

Answer 7

Vaginal brachytherapy usually preferred over pelvic RT due to toxicity profile.

Question 7

What are the indications for adjuvant radiotherapy following surgery for endometrial cancer?

Answer 7

Stage I G3 with adverse risk factors (age >70, lymphvascular space invasion or tumour >2cm), stage II or stage III.

Question 8

What are the indications for adjuvant chemotherapy alongside EBRT?

Answer 8

Nodal disease (ie. stage III disease), 2 cycles of cisplatin concurrently with RT then 4 cycles carbo/paclitaxel.

Question 9

When should surgery be considered in stage III and stage IV disease?

Answer 9

If macroscopic complete resection is feasible. Consider delayed surgery if meaningful response to chemotherapy.

Question 10

Management of unresectable locally advanced tumours?

Answer 10

Definitive radiotherapy with EBRT and IU brachytherapy or NACT prior to resection/definitive RT

Question 11

First line management of recurrent or metastatic endometrial cancer in low risk?

Answer 11

Hormone treatments including megesterone, aromatase inhibitors, tamoxifen or fulvestrant.

Question 12

What factors predict response to hormone therapy?

Answer 12

Low grade, slowly progressing, HR positive, lung only metastases and long disease free interval.

Question 13

How would you manage patients with recurrent stromal tumours?

Answer 13

Aromatase inhibitors, progestogens or GnRH analogues (in pre-menopausal women) have good long term outcomes. Avoid tamoxifen.

Question 14

First line treatment in recurrent or metastatic pMMR endometrial cancer?

Answer 14

6 cycles of 3 weekly Carboplatin AUC5-6 and paclitaxel 175mg/m2

Question 15

Second line treatment in recurrent or metastatic pMMR endometrial cancer?

Answer 15

Pembrolizumab and Lenvatinib (irrespective of MMR). Consider rechallenge with platinum if long DFI

Question 16

First line treatment in recurrent or metastatic dMMR endometrial cancer?

Answer 16

Dostarlimab + Paclitaxel + Carboplatin (or can use dostarlimab monotherapy or pem/len in the second line if IO not used in first line)

Question 17

Is lymphadenectomy indicated for localised uterine sarcoma?

Answer 17

Not usually unless extrauterine involvement or clinically enlarged lymph nodes

Question 18

What is the advised approach to endometrial intraepithelial neoplasia?

Answer 18

Hysterectomy as high risk of progression to cancer. If patient declines surgery then progestin (megestrol for up to 6 months) with repeat biopsy in 3-6m.

Question 19

When should SLNB in uterine cancer?

Answer 19

If myometrial involvement but not considered high-intermediate or high risk therefore not needing surgical staging.