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FRCR CO2A > Uterine Cancers FRCR CO2A > Flashcards

Uterine Cancers FRCR CO2A Flashcards

1
Q

which is the mc cancer affecting Uterus?

A

Adenocarcinoma

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2
Q

What’s major RF a/w uterine cancer?

A

unopposed estrogen stimulation, a/w obesity, common in developed countries

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3
Q

what are different types of malignancies affecting uterus?

A

Endometrial Carcinoma (90%)
Uterine sarcomas
Mixed mullerian tumor
Endometrial stromal sarcoma
Leiomyosarcoma
Lymphomas

Malignant secondary:
Direct spread from ovary, rectum, bladder, cervix and vagina

s/times breast

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4
Q

which age group is typically affected by endometrial carcinoma/

A

post menopausal and median age is 60 years

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5
Q

What are factors increasing risk of endometrial cancer?

A
  1. increasing age
  2. obesity
  3. long term exp to unopposed estrogen
  4. genetic factors
  5. atypical endometrial hyperplasia
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6
Q

How is Obesity a/w malignant germ cell tumors of ovary

A

conversion of androstenedione to estrogen in peripheral fat

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7
Q

what are sources of exogenous estrogens?

A

Estrogen only HRT
Tamoxifen for breast cancer (weak estrogenic effect on uterus)

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8
Q

what are endogenous estrogen sources?

A

Granulosa cell tumors
PCOD
Increasing years of menstruation
Nulliparity
Infertility

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9
Q

what genetic factors are a/w endometrial cancers?

A
  1. a + family h/o endometrial, breast or colorectal cancer in 2st degree relative
  2. HNPCC, Lynch type II
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10
Q

what cancers is lynch type II associated?

A

Colorectal
Pancreatic
endometrial
breast
ovarian cancers

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11
Q

what factors decrease the risk of endometrial cancer?

A
  1. Grand multiparity
  2. OCP use
  3. physcial activity
  4. diet including phyto-estrogens
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12
Q

what are types of endometrial cancer?

A

Type I and Type II

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13
Q

what are Type I endometrial cancer?

A

Endometrioid and mucinous subtypes

Estrogen dependant tumors. and a/w atypical endometrial hyperplasia

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14
Q

What are Type II endometrial cancer?

A

lack an association with estrogen stimulation and are aggressive

serous and clear cell

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15
Q

What are IHC features of endometrial cancer?

A

Express ER and PR

Type II: loss of function of tumor suppressor pathways, PTEN

Type II: TP53

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16
Q

How does endometrial cancer spread?

A

Locally through myometrium, to the serosal surface of uterus, to the cervix, the parametria, the fallopian tubes, the vagina, the bladder, and the rectum

Through Lymphatics to the pelvic nodes, PA nodes and mediastinal nodes

Blood: Lungs, Liver and Bones and peritoneum

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17
Q

what are regional LNs for endometrial cancer?

A

Pelvic and PA nodes

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18
Q

What’s the mc presentation of endometrial cancer?

A

Postmenopausal bleeding

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19
Q

what % of risk is of endometrial cancer in women with postmenopausal bleeding?

A

15%

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20
Q

what are s/s of endometrial cancer?

A
  1. post menopausal bleeding
  2. Vaginal discharge
  3. other abnoraml bleeding (intermenstrual, menorrhagia, postcoital) and pelvic mass

symptoms due to local spread:
1. pelvic pain, renal failure , hematuria, bowel symptoms, back pain (PA node)

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21
Q

Is there any benefit of screening for endometrial cancer?

A

No

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22
Q

How is Investigation and staging proceeded in endometrial cancer?

A
  1. Pelvic Examination (speculum )
  2. TVS : endometrial thickness
  3. Hysteroscopy : allows inspection of uterine cavity
  4. Sigmoidoscoopy and cystoscopy if extension to rectum and bladder is suspected
  5. pregnancy should be ruled out
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23
Q

what are the staging investigations for endometrial cancer?

A

Staged surgically

MRI > TVS for depth of myometrial invasion, involvement of cervix and LN involvement
CxR
CA 125

24
Q

what is the treatment of Stage I endometrial Cancer?

A

TAH and BSO and peritoneal washing followed by selective RT for high risk cases.

Laparoscopic or vaginal hysterectomy for obese pts

Primary RT for medically unfit pts

Grade I and St I tumors, unfit for Sx or RT: intrauterine Progesterone

25
Q

What is the Rx for stage II endometrial cancer?

A
  1. increased risk of occult LN involvement
  2. if Cervical involvement is identified pre-op, radical hysterectomy f/b post op RT
26
Q

What’s the Rx for Stage III - IVA endometrial cancer?

A

Radical Radiotherapy
or Palliative RT, ChT, Hor Therapy

may be unsuitable for Sx bcoz disease extends outside the uterus

27
Q

what’s the Rx for Stage IVB endometrial cancer?

A

Palliative Rx

28
Q

Why is ovary removed in surgery for endometrial cancer?

A

TAH + BSO and peritoneal washings

to exclue an ovarian metastasis or synchronous ovarian cancer

29
Q

Is Lymphadenectomy required in st I endometrial cancer?

A

No improvement in survival

30
Q

When is Radical Hysterectomy and lymphadenectomy indicated in endometrial cancer?

A

Stage II disease onwards

31
Q

What’s the standard Rx for stage III endometrial cancer?

A

Radical RT

32
Q

How is EBRT for endometrial cancer planned?

A
  1. supine, hands on chest, knees supported with wedge, Bladder should be comfortably full, IV Contrast for delineation of nodal volume
33
Q

What does CTV include in endometrial cancer?

A

Primary tumor, the uterus, cervix, upper vagina, parametria and adnexae

REgional Nodes: int and ext iliac, obturator, presacral and common iliac

34
Q

What’s the conventional field borders for RT for endometrial cancer?

A

Supr: L5-S1 Vertebrae
Infr: 2 cm below infr extent of tumor (no higher than lower border of obturator foramen)
Lat: 1.5 cm outside the bony pelvic wall
Postr: lower margin of S2, approx 2 cm infront of sacral hollow
Antr: through the pubic symphisis

35
Q

What are usual RT dose regimens for endometrial cancer?

A

Initial
45 Gy/ 25#
50.4 Gy/ 28#

Brachy
21 - 24 Gy in 3 to 4 fractions to pt A

36
Q

What’s the Brachy dose without EBRT?

A

HDR: 34 to 40 Gy in 4 to 7 fractions, 2 cm from mid point along the uterine applicator
LDR: 50 Gy in 1 fractions or 75 Gy in 2 fractions 2 cm from the intrauterine tube

37
Q

When is RT indicated in Stage IA endometrial cancer post op?

A

G1 G2: Observation, Vaginal BT if LVSI or age > 60 years

G3: Vaginal BT (preferred) or Observation if no myoinvasion or
EBRT if age > 70 years or LVSI

38
Q

When is RT indicated in Stage IB endometrial cancer post op?

A

G1: observation if age < 60 yrs and LVSI -
Vaginal BT (preferred)

G2; Vaginal BT or EBRT if age > 60 yrs and/or LVSI
Observation if age < 60 yrs and no LVSI

G3: RT (EBRT + Vaginal BT) and/or systemic treatment

39
Q

What are High Intermediate Risk FActors for endometrial cancer post op?

A

PORTEC study group: 2/3
1. Deep Myometrial invasion
2. Age > 60 yrs
3. Grade 3 tumors

40
Q

How do you define High Risk Stage I disease in PORTEC 3 study?

A
  1. stage IA with myometrial invasion, Gr 3 with LVSI
  2. Stage IB Gr III
  3. Stage IA with myometrial invasion with serous or clear cell histology
41
Q

When is Adjuvant Chemotherapy used in endometrial cancer?

A

stage III and IV patients and stage I with intermediate and high risk factors

42
Q

what’s the response rate of carboplatin and paclitaxel in endometrial cancer?

A

63 to 87 %

43
Q

what are 2nd L ChT option in endometrial cancer?

A
  1. PLD
  2. Topotecan
44
Q

Is hormonal therapy advised in adjuvant setting for endometrial cancer?

A

No, no survival advantage but unacceptable cardiac morbidity and mortality

45
Q

What’s role of Hormonal therapy in Endometrial Cancer as fertility sparing option?

A

Grade I endometrial carcinoma, complete response rate of 77.1 % after a median treatment duration of 10 months on MDPA

46
Q

what’s the common recurrence pattern if no RT was given in st I patients of endometrial cancer?

A

Locoregional relapse

Rx with RT, 5 yr survival of 65%

47
Q

what are prognostic factors for endometrial cancer?

A

Adverse Prognostic factors:
1. Myometrial invasion
2. Grade 3 disease
3. Non Endometroid histology: clear cell, serous, adenosquamous and LN mets

48
Q

what are common types of uterine sarcomas?

A

Leiomyosarcoma (50%)
Carcinosarcoma (30%)
Endometrial stromal sarcoma (20%)

49
Q

What’s benign counterpart of Leiomyosarcoma?

A

Fibroid or leiomyoma, 5 to 10 % conversion rate

50
Q

Leiomyosarcoma of uterus: Features

A
  1. highly malignant tumor
  2. relapses distantly to liver and lung
  3. OS 15 % to 25 % and stage I and II 5 yr survival 40 to 70%wha
51
Q

What’s is mixed mullerian tumor

A

mixed of malignant epithelial cells and stromal cells , spread to LNs and poor prognosis, 3 yr survival at 22 %w

52
Q

How are uterine sarcomas treated?

A

Surgery and pelvic and para aortic LN diseection

Post op RT in carcinosarcoma reduces risk but without effect on OS

53
Q

is there any advantage of post op RT in leiomyosarcoma?

54
Q

is there any advantage of post op Chemo in leiomyosarcoma?

55
Q

What chemo drugs are used in uterine sarcomas ?

A

Doxorubicin and Ifosfamide
RR 15 to 30%

Gemcitabine and Docetaxel
RR 53%

56
Q

What’s the current SOC for metastatic Endometrial cancer? (NCCN, 2025)

A

Carboplatin/paclitaxel/pembrolizumab (except for carcinosarcoma)
(category 1)c,d,k,8
* Carboplatin/paclitaxel/dostarlimab-gxly (category 1)c,d,k,9
* Carboplatin/paclitaxel/durvalumab (for dMMR only) (category 1)c,d,k,10
* Carboplatin/paclitaxel/trastuzumab
(for HER2-positive uterine serous carcinoma or carcinosarcoma)d,g,11
* Carboplatin/paclitaxel (category 1 for carcinosarcoma)

57
Q

What’s the SOC chemotherapy for endometrial cancer in adjuvant setting (st I-IV)?

A

Carboplatin/paclitaxel/pembrolizumab (for stage III–IV tumors, except for
carcinosarcoma) (category 1)b,c,d,7,8
* Carboplatin/paclitaxel/dostarlimab-gxly (for stage III–IV tumors)
(category 1)c,d,e,9
* Carboplatin/paclitaxel/durvalumab (for stage III–IV dMMR tumors only)
(category 1)c,d,f,10
* Carboplatin/paclitaxel/trastuzumab (for stage III–IV HER2-positive uterine
serous carcinoma or carcinosarcoma)d,g,11
* Carboplatin/paclitaxel/bevacizumab
(stage III–IV with measurable disease)d,12,13
* Carboplatin/paclitaxel14

FRCR CO2A (19 decks)

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