Uterine neoplasia

Question 1

Endometrial hyperplasia - def

Answer 1

Premalignant condition that can predispose to endometrial carcinoma

Question 2

Endometrial hyperplasia - path

Answer 2

Characterised by overgrowth of endometrial cells. Caused by excess unopposed estrogens (either endogenous or exogenous)

Question 3

Endometrial hyperplasia - presentation

Answer 3

Most commonly diagnosed in women over 40y with irregular menstruation or in those with post-menopausal bleeding

Question 4

Endometrial hyperplasia - ix/dx

Answer 4

1. Endometrial sampling or formal endometrial curettage

Atypia = appearance of individual glandular cells (increased nuclear:cytoplasmic ratio)

Question 5

Endometrial hyperplasia - mx

Answer 5

Depends on age, histology, symptoms and desire for retaining fertility

No atypia

1. Exclude treatable causes of unopposed estrogens (estrogen-only HRT or estrogen-secreting tumour)
2. Treat with continuous oral progestagens if premenopausal
3. Levonorgestrel IUD if post-menopausal
4. Risk of progression to cancer = 1-3.5%
5. Rebiopsy only if abnormal bleeding continues

Atypical endometrial hyperplasia
1. 50% of women with atypical hyperplasia have concurrent adenocarcinoma. Counsel about high risk of developing endometrial carcinoma
2. Unless fertility desired or unacceptably high operative risk, TAH (+BSO if >45y)
Conservative tx
3. High-dose oral progestagens, or Mirena if not trying to conceive
4. Re-biopsy every 3-6mo until progression or regression
5. Strongly consider hysterectomy once fertility not required

Question 6

Endometrial cancer and endometrial hyperplasia - risk factors

Answer 6

Caused by unopposed estrogen (i.e. no protective effect of progesterone), whether endogenous or exogenous

1. Obesity
2. Nulliparity (pregnancy associated with high progesterone levels)
3. PCOS (anovulatory cycles - no corpus luteum, no progesterone)
4. Early menarche/late menopause (anovulatory cycles)
5. HNPCC (Lynch II syndrome) - high risk of colorectal, endometrial and ovarian tumours; inherited as autosomal dominant condition

Question 7

Endometrial cancer and hyperplasia - protective factors

Answer 7

1. Parity

2. COCP

Question 8

Endometrial cancer - presentation/history

Answer 8

1. Most commonly presents with PMB
2. Younger women present with menstrual disturbance (heavy or irregular periods)
3. 1% picked up on routine cervical smear
4. PV discharge (may occur instead of bleeding - have an increased index of suspicion in post-menopausal women)
5. Pyometra (may occur instead of bleeding - 50% of post-menopausal women with pyometra have underlying carcinoma)

Note: 90% of endometrial cancer is dx in women >50y; not common dx in premenopausal women

Question 9

Endometrial cancer - examination

Answer 9

1. Rule out other causes of bleeding (vulval, vaginal and cervical pathology) with vulval, vaginal and speculum examination
2. Bimanual examination - uterine size, mobility, adnexal masses

Question 10

Endometrial cancer - ix

Answer 10

1. Haematological ix (3) = FBE, UEC, LFTs
2. TVUSS (if no requirement for endometrial sampling)
3. **Dx = endometrial biopsy. May do blind outpatient sampling (e.g. pipelle) or hysteroscopy
4. CT chest/abdo/pelvis (preoperative staging)
5. CXR (staging)

Question 11

Endometrial cancer - mx

Answer 11

1. Surgery - TAH, BSO and pelvic washings (can be laparoscopic or open)
   - But if uterus enlarged, cannot be morcellated in laparoscopy -> abdominal route preferred in this case
   - Removes primary malignant site and allows histopathological assessment of specific prognostic factors - cancer grade, depth of myoinvasion, presence of lymphovascular invasion and cervical stromal involvement
2. Pelvic lymphadenectomy - controversial (two RCTs suggest no survival advantage in early disease)
3. Adjuvant radiotherapy (vault brachytherapy if intermediate risk, external beam radiation therapy [EBRT] +/- vault brachytherapy if high risk)
4. Hormonal - high dose progesterone for advanced and recurrent disease, aiming for palliation of symptoms (bleeding) - no survival advantage demonstrated
5. Palliative radiotherapy - EBRT (external beam radiation therapy) given at lower dose and in few fractions to control local symptoms (e.g. bleeding)

Question 12

Endometrial polyps (adenoma) - overview

Answer 12

1. Focal overgrowth of endometrium. 0.5% contain malignant cells (commonly adenocarcinoma)
2. More common in women >40y. Can occur at any age
3. Commonly cause abnormal uterine bleeding
4. Ix = ultrasound (contrast sonohysterography used on occasion, don’t need CT or MRI, can also use hysteroscopy), polyps

Question 13

Uterine fibroids (leiomyoma) - def

Answer 13

Benign tumours of myometrium of uterus

Question 14

Fibroids - symptoms

Answer 14

1. Dysmenorrhoea
2. Menorrhagia
3. Pressure symptoms (esp. frequency)
4. Pelvic pain
5. Infertility associated

Question 15

Fibroids - types

Answer 15

1. Submucosal
2. Intramural
3. Subserosal
4. Cervical
5. Pedunculated

Question 16

Fibroids - dx (3)

Answer 16

1. Clinical ex (hard, irregular uterine mass) may be sufficient
2. Transvaginal or abdominal ultrasound - types and dimensions
3. Rarely - MRI when U/S inconclusive

What about other investigations?

Question 17

Fibroids - mx

Answer 17

1. No tx if minimal sx
2. GnRH analogues to shrink fibroids but only if prior to surgery
3. Myomectomy (open, laparoscopic or hysteroscopic - depending on location)
4. Hysterectomy if family completed or >45y (guaranteed cure)
5. Uterine artery embolisation (why?)

Question 18

Uterine sarcoma - overview

Answer 18

1. Very rare, accounting for 3-5% of uterine cancers, peak incidence 50-64y of age
2. Clinical features = abnormal bleeding (most common presenting feature), pain, pelvic mass
3. Ix = biopsy, CT, PET
4. Mx = total hysterectomy + BSO, surgical cytoreduction if intra-abdominal/retroperitoneal disease present, lymphadenectomy if LN enlarged, adjuvant chemotherapy and pelvic radiation
5. 5yr survival poor