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Laura MRCOG Part 2 > 17) Gynae-oncology: Endometrial > Flashcards

17) Gynae-oncology: Endometrial Flashcards

1
Q

Proportion of patients with postmenopausal bleeding with endometrial hyperplasia

A

15%

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2
Q

How much more common is endometrial hyperplasia in renal transplant patients?

A

2 x

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3
Q

Underlying aetiology of endometrial hyperplasia

A

Unopposed oestrogen (risks include BMI, an ovulation, oestrogen secreting tumours, exogenous oestrogen)

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4
Q

Prognosis of hyperplasia without atypia

A

Cancer risk <5% over 20 years (1% “simplex”, 4% “complex”)

75% spontaneous regression rate

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5
Q

Prognosis of hyperplasia with atypia

A

8% 4 years
12% 9 years
28% 19 years

Concomitant cancer 40%

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6
Q

Management of hyperplasia without atypia

A
  • Address reversible risk factors e.g. BMI
  • Medical therapy increases regression rate compared to observation alone
    (1) Mirena (2) Continuous oral progestogens (NOT cyclical)
  • Treat for minimum of 6 months
  • 6 monthly endometrial surveillance - 2 negative samples before discharge.
  • High risk of relapse (BMI >35, oral progestogens) then consider annual surveillance after 2 negative samples.
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7
Q

When to offer surgical management to patients with hyperplasia without atypia?

A
  • Progression to atypical hyperplasia
  • No regression of hyperplasia despite 12 months treatment
  • Relapse after completing treatment
  • Persistence of bleeding symptoms
  • Patient preference
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8
Q

Management of hyperplasia with atypia

A

(1) Surgical - hysterectomy + BS +/- BO

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9
Q

Management of hyperplasia with atypic if patient declines surgery

A

Refer to MDT
Mirena first line
Hysterectomy once fertility no longer desired
Follow up 3 monthly until 2 x negative biopsies and then every 6-12m until hysterectomy

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10
Q

Live birth rate in women who choose fertility sparing management of their endometrial hyperplasia with atypia

A

25%

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11
Q

How to manage endometrial hyperplasia in a patient on HRT?

A

If cyclical HRT then either swap to continuous or add in mirena.

If continuous HRT then review whether need to continue and consider mirena.

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12
Q

How to manage endometrial hyperplasia within a polyp?

A

Complete removal of polyp and biopsy to sample background endometrium.
Subsequent management then based on type of EH.

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13
Q

Which breast cancer treatments increase the risk of EH?

A

Tamoxifen (SERM)

Aromatase inhibitors don’t

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14
Q

What to do if EH develops in a woman on tamoxifen?

A

Decision with oncologists re: risk of stopping tamoxifen v risk of EH. Effect of mirena on breast cancer recurrence unknown.

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15
Q

Incidence of postmenopausal bleeding

A

10%

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16
Q

Most common findings in a patient with PMB

A 
60-80% atrophic endometritis/vaginitis
15-25% exogenous oestrogenen
25% endometrial polyp
15% endometrial hyperplasia
10% endometrial cancer
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17
Q

What is the most common presenting feature in a patient with endometrial cancer?

A

Vaginal bleeding (90%)

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18
Q

In a woman with PMB, what is the likelihood that she has endometrial cancer (overall)?

A

10%

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19
Q

In a woman with PMB, what is the likelihood that she has endometrial cancer (<50 years)?

A

1%

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20
Q

In a woman with PMB, what is the likelihood that she has endometrial cancer (>85 years)?

A

25%

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21
Q

In a woman with PMB, what is the likelihood that she has endometrial cancer (obese)?

A

18%

22
Q

In a woman with PMB, what is the likelihood that she has endometrial cancer (diabetic)?

A

21%

23
Q

In a woman with PMB, what is the likelihood that she has endometrial cancer (obese and diabetic)?

A

29%

24
Q

Prevalence of polyps in a patient on tamoxifen

A

30-60%

25
Q

Increased risk of endometrial cancer in a patient on tamoxifen

A

3-6 x increased risk

26
Q

Risk of malignancy within a polyp

A

Asymptomatic: 0.3%
Symptomatic: 2.3%

27
Q

Risk of atypical hyperplasia within polyp

A

Asymptomatic: 1.2%
Symptomatic: 2.2%

28
Q

How to interpret endometrial thickness on USS?

A

4mm or less than no biopsy needed

Above 4mm recommend endometrial sampling

29
Q

Risk of endometrial malignancy if ET <4mm

A

<1%

30
Q

What percentage of pipelle samples provide insufficient tissue?

A

25%

31
Q

Lifetime risk of endometrial cancer

A

3%

32
Q

What is the effect of every 5kg/m2 increase in BMI on endometrial cancer risk?

A

60% increase

33
Q

Lifetime risk of endometrial cancer in a woman with BMI >40

A

10-15% (10x higher)

34
Q

What percentage of endometrial cancers are secondary to obesity (and therefore preventable)?

A

40%

35
Q

What is the effect of regular physical exercise on endometrial cancer risk? (And what is meant by regular physical exercise in this context)

A

20 minutes moderate exercise 5 x per week reduces risk 20-30%.

36
Q

What is the effect of bariatric surgery on endometrial cancer risk?

A

70-80% reduction

37
Q

What is the effect of mirena on endometrial cancer risk?

A

54% reduction (increased to 75% if prolonged treatment)

38
Q

What is the effect of COCP on endometrial cancer risk?

A

> 5 year use reduces risk 50% (protection up to 30 years)

39
Q

What questionnaire screens for OSA?

A

STOP-BANG

40
Q

Which speculum is longer than a Cusco?

A

Winterton

41
Q

What are the two categories of endometrial cancer and their aetiology?

A

Type 1: Endometrioid - due to oestrogen excess, typically low grade with good prognosis.

Type 2: Non-endometrioid. Typically serous but can be any other type. Not oestrogen driven and occur in small atrophic endometrium. Aggressive.

42
Q

What proportion of patients with endometrial cancer present at stage 1?

A

70-75%

43
Q

What percentage of endometrial cancers are inherited?

A

2-5%

44
Q

Risk of endometrial cancer with Lynch syndrome

A

40-60% lifetime risk

45
Q

Where should patients with endometrial cancer be operated on?

A

FIGO 1A Endometrioid G1/G2 - DGH. Anything else should be done at a cancer centre.

46
Q

What are the treatment deadlines for patient with endometrial cancer?

A

Should be seen 2 weeks from referral and have treatment started 62d from referral (31d from decision to treat).

47
Q

What investigations are required once endometrial cancer confirmed?

A 
Chest imaging (CXR/CT)
CT A/P (or MRI) if high risk histology.

If high risk for mets or unexpected high risk findings in post-op histology: CT C/A/P.

48
Q

Treatment for endometrial cancer

A

Stage 1/2:

  • Hysterectomy and BSO
  • No evidence for lymphadenectomy
  • If high grade/non-endometrioid then surgical staging (including pelvic and para-aortic lymphadenectomy and mental biopsy)

Stage 3/4:

  • Complete surgical resection of all visible disease
  • Systematic lymphadenectomy
  • Neoadjuvant chemo and then surgery an option
49
Q

Adjuvant treatment for endometrial cancer

A

Progestogens not used routinely.
Radiotherapy:
- Not for low risk endometrioid
- Intermediate risk: EBRT or brachytherapy
- High risk: EBRT (unless had lymphadenectomy and nodes negative)

Chemo:
- Platinum based chemo offers small benefit in survival.

50
Q

Management options for endometrial cancer in a patient unfit for surgery

A

Vaginal hysterectomy
Definitive pelvic radiotherapy
Conservative management with progestogens/aromatase inhibitors.

51
Q

What proportion of endometrioid endometrial cancers occur in women <45 years and what proportion of those women have a synchronous ovarian tumour?

A

5% endometrioid endometrial cancer in women <45 years and 25% have a synchronous ovarian tumour.

52
Q

Fertility preserving option for endometrial cancer

A

Short term conservative management with progestogens if closely followed up.

Laura MRCOG Part 2 (56 decks)

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