Endometrial cancer

Question 1

List the causes of PMB

Answer 1

vaginal atrophy (60%)
hormonal effect
endometrial polyp
endometrial hyperplasia
endometrial cancer
cervical cancer

Question 2

For a woman presenting with PMB what is her risk of cancer?

Answer 2

3-20%

Question 3

For a woman presenting with PMB what is her risk for endometrial hyperplasia?

Answer 3

5-15%

Question 4

What would you tell a woman presenting with PMB regarding management?

Answer 4

Most likely benign cause
3-20% risk of cancer
5-15% risk of endometrial hyperplasia
Modifiable risk factors should be modified
Advise about the steps in investigation

Question 5

In pre- menopausal bleeding what is the normal ET on TV USS?

Answer 5

<7mm is normal

TV USS useful to review structural anomalies

Question 6

what is the ET cut off for TV USS in investigation of PMB?

Answer 6

3-4mm

Risk of cancer is <1% if the ET is less than cut off

Question 7

What is the role of TVUSS in women on tamoxifen?

Answer 7

Women on Tamoxifen should only have TVUSS for investigation if they are symptomatic i.e. with PMB/PCB
Tamoxifen can cause thickened/cystic stripes
No cut off for TV USS - all symptoms should be investigated

Question 8

What are the three principles for the management of hyperplasia?

Answer 8

Is there presence of atypia?
What are the women’ fertility wishes
What is the women’ suitability for surgery

Question 9

For endometrial hyperplasia without atypia, what are the conservative management options used?

Answer 9

Weight loss
Metformin
LNG-IUD/Mirena
Oral contraceptives
cyclical progesterone

Question 10

How would you justify conservative management of Endometrial hyperplasia without atypia?

Answer 10

Risk of progression to cancer is <5% in 20 years
Most regress spontaneously
Can just watch and wait
However much quicker regression if use progesterone treatment

Question 11

What is the lifetime risk of uterine cancer?

Answer 11

1:45

Question 12

What is the mainstay of management for uterine cancer?

Answer 12

Surgical resection

Radiation treatment reduces local recurrence but does not impact on survival

Question 13

What are the risk factors of endometrial cancer?

Answer 13

Endometrial hyperplasia
Obesity
T2DM
Hypertension
Nulliparity
Early menopause
PCOS
Tamoxifen treatment
Familial syndromes (Lynch, Cowden)
estrogen secreting tumours

Question 14

What management steps would you take for a patient with endometrial cancer (lets say pipelle or D&C comes back with finding of invasive cancer)

Answer 14

Ca125 - high preoperative Ca125 associated with advanced disease
CT CAP (in Auckland we do MRI pelvis + CXR unless high grade known)
MDT
Confirmation of pathology

Question 15

What are the intra-operative principles of staging an endometrial cancer?

Answer 15

Hysterectomy BSO (risk reduction ovarian ca)
+/- peritoneal washings (optional)
+/- pelvic +/- para-aortic lymph nodes
Minimally invasive surgery is an option

Question 16

What are the management options for a confirmed endometrial cancer?

Answer 16

Surgical (first line)
Conservative
- for the surgically unfit
- for women desiring fertility retention
Medical
- up front Chemo/Rad therapy in some scenarios
Palliative

Question 17

With regards to endometrial cancer, what is the current thoughts on lymphadenectomy?

Answer 17

Previously pelvic and para-aortic lymphadenectomy completed as standard
Now controversial - no survival benefit
apparent early endometrial cancer only associated with 19% LN positive
morbidity from lymphadenectomy ++

Question 18

what are the complications associated with lymphadenectomy?

Answer 18

Intra-operative
- vessel injury
- nerve damage
- VTE
Post operative
- Lymphocele (20%)
- lymphoedema (1.5-28%) 60% report affect on ADLs
- infection

Question 19

During pelvic lymphadenectomy for endometrial cancer which nerves can be damaged?

Answer 19

Obturator

genitofemoral

Question 20

What are the non surgical management options for endometrial cancer?

Answer 20

Rationale - only if cannot perform surgery or fertility preserving
Progestin therapy - LNG-IUD + oral progestin
repeat endometrial biopsies (3-6 monthly)
optimise medical problems (pre-operatively)
consider bariatric surgery

Question 21

List 8 poor prognostic factors associated with endometrial cancer

Answer 21

Increasing age (>65)
Stage (>1B)
Increasing myoinvasion
vascular invasion
Tumour extension beyond fundus
Grade 3
Histological subtypes (clear cell, serous, adenosquamous)
tumour >2cm

Question 22

Briefly describe LYNCH syndrome

Answer 22

most common form of hereditary colon cancer (1:1000 individuals)
Defect in DNA MMR genes (mismatch repair genes)
increased endometrial, ovarian, stomach, small intestine, hepatobiliary, ureter, brain and skin
50% present with Gynae cancer as their sentinel cancer
22% >stage 2

Question 23

Briefly describe the Cowden syndrome

Answer 23

autosomal dominant mutation of PTEN
PTEN - tumour supressor gene
loss of function of PTEN contributes to oncogenesis

Question 24

What are the key points for radiation treatment in endometrial cancer?

Answer 24

• Vaginal brachytherapy can be used to reduce the risk of local recurrence following surgical resection
• radiation therapy can be used for non surgically resectable disease
• used in palliative treatment to control symptom of bleeding
• used to treat recurrence

Question 25

in what scenario would you consider radiation therapy for stage 1 endometrial cancer?

Answer 25

If >2 poor prognostic factors could consider vaginal brachytherapy - if age >65 - deep myometrial invasion - grade 3 disease - serous or clear cell histology - LVSI (lymph vascular space invasion)

Question 26

what did the SEER study show with regard to stage 2 endometrial cancer and radiation therapy?

Answer 26

For patient with clinically overt and surgically resectable stage 2 disease the SEER study showed that when adjuvant radiotherapy was used for these patients there was an improved survival (post both simple and radical hysterectomy)

Question 27

For stage 2 endometrial cancer when is radiation therapy considered appropriate?

Answer 27

- Could argue that following SEER study then all surgical resectable overt stage 2 disease would benefit - if surgery is not considered feasible then full pelvic radiation therapy with intracavity brachytherapy may be employed

Question 28

What are the short term side effects of Radiation therapy? 'itis'

Answer 28

urinary - radiation cystitis GI - enteritis, colitis, proctitis Vaginal - ulceration, erythema, discharge, infection Skin - erythema, moist desquamation

Question 29

What follow up should women with endometrial cancer have?

Answer 29

NCCN guidelines: physical exam every 3-6 months for 2-3 years, then 6-12 months imaging as clinically indicated patient education regarding symptoms or recurrence and sexual health Ca 125 optional Treatment of recurrence - MDT

Question 30

How does recurrence of endometrial cancer present?

Answer 30

5-15% of patients with early stage disease with have a recurrence 75% of recurrence will occur in the vagina and present with bleeding

Question 31

What are the long term side effects on the urinary tract of radiation therapy?

Answer 31

Urinary: - bladder fibrosis - haematuria - ulceration - pain - UV and VV fistula

Question 32

What are the long term side effects of radiation therapy on the Gut?

Answer 32

GI: - chronic enteropathy (chronic diarrhoea and malabsorption) - fibrosis - dysmotility or obstructive/ileus - ulcerations

Question 33

what are the vaginal side effects of radiation treatment long term?

Answer 33

- sexual dysfunction - stenosis - vaginismus - adhesions

Question 34

what are the long term side effects of radiation treatment?

Answer 34

- urinary - fibrosis, ulceration, reduced capacity, haematuria, pain - GI - chronic enteropathy - malabsorption, diarrhoea - vagina - stenosis, sexual dysfunction, ulceration - ovaries - premature menopause - bone - insufficiency fractures - skin - hyperpigmentation, talangiectasia, fibrosis

Question 35

What is the risk of malignancy in hyperplasia with atypia?

Answer 35

43% of cases showed invasive disease when hysterectomy performed progression with atypia is quoted as 8% in 4yrs, 12% in 9 yrs nearly 30% after 19 yrs

Question 36

What is the risk of malignancy in hyperplasia with atypia?

Answer 36

43% of cases showed invasive disease when hysterectomy performed progression with atypia is quoted as 8% in 4yrs, 12% in 9 yrs nearly 30% after 19 yrs