Endometrial Cancer Flashcards
Uterine Sarcome/Leiomyosarcoma
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- only 10% of uterine cancers: cancer of the muscular layer of the uterine wall; the myometrium - outer muscle layer
- occurs in women older than 50 commonly
Symptoms
- enlarged rapidly growing pelvic mass
- can see an increse in pelvic width, abdominal girth
- occationally pain with sex, vaginal bleeding/pain
Diagnosis
- surgery/pathology results along with TVUS
Treatment
- surgical removal: ususally a total hysterectomy wiht bilateraal salpingo oophectomy (BSO)
- chemco is frequently done with good results, radiation uncommon
Prognosis
- localized: 60%
- distant: 12%
- overall SEERs: 38%
Endometrial Cancer
Etiology and Risk Factors: what can increase a womens risk of getting this
Etiology
- accounts for 90% of all uterine CA
- this is a cancer of the inner lining; endometrium : often this is referred to as “uterine cancer”
- highly curable due to earl diagnosis!! : biggest sign = post-menopausal bleeding
- peak incidence is 50-70: think of this as a cancer of women right around menopause
Risk Factors
chronic exposure to unopposed estrogen
- estrogen will continuously build up the endometrial lining, increasing mucous and the vessels: no way to shed: increased CA risk and metaplasia
- can be endogenous estrogen: like estrogen secreting tumor
- can be exogenous like tamoxifen > 2 years or HRT
Obestiy & T2DM
- adipose tissues secrete estrogen
increased periods: menses
- due to exposure to E2 (estradiol)
- can be from never being pregnant, early menses, late menopause
PCOS
- a state of constant estrogen without progesterone (low pregestin = unopposed estrogen)
family history: colon cancer, or lynch syndrome/HNCC
Endometrial Hyperplasia & Link to Endometrial CA
symptoms
2 types of endometrial hyperplasia
Endometrial Hyperplasia
- thickening/overgrowth of the endometrium: abnormally
- high risk of turning into endometrial cancer becuase of this thickening
Symtpoms of Endometrial Hyperplasia
- abnormal uterine bleeding (90%)
- metrorrhagia: bledding often
- menorrhagia: bledding laarge amounts
- period of amenorrhea: then hevay bleeds
Endometrial Hyperplasia (these are patterns which are reported by the radiolosits and those who can look at the cells)
Hyperplasia without atypia: smaller risk of becoming cancer
- simple = endometrium with dilated glands
- complex = endometirum with glands that are crowded and compleex pattern
Atypical Hyperplasia : larger risk of becominig cancer
-simple
complex: highest cancer risk to evolve from here
Endometrial Hyperplasia
Diagnosis & Treatment Options
Diagnosis
- TAUS/TVUS (take a look)
- endometiral biopsy “blind biopsy of cells”
- hyperscopy: with camera to target specific cells if US shows areas of concern
Treatment
Hyperplasia without atypia: can do a D&C to “cut out” the endometiral thickness & preserve fertility
Hyperplasia with/without atypia: can use progestin pills or shot to cause sloughing of the endometrium
if the atypical hyperplasia doesnt resolve after 6-9 months of progestin meds., hysterectomy can be offered
Specifics about the following diagnostic procedures
EMB
TVUS & thickness measurements
Hysteroscopy
EMB
- in office proceudre: no anesthesia
- sampling the endometrial cells for hyperplasia: 90% successful in getting accurate diagnosis usually
- if unable ot be done: D&C can be done with anestehsai in outpt. setting
TVUS
screening method
- attempts to measure and understand the thickness of the endometrium and the size of the uterus
- check a few days after menses: want to measure at thinnest time
- < 5 mm - normal : check a few days after menses
- > 12 mm - get EMB
- > 5-7 mm in a postmenopasual women = get EMB
Hysteroscopy
- visualization and targeted sampling of the nedometrium
- can be done in office, as procedure appt.
Endometrial Cancer
Types of Cancers it can be
subtypes
Staging
Grading
Endometrical Cancer
Types
most common: endometroid adenomcarcinoma (good prognosis)
Clear Cell Carcinoma
Uterine Papillary Serous Carcinoma
Carcinosarcoma
Subtypes: estrogen receptive or not
Type 1: estrogen dependent: good prognosis
Type 2: non estrogen dependent: poor prognosis
Staging
- decides depth of CA after a TAH, BSO, ometectomy, ex.lap is done
- STage 1: confied to uterine body
- Stage 2: invovles uterine body + cervix
- Stage 3: spreads outside uterus: but stays within pelvis
- Stage 4: outside of pelvis spread or into the bladder/rectum
Graded
- the pathological classification of cells : differentation
- G1: well differentiated
- G2: intermed.
- G3: poorly differentiated
Endometrial Cancer : Treatment
Approach
Approach to Treatment
- depends on age, tumro stage and grade, the histological report & pronostic factors (depth and invovlement of others, lymph nodes, etc.)
because most are diagnosed and found early: treatment with surgery (TAH with BSO +/- lymph) can be curative
Radiation: can be done for stage 1 &2
- intravaginal brachythearpy
- pelvic external beam radiation
chemoc is reserved for adnvaced or recurrent CA
Recurracance and symptoms of that for endometrial CA
Recurrance
- survey for following 5years with biannually/quaterly exams & pap of the cervical cuff: where cervix used to be
symptoms of recurrance
- abd pain
- bledding
- fatigue
- oncology decides HRT
- continue normal screenigns of mammo, dexa and colonscopy
Gestational Trophoblastic Disease
etiology
who is likely to get this
Etiology
- a tumor from tissue that forms with conception with implantation of blastocyte in the uterus/endometrium
- trophoblasts = cells which surround the blastocyte in endometrium
- these are benign: but hydatidiform moles: meaning they have the potential to become malignant /dysplastic
- GTN: gestaional trophoblastic neoplasia: have the ability to locally invade and metastizie
Who
- women of extreme reproductive ages: very early and very late (older than 45)
often times
- women get “pregnant” = its a hydiform mole aka molar pregnancy
- they get it removed : but potentially a few cells remain
- then it becomes GTN: cancer
Signs/Symptoms of a hydatidiform mole
Molar Pregnancy
- abnormal first trimester bleeding
- passage of grape-szied clusters in vagina: hydrophic: villi
- placenta growing WAY too fast on exam or on TVUS
- serum HCG will be WILDLY ELEVATED: normally doubles every 24 but this will be much higher
- hyperemesis: because HCG high = triggers nasues
- PIH in first trimester (HTN)
molar pregnancy: can be complete or partial
GTN: commonly a diagnosis after complete moles more than something which happens after partial moles
Diagnosis & treatment of a Molar Pregnancy
Molar Preg. Diagnosis
- usually by TVUS & results of HCG study
- early dx. = better treatment
Treatmen t
- D & E of the molar mass asap
- can consider hysterectomy in women > 40
- serum HCG will be monitored and aid in treatment: and watched for the return of GTN
if HCG : under 5 = good
if GTN starts: will see HCG increase dramatically
Appearance of GTN after a Molar PRegnancy
how to measure HCG and when to stop
risk factors for developing GTn after molar
GTN: gestational trophoblasitc neoplasia
- commonly within 6-12 months of the molar
- see increase in serum HCG
- if you see 2 normal HCG levels: risk of GTN extremely low
for partial mole: confirm return to normal HCG level x2 test: then good
for complete mole: confirm return to normal HCG and monitor for 6 months
GTN Risk Factors
- age > 40
- preevacuation of hcg> 100,000
- excessive uterine enlargement
- theca lutein cysts > 6cm
Prognosis of a Molar Pregnancy
After D&E = pt can have a normal subsequent rpegnancy
- small risk of molar recurrance, more likely if they’ve hade more thant 1 molar
GTN
Diagnosis & Treatment
Diagnosis of GTN
- HCG elvels increasing over time
- evidence of METS : choriocarcinoma in virtually every body part
- bleeding and pain from areas which are NOT in the pelvis
Histology can show
- invasive moles, choriocarcinoma, trophoblasic disease
Treatment
- D&E repeat curettage: increased risk of uterine perforation (because structrues are compromised)
immendiate eval of METs
- cbc, coags, CMP t&S, HCG
- pelvis exam : if masses dont biopsy: risk of hemorrhage
Chemois primary treatment for most stages of GTN
low risk: can usually preserve uterus
hight risk: usually need surgery or radiation
hCG remission goals after GTN
Serial hCG levels every 2 weeks for first 3 months then monthly for a year
risk of recurrance is low: but high risk GTN has higher risk of coming back so they should be monitored with hCG for longer (6-12 month intervals beyond first year)
