Endometrial cancer Flashcards
Definition
Malignancy that originates from the lining of the uterus = endometrium.
The most common type of cancer is adenocarcinoma
Epidemiology
- Age > 50 years
- Family history and familial syndromes: such as HNPCC and cowden syndrome (PTEN)
Type 1 cancer risk factors
- Early menarche and late menopause: longer lifetime exposure: longer lifetime exposure to oestrogen
- Nulliparity: longer lifetime exposure to oestrogen
- Hormone replacement therapy (HRT):
- Poly cystic ovary syndrome
- Obesity
- Tamoxifen: pro-oestrogenic effects on the uterus
- Granulosa-theca tumours: ovarian tumour which secretes oestrogen.
Protective measures against endometrial cancer
COCP
Smoking
Pathophysiology
Type 1 (MC): occurs due to endometrial hyperplasia which is driven by oestrogen exposure.
- these can be classified into hyperplasia with or without cellular atypia, where the former confers a higher risk of progression into cancer.
Type 2: Arise from an atrophic endometrium and are oestrogen independent.
Type 1 endometrial cancer
Prevalence: 80-90%
Pathogenesis: oestrogen dependant, from endometrial hyperplasia
- PTEN and Kras mutation
Clinical features: Occurs at ~60 years old
Histology: Endometrioid (looks normal)
Prognosis: Good
Type 2 endometrial cancer
Prevalence: 10-20%
Pathogenesis: oestrogen independant, from atrophic endometrium p53 mutation
- PTEN and Kras mutation
Clinical features: Occurs at ~70 years old
Histology: Serous, clear cell
Prognosis: Poor
Signs
Bimanual exam:
- Uterine or adnexal mass
- Fixed uterus
Symptoms
Postmenopausal bleeding: classic symptoms
- painless, unexplained bleeding > 12 months after menstrual has stopped
Premenopausal bleeding: intermenstrual bleeding
Other causes of postmeopausal bleeding
Atrophic vaginitis (which is the most common cause)
Diagnosis
Any female > 55 years old with postmenopausal bleeding should be referred to a suspected endometrial cancer pathway in order to be seen within 2 weeks.
FIRST LINE = Transvaginal USS: to assess endometrial thickening
- > 4 mm = suggestive of endometrial cancer
GOLD STANDARD = Endometrial pipelle biopsy = Completed when TVUS suggestive of endometrial cancer
Hysteroscopy: only performed if GS not feasible.
Staging imaging: if Dx confirms malignancy = X-ray, MRI, or CT imaging
Staging
International Federation of Gynaecology and Obstetrics (FIGO) staging system:
- Stage I = Confined to the body of the uterus
- Stage II = Local spread to the cervix
- Stage III = Spread to the pelvis : adnexa, vagina, lymph nodes
- Stage IV = Invasion of neighbouring organs or distant metastases, such as bladder or bowel
Treatment Endometrial hyperplasia without cellular atypia
- Address risk factors such as obesity and HRT use
- Offer a minimum of 6-monthly surveillance and regular endometrial biopsies to ensure histological regression
- If there is no regression: offer progestogens for 6 months, usually intrauterine such as Mirena coil
Treatment Endometrial with cellular atypia
- Postmenopausal: total hysterectomy and bilateral salpingo-oophorectomy
- Premenopausal: total hysterectomy. The decision to remove the ovaries is individualised, however, should be considered as it may reduce the risk of future ovarian malignancy
Early disease: stage I and II
- Total or radical hysterectomy and bilateral salpingo-oophorectomy : +/- lymphadenectomy
- Adjuvant radiotherapy : +/- chemotherapy depending on the stage
- Fertility sparing: preserve fertility with progestogens if low-risk and monitored regularly
