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OBGYN Oral Exam > Endometrial Cancer > Flashcards

Endometrial Cancer Flashcards

1
Q

Incidence/Statistics of Endometrial Cancer

A

Most common cancer of female reproductive organs in developed countries (cervical in developing)
American Cancer Society estimates for uterus cancers in US for 2013 (2011 numbers)
- 50,000 new cases of cancer will be diagnosed
- 8000 will die from cancer

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2
Q

What is the classification of endometrial carcinomas?

A

2 Major types based on light microscopic appearance, clinical behavior and epidemiology.

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3
Q

What is Type I endometrial carcinoma?

A

Endometrioid histology
80% of endometrial carcinoma
Estrogen responsive, preceded by an atypical or complex endometrial hyperplasia
Favorable prognosis

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4
Q

What is Type II endometrial carcinoma

A

10-20% of endometrial carcinomas
Grade 3 endometrioid and non-endometrioid histology
Often high-grade, poor prognosis, and not associated with estrogen stimulation.
Precursor lesion is rarely identified

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5
Q

What are the different types of non-endometrioid histology?

A

serous, clear cell, mucinous, squamous cell, transitional cell, mesonephric, undifferentiated

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6
Q

What are endometrioid carcinoma?

A

Well-differentiated, gland forming neoplasms
Graded by gland formation and nuclear grade

Grade 1: no more than 5% solid (nonglandular growth)
G2: 6-50% solid growth
Grade 3>50% solid growth
Squamous metaplasia not counted.

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7
Q

Serous and clear cell carcinoma

A

Myometrial and vascular invasion more common
Poorer prognosis

Serous - papillary architect that resembles serous carcinoma of vary with nuclear atypia and psammoma bodies
Clear cell: clear cytoplasm due to glycogen

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8
Q

Common genetic abnormalities in endometrioid neoplasms

A

microsatellite instability, K-ras, PTEN, defects in DNA mismatch

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9
Q

Common genetic abnormalities in non-endometrioid neoplasms

A

p53

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10
Q

Pelvic/peritoneal washing cytology

A

Assess microscopic peritoneal spread
Most will not change management based on positive peritoneal wash

Indicates higher risk of recurrence

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11
Q

Endometrial cancer and races

A

Incidence higher in whites

But mortality is 2x higher in blacks - higher incidence of aggressive cancer subtypes, access and quality of care

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12
Q

Average age of uterine cancer diagnosis is:

A

61

Between 55-64 - >30% cases - highest distribution

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13
Q

Between age 50-70, women have what % risk of being diagnosed with uterine cancer? Lifetime risk?

A
  1. 4%

2. 6%

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14
Q

When are uterine cancer most commonly diagnosed?

A

68% confined to primary site
20% spread to regional organs/lymph nodes
8% distant metastasis

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15
Q

Endometrioid major risk factor

A

Estrogen-responsive
Long-term exposure to endogenous or exogenous estrogen without opposing progestins

Multiple case controls found increased endometrial carcinoma with unopposed estrogen therapy 1.1-15 RR; 20-50% of women have endometrial hyperplasia after 1 year of use

Women’s health initiative randomized trial - hormone therapy not increase risk

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16
Q

Endometrioid risks: drugs?

A

Tamoxifen in postmenopausal
SERM - agonist at endometrium

Lack of evidence in premenopausal women
only in age > 55

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17
Q

Estrogen-associated risk factors for endometrioid cancer

A
  1. Obesity (peripheral conversion of androstenedione to estrone)
  2. Chronic anovulation (PCOS, thyroid dysfunction, elevated prolactin levels)
  3. Early menarche/late menopause
  4. E-secreting tumor (granulosa cell tumors)
  5. Diabetes (hyperinsulinemia, insulin resistance, elevated insulin-like growth factors)
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18
Q

Obesity and Endometrial cancer

A

alterations in insulin-resistance - increased risk of endometrial carcinoma

increased risk of dying - uncertain pathophysiology, continued stimulation of metastatic cells by endogeneous; obesity-associated conditions (cardiovascular/diabetes)

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19
Q

Other non-E related risk factors of endometrial cancer

A
  • Family history (first degree relatives), no candidate gene identified consistently
  • Lynch syndrome (AD germline mutation in DNA mismatch repair)
  • BRCA1 (? tamoxifen)
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20
Q

Protective factors

A
  • OCPs (progestin)
  • childbearing at older age (35-39)
  • smoking (hepatic metabolism of estrogens)
  • physical activity (obesity?)
  • Coffee, Green tea
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21
Q

Most common symptom

A

Abnormal uterine bleeding - intermenstrual bleeding who are ovulatory, frequenty, heavy (>80 ml) or prolonged
75-90% women

Amount of bleeding does not correlate with risk of cancer

Age 45yo as cutoff

22
Q

Physical exam for endometrial cancer

A

Size - hyperplasia/early do not have enlarged uterus.
Fixed, enlarged uterus may be consistent with uterine leiomyoma

Confirm source of bleeding is the uterus

23
Q

Lab

A

betahCG to exclude pregnancy

hematocrit or clotting studies

24
Q

Pelvic ultrasound

A

Postmenopausal women - endometrial thickness is < 4mm

Gold standard for evaluation for neoplasia is endometrial sampling

25
Q

When to perform D&C

A

cannot tolerate office biopsy
heavy bleeding
very high risk of endometrial cancer (Lynch syndrome)

ensure focal lesions are identified and biopsied

26
Q

Endometrial sampling

A

Office endometrial biopsy - highly effective at diagnosing endometrial hyperplasia

27
Q

Differential diagnosis for endometrial carcinoma

A 
Atrophy
Endometrial polyp
Fibroids
Cervical neoplasia
Bleeding from anus/rectum

Pregnancy/ectopic pregnancy
Menopausal transition

28
Q

What is the sensitivity for endometrial sampling?

A

90% or higher

False negative if hx of colorectal cancer, polyps, obesity

29
Q

Endometrial cancer screening

A

No high quality data to support screening to reduce cancer mortality
Except in Lynch syndrome

Biopsy is uncomfortable and invasive

30
Q

Most useful in predicting extrauterine spread of endometrial carcinoma

A

CA 125

Useful after initial treatment

31
Q

If patient cannot be surgically staged?

A

Contrast-enhanced MRI for detecting myometrial invasion and cervical involvement

Also best modality for detecting lymph node metastases

32
Q

How is endometrial cancer staged?

A

Surgically staged

Total extrafascial hysterectomy with BSO with (selective) pelvic/paraaortic lymph node dissection is standard staging

33
Q

Stages of Endometrial cancer

A

2010 classification changed
1A (tumor limited to endometrium or invades less than one-half of myometrium)

1B (tumor invades 1/2 or more of myometrium)
Better able to predict prognosis

34
Q

Is endometrial cancer curative?

A

Surgery alone usually curative for low risk disease (endometrioid histology grade 1,orr 2, confined to endometrium, no other risk factors for persistence and recurrence)

35
Q

Intraoperative gross inspection and frozen section

A

frozen section - not consistently high concordance, especially in low-stage and low-grade disease; variable between pathologies.

Large study - grade on final path was higher than that from intraoperative frozen

36
Q

When should nodes be resected?

A

Serous, clear cell, high-grade histology
Myometrial invasion greater than 50%
Large tumor (>2 cm in diameter or filling endometrial cavity)

37
Q

Which nodes are resected

A

Distal 1/2 of common iliac artery
Proximal 1/2 of external iliac artery
Distal 1/2 of obturator fat pad anterior to obturator nerve

New research into sentinel node biopsy - further study needed

38
Q

Cervical involvement

A

Historically radical hysterectomy

Simple hysterectomy with lymphadenectomy (lymphovascular space invasion better predictor of parametrial extension)

39
Q

Laparoscopic

A

Faster recovery time

Limitation - dissect paraaortic nodes above IMA

40
Q

Inoperable patients or refusing surgery

A

Stage I disease - primary pelvic radiation may be acceptable

41
Q

Patient who wants to preserve fertility?

A

Stage I grade I may be candidate for treatment with progestin therapy.

42
Q

5 year survival

A

Stage I - 80-90%
Stage II - 70-80%
Stage III/IV - 20-60%

43
Q

Medium risk patients

A

Invades myometrium or cervical stromal invasion
Candidates for adjuvant radiation therapy

No role for chemotherapy

44
Q

High risk patients

A

Stage III disease regardless of grade
Uterine serous/clear cell carcinoma of any stage

Receive chemo with or without radiation therapy given high risk of distant and locoregional relapse

45
Q

Surveillance protocols

A

Monitoring for symptoms (70%)
Routine use of CA 125 (varies)

Review of symptoms and PE every 3-6 months for 2 years, then every 6 months or annually.
Vaginal cytology every 6 months for 2 years, then annually
Genetic counseling for lynch

46
Q

Symptoms of recurrence

A

Bleeding, abdominal/pelvic pain, persistent cough, unexplained weight loss

47
Q

When do recurrences occur?

A

68-100% within 3 years

Most common in vaginal vault, pelvis, abdomen, lung

48
Q

What is stage 2 endometrial cancer?

A

Invades connective tissue of cervix

49
Q

What is stage 3a endometrial cancer?

A

Serosa or adnexa through extension or metastasis

50
Q

What is stage 3b endometrial cancer?

A

Vaginal involvement

51
Q

What is stage 4 endometrial cancer?

A

Invades bladder mucosa

OBGYN Oral Exam (4 decks)

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