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Flashcards in Endometrial cancer Deck (28):
1

Endometrial cancer incidence

4th most common cancer in females
most common gynecological cancer
5 year survival ~70%

2

Oncogenesis of endometrial cancer

unopposed estrogen leading to hyperplasia, then ca

3

Natural history of endometrial cancer

extension through uterus
spread into lymph nodes and blood

4

Risk factors of endometrial cancer

unopposed estrogen (exogenous hormones, obesity, anovulation)
obesity: 3-10x
Lynch syndrome (lifetime risk 40-60%)
HTN
diabetes: 2-3x
irregular menstruation
nulliparity

5

Prevention of endometrial cancer

decrease BMI

6

Pre-cancerous stage of endometrial cancer

endometrial hyperplasia

7

Spread of endometrial cancer

Local: uterus, cervix, colon, bladder
Lymph: para-aortic nodes or pelvic nodes
Blood: uncommon, metastasis to lungs, liver, bone

8

SSx of endometrial cancer

Postmenopausal bleeding
abnormal vaginal bleeding

9

Diagnosis of endometrial cancer

biopsy
D&C if biopsy not enough
US can give suspicion but not diagnosis

Use IHC for all endometrial ca to screen for Lynch syndrome

10

Staging of endometrial cancer

surgical
I: confined to uterus (majority of patients present here)
II: cervix
III: adnexae
IV: bowel, bladder, distant metastasis (rare)

11

Tx of endometrial cancer

1) Surgery!
Hysterectomy + bilateral salpingo-oophorectomy +/- lymmphadenectomy

Adjuvant:
depending on stage and risk of recurrence
Pelvic radiation - local
Chemo - distant
Hormone therapy - advanced stage, well-differnetiated (grade 1)

12

Followup of endometrial cancer

For recurrence:
- Pelvic exam q6/12 for 2-3 y, then annually
- Screening tests are NOT USEFUL
- most are symptomatic (vaginal bleeding)
- majority recur in pelvis

To maximize survivorship:
-reduces risk of other cancers
-QOL

13

Type I endometrial ca

"low risk"
more common
Age ~62 (20%

14

Type I endometrial ca risk factors

Estrogen-related (E>P)
obesity: conversion of androstenediol --> estrogen
PCOS
T2DM: hyperinsulinemia
Tamoxifen: selective estrogen receptor modulator - used to treat breast ca, but increases endometrial hyperplasia

15

Type II endometrial ca

high risk
rare
age ~70
almost always postmenopausal
NOT estrogen related, more likely to have normal BMI
non-endometriod: serous, clear cell, malignant mixed mullerian tumour (carcinosarcoma)
All high grade (grade 3)

16

Prognostic factors in endometrial cancer

Grade
Depth of myometrial invasion
Cervical stroma involvement

17

other cancer risks after endometrial cancer

breast: 2x higher, estrogen, 1-2% in 5 y

Colorectal: 3-7x, obesity, radiotherapy, Lynch syndrome; 1-2% in 5 year

18

Lynch syndrome

hereditary non-polyposis colorectal cancer (HNPCC)
inherited mutation in DNA mismatch repair MMR gene
High lifetime risks of cancer
- Colorectal 60%
- endometrial 60%
- ovarian 10%
- gastric 10%

19

Screening to reduce cancer risk in Lynch syndrome

CRC: biannual colonoscopy from 25 y, then annual from 40
Endometrial/ovarian:
- annual endometrial biopsy and US from age 25-35 (not proven to be effective)
- prophylactic surgery

20

How to counsel on prophylactic surgery for ca

Early (age 30) vs later (early 40s)
hormone replacement therapy afterwards

Progestins as alternative to surgery for young women
- grade 1 endometriod tumours, no myometrial invasion
- adverse effects
- response rate 60-70%; need regular surveillance
- keep fertility!

21

Amsterdam II criteria

3-2-1 rule
3 family members
2 generations
1 under age 50
but family history not enough

22

Lynch syndrome Dx

Amsterdam II criteria
Immunohistochemistry to detect 4 MMR proteins

23

IHC algorithm for endometrial ca

Test all endometrial ca patients for 4 MMR proteins
Normal 80%
Abnormal 20% --> refer to hereditary cancer program
- Mutation 10%; no mutation 90%

24

Indications for bilateral salpingo-oophorectomy in endomterial ca

Concurrent ovarian pathology
synchronous ovarian primary (low grade endometriod tumour), up to 25% (good prognosis)
Ovarian metastases less likely ~3%

25

CI for bilateral salpingo-oophorectomy in endometrial ca

morbidity/mortality from early BSO
osteoporosis, CHD, lung and CRC

26

HT after endometrial ca

Stage I/II/III: no increased risk with HRT
benefits > risks

27

Protective factors for endometrial ca

Multiparity (>3): 0.3 RR
OCP (5 y): 0.5
Exercise (2.5 h/week): 0.5
Smoking (current vs never): 0.7
Coffee (per cup): 0.9

28

Immediate precursor to endometrial ca

Complex Atypical Hyperplasia