Endometrial Cancer

Question 1

Is endometrial cancer the most common gynaecological cancer in the UK?

Answer 1

Yes

Question 2

The majority are diagnosed in what age group?

Answer 2

Peak incidence = 64-74

The majority 93% occur in women over 50

Question 3

There is marked geographical variation. North American: Chinese =

Answer 3

7:1

Reflects the differences in risk factors

Question 4

What risk factors are there?

Answer 4

Obesity
DM, HTN 
Nulliparity 
Early menarche and late menopause 
Unapposed oestrogen 
Tamoxifen 
PCOS - anovulatory cycles, absence of corpus luteum and therefore progesterone 
PMH of breast or ovarian cancer 
BRCA1/2 gene mutation 
FH HNPCC (Lynch syndrome) - confers higher risk of breast, endometrial and ovarian cancers 
Endometrial polyps and hyperplasia 
Parkinson’s disease

Question 5

What factors are protective?

Answer 5

COCP
Continuous, combined HRT 
Parity
Smoking 
Physical activity 
Coffee and tea

Question 6

What is the most common type of endometrial cancer?

Answer 6

Type 1 = Adenocarcinoma (80%)
Type 2 = papillary serous, clear cell, carcinosarcoma (20%)
Sarcoma = very rare

Question 7

What is the pre malignant condition?

Answer 7

Endometrial hyperplasia

Question 8

How is endometrial hyperplasia classified?

Answer 8

Complex with or without atypica

With atypical cells: malignancy coexists in 25-50% and 20% will develop cancer in 10 years

Question 9

How does it present?

Answer 9

Usually post menopausal bleeding
Usually little and occasional, then bleeding gets heavier and more frequent
Less commonly: blood stained, watery or purulent discharge

Premenopausal:
Change in bleeding pattern 
Irregular bleeding 
Intermenstrual bleeding
Heavier bleeding

Question 10

What percentage risk of endometrial cancer does a woman have with PMB?

Answer 10

10%

Question 11

What staging system is used?

Answer 11

FIGO staging
S1 - limited to myometrium
S2 - cervical spread
S3 - outside uterus but not pelvis e.g ovaries, tubes, vagina, pelvic, para-aortic LNs
S4 - bladder/ bowel involvement, distant metastases

Question 12

What is the predicted 5 year survival for S1?

Answer 12

80%

Question 13

What is the predicted 5 year survival for S2?

Answer 13

60%

Question 14

What is the predicted 5 year survival for S3?

Answer 14

20%

Question 15

What is the predicted 5 year survival for S4?

Answer 15

20%

Question 16

Who should be referred using the suspected cancer 2 week pathway ?

Answer 16

Women 55 years old and over with PMB

Consider referral in under 55 y/o with PMB

Question 17

What is the first line investigation?

Answer 17

Trans-vaginal US

Question 18

A normal endometrial thickness (less than 4mm) has what negative predictive value of endometrial cancer?

Answer 18

96% - no require for biopsy unless symptoms recurrent

Question 19

How is diagnosis confirmed?

Answer 19

Hysteroscopy with endometrial biopsy - pipelle or dilatation and curettage

Question 20

What investigations/ imaging is done for staging?

Answer 20

FBC, U&E, LFTs
CT CAP
MRI pelvis

Question 21

What factors influence treatment?

Answer 21

Stage
Age and fitness for surgery
Patient preference

Question 22

80% have primary surgery…

Answer 22

Hysterectomy and bilateral salpingo-oophorectomy, peritoneal washing
- laparoscopic or open

Question 23

When is adjuvant radiotherapy used?

Answer 23

Increased risk of recurrence

Low grade disease with deep myometrium invasion and high grade disease with superficial invasion

Question 24

What type of adjuvant radiotherapy is done?

Answer 24

External beam or brachytherapy

Question 25

What management can be done for advanced disease/ inoperable/ unfit for surgery?

Answer 25

Chemotherapy RT Hormones e.g aromatase inhibitors, progestogen therapy Palliative care

Question 26

Why is tamoxifen a risk factor?

Answer 26

It acts against the growth promoting effects of oestrogen in breast tissue, but it acts as an oestrogen in other tissues e.g uterus and bones - helps preserve bone density - increased risk of cancer in uterus (causes the endometrial lining to grow)

Question 27

Why is endometrial cancer often diagnosed early?

Answer 27

They are picked up because of PMB or irregular vaginal bleeding

Question 28

Irregular bleeding is a common symptoms of many other symptoms such as...

Answer 28

``` Endometriosis Fibroids Endometrial hyperplasia Polyps Dysfunctional uterine bleeding (no obvious underlying cause) ```

Question 29

Why is obesity a risk factor?

Answer 29

The greater the amount of subcutaneous fat, the faster the rate of peripheral aromatisation of androgens to oestrogen

Question 30

What examinations should be done?

Answer 30

Abdominal - for abdominal or pelvic masses Speculum - evidence of vulval/ vaginal atrophy or cervical lesions Bimanual - assess size and axis of uterus prior to sampling

Question 31

How can hyperplasia without atypia be treated?

Answer 31

Progestogens e.g Mirena IUS | Surveillance biopsy

Question 32

How should atypical hyperplasia be treated?

Answer 32

TAH + BSO | If contraindicated, regular surveillance biopsies

Question 33

How is non malignant simple or complex hyperplasia without atypia treated?

Answer 33

With progestogens e.g mirena IUS | Surveillance biopsies to identify any progression to atypia of malignancy

Question 34

How is atypical hyperplasia managed?

Answer 34

Highest rate of progression to malig, so should be treated with total abdominal hysterectomy + bilateral salpingo-oophorectomy If contraindicated - reg surveillance performed