Endometrial cancer (Complete)

Question 1

Definition endometrial cancer

Answer 1

Malignancy that originates from the endometrium, the inner lining of the uterus.

Question 2

What is the clinical significance of endometrial cancer?

Answer 2

6th most common cancer in woman

15th most common cancer worldwide

Question 3

What is the main aetiological cause of enodmetrial cancer?

Answer 3

Excess unoppososed oestrogen

(Increased proliferation of the glandular endometrial cells, –> greater gland:stroma ratio than is seen in normal endometrium)

Question 4

What risk factors are associated with endometrial cancer?

Answer 4

Factors which can increase endogenous or exogenous exposure to oestrogen such as:

Obesity and T2DM

PCOS (Increase in androgens which can be converted into oestrogen, persistent follicles also produce oestrogen, low progesterone which opposes oestrogen)

Oestrogen-only HRT

Nulliparity (lack of pregnancy interruption)

Late menopause

Early menarche (Greater lifelong period of oestrogen)

Tamoxine therapy (Breast cancer treatment)

Lynch syndrome (HNPCC)

Question 5

What are the three main ways PCOS can lead to increased oestrogen production?

Answer 5

Increased androgen production: Gets converted to oestrogen

Chronic annovulation: Ovarian follicles fail to mature and continuously releases oestrogen which doesnt follow hormonal cycle.

Imbalance in hormones: Decrease in progesterone which balanced oestrogen

Question 6

Why is obesity associated with endometrial cancer?

Answer 6

Fat cells contain enzyme aromatase

Aromatase synthesises extra-ovarian oestrogen

Question 7

Why are some breast cancer patients at risk of endometrial cancer?

Answer 7

Tamoxifen therapy is used in management of breast cancer and associated with endometrial cancer

Question 8

What GI condition is associated with increased risk of endometrial cancer?

Answer 8

Lynch syndrome (Hereditary non-polyposis colon cancer/HNPCC)

N.B. Up to 40% will go on to develop endometrial cancer

Question 9

What are some protective factors for endometrial cancer?

Answer 9

Regular exercise

Multiparity

Combined oral contraceptive pill use

Tobacco consumption (unclear as to why)

Question 10

What is the most common form of endometrial cancer?

Answer 10

Adenocarcinoma

Question 11

Endometrial adenocarcinoma can be subdivided into which two types?

Answer 11

Endometrioid (80%): Associated with excess unopposed oestrogen

• Endometriod endometrial carcinoma (most common)
• Secretory endometriod carcinoma
• Mucinous endometrioid carcinoma

Non-endometrioid (20%): Associated with endometrial atrophy (elderly) versus oestrogen

• Serous carcinoma
• Clear cell carcinoma
• Papillary serous carcinoma

Question 12

Which type of endometrial adenocarcinoma is associated with endometrial atrophy seen in edlerly woman?

Answer 12

Non-endometriod carcinomas:

Serous carcinoma

Clear cell carcinoma

Papillary serous carcinoma

NOT associated with excess oestrogen

Question 13

Endometriod endometrial carcinoma is associated with mutation in which gene?

Answer 13

PTEN

Type of tumour suppresor gene

Question 14

Papillary and serous cell carcinoma are associated with mutations affecting which protein?

Answer 14

p53

Tumour suppresor

Question 15

Clear cell carcinomas are associated with mutations in which genes?

Answer 15

PTEN

p53

HER2

Question 16

What are some of the main signs/symptoms of endometrial cancer?

Answer 16

Post-menopausal bleeding (90% cases)

Irregular or inter menstrual bleeding in premenopausal women.

Recent onset menorrhagia (heavy bleeding) especially in women >45 years of age

Abdominal discomfort/bloating

Anaemia

Weight loss

Question 17

What examination should be performed in patients suspected of endometrial cancer? What are the subsequent findings?

Answer 17

Bi-manual pelvic examination

Uterine mass or enlarged uterus

A fixed uterus

Adnexal mass indicating extra-uterine disease

Question 18

What examinations should be done for patients suspected of endometrial cancer?

Answer 18

Bedside:

Basic obs: Weight loss

Bloods:

FBC: Anaemia
Blood glucose: If patient obese/check for metabolic causes

Imaging:

Transvaginal ultrasound

Endometrial biopsy: Following suspicious ultrasound

CT chest abdomen and pelvis: If advanced disease suspected

Question 19

Which presentations warrant 2-week cancer referral?

Answer 19

Any woman over 55 with post menopausal bleeding

Question 20

What is the first-line investigation for endometrial cancer?

Answer 20

Transvaginal ultrasound

Question 21

What findings on transvaginal ultrasound are indicative of endometrial cancer?

Answer 21

Abnormal thickening of endometrium

(>4mm = 96% probability of endometrial cancer)

Question 22

Following transvaginal ultrasound findings, what investigation is diagnsotic for endometrial cancer?

Answer 22

Endometrial biopsy (Pipelle or hysteroscopy)

Question 23

What alternative is offered if pipelle endometrial biopsy is contraindicted?

Answer 23

Hyesteroscopy

Question 24

What histological findings distinguishes endometriod from non-endometriod cancers?

Answer 24

Endometriod

• Closely resemble normal endometrial glands
• More likely to be low-grade
• More likely to be associated with PTEN mutations

Non-endometriod:

• More likely to be high-grade
• Associated with p53, HER2 and PTEN

Question 25

What system is used to stage endometrial cancer?

Answer 25

FIGO system

Question 26

Stage 1 endometrial cancer

Answer 26

Cancer located only in the uterus

Question 27

Stage 2 endometrial cancer

Answer 27

Cancer spread to cervix

Question 28

Stage 3 endometrial cancer

Answer 28

Cancer spread to pelvic area

Question 29

Stage 4 endometrial cancer

Answer 29

Cancer spread to bladder, rectum or distal organs

Question 30

What is the management plan for patients diagnosed with endometrial cancer?

Answer 30

**_Surgery_**: Total hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy. **_Medicine_**: Radiotherapy and chemotherapy: Used in adjunt with surgey in patients with advanced disease

Question 31

For elderly woman in which surgery is contraindicted, what alternative management options are available?

Answer 31

Progestogen therapy

Question 32

What are some complications of management for patients with endometrial cancer?

Answer 32

Lymphoedema Bladder instability (Bladder denervation) Bowel and bladder fistulae Vaginal stenosis (sexual dysfunction and makes future pelvic examinations difficult) Early menopause

Question 33

What differentials should be considered alongside endometrial cancer?

Answer 33

**Uterine fibroids**: Heavy menstrual bleeding, pelvic pressure or pain, frequent urination, constipation. **Endometrial polyps**: Irregular menstrual bleeding, bleeding between menstrual periods, heavy menstrual periods, vaginal bleeding after menopause. **Cervical cancer**: Abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.

Question 34

How does uterine fibroids differ to endometrial cancer?

Answer 34

**Nature of bleeding**: Fibroids: Heavy irregular menstrual bleeding Endometrial cancer: Post-menopausal bleeding **Pain**: Uterine fibroids moresoe associated with pain and pressure whereas is a later presentation in endometrial cancer **Systemic symptoms**: More common in endometrial cancer

Question 35

How does endometrial polyps differ to endometrial cancer?

Answer 35

**Bleeding pattern**: Endometrial cancer more peristent and severe **Pain**: Usually does not occur with endometrial polyps **Systemic symptoms**: Occurs in endometrial cancer

Question 36

How does cervical cancer differ to endometrial cancer?

Answer 36

**Age**: Endometrial more likely to affect middle-aged, post-menopausal woman **Bleeding pattern**: Endometrial: Post-menopausal bleeding Cervical: Post-coital bleeding **Discharge**: Cervical more associated with bloody, foul-smelling discharge **Pain**: Cervical cancer moresoe dyspareunia and bladder symptoms