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FRCR2 > endometrium > Flashcards

endometrium Flashcards

1
Q

What are the endometrial cancer histologies

A

Endometrioid adenocarcinoma
Clear cell
Papillary serous
Carcinosarcoma (tx as high grade endometrial adenoca)
Leiomyosarcoma / endometrial stromal sarcoma - treat as sarcoma
Squamous, small cell, lymphoma

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2
Q

What are the risk factors for endometrial cancer

A

Oestrogen exposure - oestrogen only HRT, PCOS, obesity, nulliparity, increasing years of menstruation
Previous breast cancer

Genetic factors - Lynch type II

Atypical endometrial hyperplasia

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3
Q

What is the endometrial management of Lynch syndrome

A

Yearly TV USS from 35yrs, prophylactic H+BSO from 40

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4
Q

What is the frequency of concurrent ovarian and endometrial carcinoma

A

8%
If histologies match - treat as endometrial that has spread to the ovary
If different histology = two primaries, and treat highest stage first

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5
Q

What are the molecular subgroups of endometrial carcinoma

A

EC - POLE mut
EC - dMMR
EC - pMMR, p53 mut - poorest outcome, and greatest benefit from chemo
EC - pMMR, p53 WT - NSMP

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6
Q

How often are POL-E mutations seen in endometrial cancer
What is the consequence

A

10%
High mutational burden and typically have better outcomes
Can consider de-escalating treatment

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7
Q

What are the four proteins tested for in Lynch syndrome

A

PMS2, MSH6, MSH2, MLH1
Loss of one of these = diagnostic for Lynch
Need to test germline status too

3% of endometrial cancers and 10% of dMMR ECs are related to Lynch syndrome

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8
Q

When is the endometrium thickness abnormal

A

> 3mm if post menopausal and not on HRT

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9
Q

How is endometrial cancer investigated

A

TV USS + hysteroscopy & biopsy
MRI pelvis
Staging CT
+/- PET
+/- cystoscopy / sigmoidoscopy

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10
Q

What surgery should be done in a Stage 1 serous EC & carcinosarcoma

A

TAH & BSO, with omentectomy, peritoneal biopsy and LN staging

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11
Q

When should LN evaluation take place for endometrial cancer

A

≥Gr3, ≥FIGO IB, non-endometrioid histology,
SNLB or sentinel lymphadenectomy

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12
Q

How can fertility be spared for a stage 1 endometrial cancer

A

Gr1 stage 1A only
Ovary sparing TAH

Or mirena coil and oral progesterone

Monitor closely - repeat endometrial biopsy at 3 & 9 months.
Hysteroscopy 6 & 12 months.
After 1 year, if CR, can have fertility treatment, followed by complete hysterectomy (discussion)

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13
Q

What is the management of a stage one endometrial cancer

A

TAH + BSO unless PM and Gr1 stage 1A
If G1/2 - SLN biopsy, and adj chemo if node positive
Gr3 - adjuvant chemotherapy

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14
Q

What is the management of a stage 2 endometrial cancer

A

TAH + BSO + pelvic lymphadenectomy
+ omentectomy if serous histology (behaves like ovarian)

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15
Q

What is the management of a stage 3 endometrial cancer

A

TAH + BSO + lymphadenectomy
Adj chemo and EBRT and brachy

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16
Q

What is the management of a stage 4 endometrial cancer

A

Operable - consider exenteration & adjuvant treatment
Inoperable - NACT, EBRT (45Gy/25#) and boost to macroscopic disease, +/- surgery if disease becomes operable

17
Q

What is the benefit of adjuvant RT for endometrial cancer

A

10% improvement in local recurrence risk
No improvement in overall survival

18
Q

When is adjuvant RT indicated for endometrial cancer

A

> 60yrs, stage 1b (deep myometrial invasion), grade 3

19
Q

What was the outcome of portec 2, regarding adj brachytherapy vs pelvic EBRT for endometrial cancer

A

Rate of local or distant recurrence was no difference, but the toxicity of brachytherapy was much less
Vaginal brachytherapy therefore recommended for high/intermediate risk endometrial cancer.

20
Q

When should adjuvant brachytherapy not be given for endometrial cancer

A

Substantial LVSI, p53-abn & LCAM1 overexpression
Better treated with EBRT, not brachytherapy

21
Q

How is a low risk endometrial cancer defined in the adjuvant setting

A

Stage 1A, endometriod, gr1-2, LVSI negative or focal
Or stage 1-2 and POLE-mut

22
Q

How is an intermediate risk endometrial cancer defined

A

Stage 1B, endometriod, gr 1-2, LVSI negative or focal
Stage 1A, endometrioid, but grade 3, LVSI negative or focal
Stage 1A, non-endometrioid histology
Stage 1A, p53 abn
ie Stage 1B, grade 3, p53 abnormal or non-endometroid = int risk

23
Q

How is high-intermediate risk endometrial cancer defined

A

Stage 1 (A or B), endometroid, high LVSI, any grade
Stage 1B, endometroid, grade 3, any LVSI status
Stage 2

ie high LVSI, 1B & gr3 or stage 2 disease

24
Q

How is a high risk endometrial cancer defined

A

Stage 3-4A endometroid cancer, with no residual disease
Stage 1-4a non-endometriod, no residual disease
Stage 1b-4a endometrioid, but p53mut

25
Q

What adjuvant treatment is needed for a low risk endometrial cancer

A

None
Stage 1A, Gr1-2, LVSI negative OR stage 1-2 & POLE-mut

26
Q

When is adjuvant treatment indicated for endometrial cancer

A

Adjuvant treatment indicated if intermediate risk or above, but not for a stage 1A p53-abn

27
Q

What adjuvant treatment is indicated for intermediate risk endometrial cancer

A

Vaginal brachytherapy
Can consider omitting if only one of age >60, gr3 and stage ≥1b

28
Q

What adjuvant treatment is indicated for high-int risk endometrial cancer

A

Adjuvant EBRT for substantial LVSI
Consider vaginal brachytherapy otherwise

29
Q

What adjuvant treatment is indicated for high risk endometrial cancer

A

Sequential chemotherapy and EBRT

30
Q

What RT regime is given for primary RT to the endometrium

A

Phase 1 (45Gy/25#) then phase 2 as brachytherapy / Dobbie (7Gy/1#) to vaginal vault
Or phase 1 (45Gy/25#) followed by EBRT (20Gy/10#) boost to macroscopic disease
Or SIB (60Gy/25#) to tumour with 45Gy/25# to pelvis

31
Q

What brachytherapy dose is given post H+BSO to intermediate risk endometrial cancer

A

21Gy/3# to vaginal vault to reduce risk of local recurrence (15% to 2%)

Prescribed to 0.5cm depth

32
Q

What volumes are included for adjuvant RT for an endometrial cancer

What is the CTV-PTV margin

A

CTV1 - parametrium and top 2.5cm of vagina
CTV2 - nodal elective volume - Inguinal, int/ext iliacs, obturator and pre-sacral nodes.
Planned from L5/S1 to approx femoral heads, where ext iliacs leave pelvis

PTV1 -CTV1 + 10mm
PTV2 - CTV2 + 8mm

33
Q

How is metastatic endometrial cancer managed

A

If low volume or indolent disease, can consider treating with hormonal treatment only - tamoxifen / AI / medroxyprogesterone (Megace)

Assess MMR / MSI status

1st line - Combination carboplatin (AUC5)/paclitaxel (175mg/m2), or doxorubicin/paclitaxel if Pt-ChT not suitable

2nd line - Pt-rechallenge, dostarlimab if dMMR/MSI-H, pembro/lenva if pMMR

34
Q

What is the response rate of metastatic endometrial cancer to megace
What is the side effect

A

20-30%
Main side effect is cardiac toxicity

35
Q

What is the management of locally recurrent endometrial cancer

A

Re-biopsy if possible, repeat imaging and staging
If no RT previously -> EBRT +/- BT
If previous BT only -> EBRT
If prev EBRT -> surgery if amenable, or systemic treatment

36
Q

What 3 types of uterine sarcoma are most common

A

Leiomyosarcoma - high local recurrence rate
Endometrial stromal sarcoma
Carcinosarcoma - high risk, all treated with surgery, chemo, RT, vault brachy

37
Q

How is an endometrial leiomyosarcoma treated

What is the prognosis

A

Surgery - TAH only, as it doesn’t metastasise to ovaries
Adj ChT & RT

For advanced disease, treat with ifosfamide/doxorubicin or gemcitabine/docetaxel

OS 15-25%
Stage I & II have 5-yr survival rate 40-70%

38
Q

How is an endometrial stromal sarcoma treated

A

Surgery - TAH & BSO
Tend to be very hormone sensitive
2nd line - ifosfamide

39
Q

How is an endometrial carcinosarcoma treated

A

Surgery, ChT, RT, BT
treat with carboplatin as they behave more like endometrial adenocarcinomas than sarcoma

FRCR2 (28 decks)

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