PB#149: Endometrial Cancer Flashcards
(115 cards)
1
Q
Percentage of endometrial cancer cases that are stage I at time of dx; mean age of dx of endometrial cancer in US
A
> 70%; 63 y/o
2
Q
Reported 5-year survival rate w/ endometrial cancer
A
90%
3
Q
Lifetime risk of developing uterine cancer among White pts; lifetime risk of developing uterine cancer among Black pts
A
2.81%; 2.48%
4
Q
Type of tumors that are more likely to be seen in Black pts
A
Nonendometrioid, high-grade (type II) tumors, which are associated w/ more advanced stage of disease (ie stage III-IV) at time of dx
5
Q
Classifications of endometrial cancer (2)
A
Type I (endometrioid) adenocarcinoma, Type II (clear cell and papillary serous) adenocarcinoma
6
Q
Most common histologic type of endometrial cancer; percentage of endometrial cancers that are this type
A
Type I tumors; >75% of all cases
7
Q
Are most cases of type I endometrial cancer low-grade?
A
Yes
8
Q
Precursor lesion for type I endometrial tumors
A
EIN/AEH
9
Q
Risk of progression to endometrioid carcinoma when EIN is absent
A
1-8% (depending on degree of architectural complexity
10
Q
Cumulative 19-year risk of carcinoma among pts w/ nonatypical endometrial hyperplasia
A
4.6%
11
Q
Percentage of cases of EIN w/ coexisting undiagnosed endometrioid carcinoma
A
30-50%
12
Q
19-year cumulative risk of EIN developing into endoemtrial carcinoma, when treated conservatively
A
27.5%
13
Q
Percentage of cases of endometrial cancer diagnosed coexisting w/ EIN that demonstrated deep myometrial invasion
A
11%
14
Q
Percentage of all cases of uterine cancers that are uterine papillary serous histology; percentage of endometrial cancer-related deaths caused by papillary serous cancers
A
~10%; 40%
15
Q
Proposed precursor lesion for uterine papillary serous carcinoma
A
Endometrial intraepithelial carcinoma
16
Q
Can serous endometrial intraepithelial carcinoma be associated w/ extrauterine tumor at time of dx?
A
Yes
17
Q
Rare high-grade endometrial tumors other than endometrioid and papillary serous (2)
A
Clear cell, carcinosarcoma/malignant mixed mullerian tumor of uterus
18
Q
Risk factors for type I endometrial cancer (15)
A
Older age, residency in North America/Northern Europe, higher level of education/income, white race, nulliparity, hx of infertility, menstrual irregularities, late menopause, early menarche, long-term use of unopposed estrogen, tamoxifen use, obesity, estrogen-producing tumor, hx of DM2/HTN/gallbladder disease/thyroid disease, Lynch syndrome
19
Q
Risk factor seen in most cases of type I endometrial cancer
A
Prolonged exposure to unopposed estrogen (either endogenous or exogenous)
20
Q
Sources of unopposed endogenous estrogen (3)
A
Chronic anovulation (ie PCOS), estrogen-producing tumors, excessive peripheral conversion of androgens to estrone in adipose tissue
21
Q
At what BMI does risk for endometrial cancer begin to increase?
A
> 27
22
Q
Amount by which systemic unopposed estrogen therapy increases risk of endometrial cancer
A
Up to 20-fold
23
Q
Method by which risk of endometrial cancer with unopposed estrogen therapy can be mitigated
A
Concomitant progestin use
24
Q
When progestin use is done intermittently, what is minimum amount of time per month that it should be given?
A
At least 10 days/month
25
At what age does endometrial cancer risk increase in association w/ tamoxifen use?
>50 y/o (RR = 4.01)
26
Do raloxifene and/or ospemifene increase risk of endometrial cancer/AUB?
No
27
Percentage of pts diagnosed w/ endometrial cancer before 50 y/o; percentage of pts diagnosed w/ endometrial cancer before 40 y/o
15%; 5%
28
Features of younger pts who develop endometrial cancer (4)
More likely to be obese, nulliparous, w/ well-differentiated endometrioid histology, w/ lower stage disease
29
Most common risk factors for endometrial cancer in young pts (3)
Increasing BMI, nulliparity, irregular menstrual cycles
30
How much does the risk of endometrial cancer increase in pts <45 y/o whose BMIs are >35?
22-fold
31
Demographic features more associated w/ type II endometrial cancers (4)
Older, nonwhite, multiparous, current smokers
32
Reproductive characteristics associated w/ increased risk of endometrial cancer (4)
Nulliparity, infertility, early menarche, late menopause
33
Meds that decrease risk of endometrial cancer (3)
COCs, Depo, LNG-IUD
34
Factor that decreases risk of type I endometrial cancer
Smoking (especially in postmenopausal pts)
35
Inheritance pattern of Lynch syndrome; class of mutated genes in Lynch syndrome
AD; MMR gene
36
Common genes that are mutated in Lynch syndrome (4)
MLH1, MSH2, PMS2, MSH6
37
Cumulative risk of endometrial cancer by 70 y/o in pts w/ Lynch syndrome
16-61% (depending on specific genetic mutation)
38
Percentage of pts in whom endometrial cancer is diagnosed at <50 y/o who have underlying dx of Lynch syndrome
Almost 10%
39
Age at which risk of endometrial cancer increases significantly in pts w/ Lynch syndrome; mean age of dx of endometrial cancer in pts w/ Lynch syndrome
>40 y/o; 48-50 y/o
40
Cancers associated w/ Cowden disease (3)
Breast, thyroid, endometrial
41
Inheritance pattern of Cowden disease; mutated gene in Cowden syndrome
AD; PTEN
42
Management consideration to reduce risk of endometrial cancer in pts w/ BRCA1/BRCA2 mutations who take tamoxifen
Hyst
43
Most common sxs of endometrial cancer (2)
AUB (ie irregular menses, intermenstrual bleeding), PMB
44
Sxs that may be seen in pts w/ advanced disease (5)
Abdominal/pelvic pain, abdominal distention, bloating, early satiety, change in bowel/bladder function
45
Components of comprehensive surgical staging for endometrial cancer (6)
Removal of uterus, cervix, adnexa, pelvic lymph nodes, para-aortic lymph nodes, pelvic washings
46
Nodal tissue that needs to be removed during pelvic lymphadenectomy
Removal of nodal tissue from distal half of common iliac arteries, ant/med aspect of external iliac artery/vein down to point at which deep circumflex iliac vein crosses external iliac artery, and obturator fat pad ant to obturator nerve
47
Nodal tissue that needs to be removed during para-aortic lymph node dissection
Removal of nodal tissue over distal IVC from level of IMA to mid-right common iliac artery, and removal of nodal tissue between aorta and L ureter from IMA to mild-left common iliac artery
48
What is necessary to demonstrate adequate nodal dissection?
Lymphatic tissue seen on pathology from both L and R sides
49
Percentage of pts w/ lymph node mets who have grossly (palpably) enlarged lymph nodes
<10%
50
Percentage of cases of para-aortic lymph node involvement in cases of metastatic endometrial cancer w/ lymph node involvement
57-67%
51
Percentage of pts w/ lymph node involvement who have isolated para-aortic lymph node involvement in absence of pelvic lymph node mets
16-17%
52
Overall risk of isolated para-aortic lymph node mets in endometrial cancer
1-3.5%
53
Factors to consider when deciding if endometrial sampling is indicated in premenopausal pts
Sxs/clinical presentation (US measurement of endometrial thickness has no dx value)
54
Initial assessment of PMB
Either EMB or TVUS (not both)
55
What endometrial thickness warrants endometrial sampling in pts w/ PMB?
>4mm
56
Specificity of outpatient EMB in detecting endometrial cancer
98%
57
If surgical endometrial sampling is pursued, what procedure should be done?
Hysteroscopy + D&C (preferred over D&C alone)
58
When should endometrial sampling be pursued in postmenopausal pts even w/ endometrial thickness <4mm on US?
Persistent/Recurrent PMB
59
How is endometrial cancer staged?
Surgically
60
When should preop assessment of metastatic disease w/ imaging and/or CA125 be considered? (3)
If pt is poor surgical candidate 2/2 medical comorbidities, if sxs suggest poss mets to unusual sites (ie bones/CNS), if preop histology demonstrates high-grade carcinoma (ie grade 3 endometrioid, papillary serous, clear cell, carcinosarcoma)
61
Situations in which gyn onc consult may be particularly beneficial (6)
Option to completely/adequately surgically stage pt is not readily available at time of procedure, preop histology (ie grade 3 endometrioid, papillary serous, clear cell, carcinosarcoma) suggests high risk of extrauterine spread, final path result reveals unexpected endometrial cancer after hyst performed for other indications, evidence of cervical/extrauterine disease (including lymph node/ovarian mets), recurrent disease is diagnosed/suspected, nonoperative therapy is contemplated
62
Stage I endometrial cancer; Stage IA endometrial cancer; Stage IB endometrial cancer
Tumor confined to corpus uteri; no, or <50%, myometrial invasion; invasion >/=50% of myometrium
63
Stage II endometrial cancer
Tumor invades cervical stroma, but does not extend beyond uterus (but endocervical glandular involvement only should be considered Stage I)
64
Stage III endometrial cancer; Stage IIIA endometrial cancer; Stage IIIB endometrial cancer; Stage IIIC endometrial cancer; Stage IIIC1 endometrial cancer; Stage IIIC2 endometrial cancer
Local and/or regional spread of tumor; tumor invades serosa of corpus uteri and/or adnexae (positive cytology should be reported separately w/o changing stage); vaginal and/or parametrial involvement; mets to pelvic and/or para-aortic lymph nodes; positive pelvic nodes; positive para-aortic nodes w/wo positive pelvic nodes
65
Stage IV endometrial cancer; Stage IVA endometrial cancer; Stage IVB endometrial cancer
Tumor invades bladder and/or bowel mucosa, and/or distant mets; tumor invasion of bladder and/or bowel mucosa; distant mets, including intra-abdominal mets and/or inguinal lymph nodes
66
Percentage of pts w/ clinically determined stage I disease who had pelvic nodal mets; percentage of pts w/ clinically determined stage I disease who had para-aortic nodal mets; percentage of pts w/ clinically determined stage I disease who had disease that spread to adnexa; percentage of pts w/ clinically determined stage I disease who had other extrauterine mets at time of surgery
9%; 6%; 5%; 6%
67
Factors for which pts is rad tx recommended? (4)
Increasing age, higher tumor grade (grade 2-3), increased depth of myometrial invasion (outer third), LVSI
68
Is lymphadenectomy recommended in apparent early-stage endometrial cancer (ie disease confined to uterine corpus/cervix)?
No
69
Potential complications of comprehensive surgical staging (3); percentage of pts s/p lymphadenectomy who reported adverse effect on QoL
Injury to major vessels/nerves, lymphedema, cellulitis; ~47%
70
Ways to mitigate negative effects of pelvic lymphadenectomy (2)
Limiting pelvic lymphadenectomy to region cephalad to deep circumflex iliac vein, avoiding removal of circumflex iliac nodes distal to external iliac nodes
71
Surgical approach associated w/ fewer moderate-to-severe postop adverse events, longer op time, shorter hospital stay, higher QoL during recovery
Laparoscopy (over laparotomy)
72
Estimated 5-year overall survival rate among laparoscopy pts; estimated 5-year overall survival rate among laparotomy pts
89.8%; 89.8% (the same)
73
Recommended standard surgical approach for endometrial cancer
Minimally invasive
74
Pts for whom a vaginal approach may be considered (3)
Elderly pts, obese pts, pts w/ comorbid conditions if risks associated w/ surgical staging via laparotomy/laparoscopy outweigh benefits (particularly if suspected cancer is early-stage and endometrioid histology)
75
If pt is in high-intermediate risk group, what are benefits of adjuvant rad tx?
Improved progression-free survival rates, decreased risk of local recurrence
76
Pts that fall into high-intermediate risk category (3)
>70 y/o w/ one risk factor, >50 y/o w/ two risk factors, any age w/ all three risk factors
77
Is whole pelvic irradiation superior to vaginal brachytherapy?
No, they are equivalent in achieving locoregional control and providing reasonable disease-specific and overall survival in pts w/ certain high-intermediate risk factors for recurrent endometrial cancer, w/ vaginal brachytherapy associated w/ significantly fewer GI toxic effects and better QoL
78
High-intermediate risk factors for recurrent endometrial cancer (3)
>60 y/o w/ stage IB/grade 1-2 disease, >60 y/o w/ stage IA/grade 3 disease w/ myo invasion, any age w/ endocervical glandular involvement and disease o/w confined to uterus (excluding those w/ stage IB/grade 3 disease)
79
Percentage of new cases of endometrial cancer that will involve disease that has spread outside the uterus
~10-15%
80
Survival rates for endometrial cancer w/ extrauterine spread
5-15%
81
Optimal surgical cytoreduction criteria
<2cm of residual tumor
82
Factor that has a direct influence on survival in surgical management of endometrial cancer w/ extrauterine spread
Extent of residual disease
83
For pts w/ extrauterine spread of endometrial cancer, median survival for pts in whom tumor was determined to be unresectable; median survival for pts w/ any residual disease; median survival for pts w/ no residual disease
2-8 months (regardless of further tx w/ rad tx and/or chemotx); 19 months; 40 months
84
Does secondary cytoreduction for recurrent endometrial cancer improve progression-free and overall survival?
Yes
85
Factors that determine survival among pts w/ recurrent cancer (3)
Type of recurrence (solitary recurrence vs carcinomatosis), ability to achieve optimal cytoreduction, time from original tx to recurrence
86
Median overall survival s/p secondary cytoreductive surgery
39-57 months
87
Only curative option for pts w/ localized recurrence who previously had rad tx
Pelvic exenteration
88
Risk of postop morbidity associated w/ pelvic exenteration; risk of postop mortality associated w/ pelvic exenteration
60-80%; 10-15%
89
Do rad tx and/or chemotx improve outcomes in pts w/ metastatic disease s/p optimal cytoreductive surgery?
Yes
90
Chemotx med combo that has greatest survival advantage in pts w/ gross residual disease (3)
Paclitaxel + doxorubicin + cisplatin
91
Overall 5-year survival rate among pts w/ advanced-stage or recurrent endometrial cancer receiving chemotx + rad tx
79%
92
Percentage of pts receiving paclitaxel + doxorubicin + cisplatin who experience grade 2-3 peripheral neurotoxicity; percentage of pts receiving doxorubicin + cisplatin who experience grade 2-3 peripheral neurotoxicity
39%; 5%
93
Percentage response rate of pts w/ advanced-stage disease treated w/ daily tamoxifen + alternating weekly cycles of Provera
33%
94
Median progression-free survival among pts w/ advanced-stage disease treated w/ daily tamoxifen + alternating weekly cycles of Provera; median overall survival among pts w/ advanced-stage disease treated w/ daily tamoxifen + alternating weekly cycles of Provera
3 months; 13 months
95
Among pts w/ advanced-stage disease treated w/ alternating 3-week cycles of Megace and tamoxifen, percentage response rate; median progression-free survival; median overall survival
27%; 2.7 months; 14 months
96
Among pts w/ advanced-stage disease treated w/ alternating 3-week cycles of Megace and tamoxifen, response rate among pts w/ grade 1 tumors; response rate among pts w/ grade 2 tumors; response rate among pts w/ grade 3 tumors
38%; 24%; 22%
97
Selection criteria for pts pursuing fertility-sparing approaches to management of endometrial cancer (6)
Well-differentiated/grade 1/endometrial endometrial carcinoma, no myo invasion, no extrauterine involvement (no synchronous ovarian tumor or mets, no suspicious retroperitoneal nodes), strong desire for fertility sparing, no contraindications to med management, and an understanding/acceptance that data on cancer-related and pregnancy-related outcomes are limited
98
Preferred endometrial sampling method for evaluating tumor grade; preferred imaging modality to evaluate presence of myo invasion
D&C; MRI
99
Most commonly used progestins for pts w/ endometrial cancer pursuing fertility-sparing tx (2)
Provera, Megace
100
How often should repeat endometrial sampling be done while pts undergo fertility-sparing progestin therapy?
q3months
101
When is definitive surgical management recommended for pts pursuing conservative options? (2)
Following completion of childbearing, or if conservative options fail
102
For which pts can ovarian conservation be considered?
Premenopausal pts w/ low risk of extrauterine disease and potential for disease recurrence
103
Why is BSO traditionally recommended at time of hyst? (2)
Possibility of occult mets in ovaries, ovarian estrogen production might lead to earlier and greater likelihood of recurrence
104
Overall survival rate for pts who did not undergo BSO; characteristics of pts in whom all recurrences were seen
93.3%; nonendometrioid histology, deep myo invasion, cervical stromal invasion, and/or inadequate adjuvant therapy
105
Risk of synchronous ovarian malignancy in premenopausal pts w/ endometrial cancer
Up to 19%
106
Overall pregnancy rate among pts w/ endometrial cancer who received fertility-sparing txs; percentage of pts requiring use of ART to achieve pregnancy
35.7%; ~18%
107
Management of incidentally identified endometrial cancer s/p hyst w/ features including endometrioid histology, grade 1-2 tumors, small tumor volume, superficial/no myo invasion
Further intervention not indicated 2/2 low risk of extrauterine disease and recurrence
108
Management of incidentally identified endometrial cancer s/p hyst w/ features including high-risk histologic cell types, grade 3 tumors, and/or deep myo invasion
Comprehensive surgical staging
109
Primary goal of surveillance s/p tx of endometrial cancer
Detection of treatable recurrent disease, thereby enabling cure or improved survival
110
Recommended surveillance frequency s/p tx
F/u visit q3-6 months x2 years > q6 months x3 years > annually thereafter
111
Recommended components of f/u surveillance visits (3)
Thorough hx, investigation of any new sxs associated w/ recurrence (ie VB, pelvic pain, weight loss, lethargy), speculum/pelvic/rectovaginal exam
112
Should imaging studies be used for routine surveillance s/p tx?
No, only to investigate suspicion of recurrent disease
113
Percentage of pts undergoing hyst+BSO for endometrial cancer that are premenopausal
25%
114
Can estrogen supplementation be offered to premenopausal pts s/p hyst+BSO?
Yes, to pts w/ early-stage disease, following counseling of risks/benefits
115
Risk of recurrence among premenopausal pts w/ early-stage disease s/p hyst+BSO who received estrogen supplementation
2.3%
