Medically Fit For Exams
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Endometrial cancer - Dr Deac Pimp

Definition

  • Malignant change of the endometrium, which is the most common gynaecological cancer

 

Risk factors

  • Post-menopausal
  • Excess endogenous oestrogens:
    • Prolonged amenorrhoea
      • PCOS
      • Obesity
    • Nulliparity
    • Early menarche
    • Late menopause
    • Obesity (accounts for 50% of cases in UK)
  • Exogenous oestrogen:
    • Unopposed oestrogen therapy
    • Tamoxifen (is an oestrogen antagonist in breast, but agonist in post-menopausal uterus)
  • Diabetes
  • HNPCC (Lynch syndrome): have 30-60% chance of endometrial cancer
  • Hypertension
  • Protective factors:
    • COC use
    • Multiple pregnancies

 

Differential diagnoses

  • Vaginal atrophy/atrophic vaginitis (cause of most cases of PMB)
  • Polyps (cervical or uterine)
  • Endometrial atrophy
  • Endometrial hypertrophy (benign or pre-cancerous)
  • Cervical cancer
  • Vaginal cancer

 

Epidemiology

  • Women have 1% risk of developing endometrial cancer by age 75
  • Peak prevalence at age 60-63
  • 15% occur pre-menopausally
  • <1% under age of 35
  • PMB (post-menopausal bleeding) has 10% risk of being endometrial cancer
  • Approx 50% of cases in UK are attributable to obesity
  • 75% present as stage 1
  • Most common gynaecological cancer, 4th most common cancer in women
  • 8,600 new cases a year in UK

 

Aetiology

  • Often malignant change/neoplasia is a result of overstimulation and hyperplasia of the endometrial lining by unopposed oestrogens
    • Endogenous or exogenous

 

Clinical features

  • Post-menopausal bleeding (PMB) is most common presentation (90%)
  • Pre-menopausal:
    • Irregular periods
    • Inter-menstrual bleeding (IMB)
    • Recent onset menorrhagia (uncommon presentation)

 

Pathophysiology

  • 80% are adenocarcinoma
  • Can be type 1 (80%) which is oestrogen dependent
  • Type 2 (20%) is oestrogen independent

 

Investigations

  • PMB = 2 week wait referral = cancer until proven otherwise
  • TVUSS (transvaginal ultrasound scan) to estimate endometrial thickness
    • Significant thickening = >3mm (some centres use 4 or 5mm)
  • Endometrial biopsy using speculum and Pipelle
  • Endometrial biopsy using hysteroscopy
  • CXR, LFTs and FBC to rule out spread and progression

 

Management

  • Staging is only possible after hysterectomy
    • MRI can give some indication of invasion and therefore staging
  • Surgical:
    • Total hysterectomy and bilateral salpingo-oophorectomy
    • Lymphadenectomy in some high grade cases
      • Not proven useful in most cases, and increases risk of lymphoedema in lower limbs
    • Laparascopic if possible
  • Radiotherapy:
    • External beam is used after hysterectomy in those likely to have lymph node involvement
    • Vaginal vault radiotherapy reduces recurrence
    • Other indications include:
      • High risk of extra-uterine spread
      • Proven extra-uterine spread
      • Inoperable
      • Recurrent
      • Palliation
  • Medical:
    • Chemotherapy can be used as an adjuvant
    • Progestogens aren’t commonly used

 

Prognosis

  • 5 year survival rates:
    • Stage 1 = 90%
    • Stage 2 = 75%
    • Stage 3 = 60%
    • Stage 4 = 25%
    • Overall = 75%
  • Recurrence is most common in vaginal vault, highest risk if:
    • Older age
    • High tumour grade
    • Deep myometrial invasion
    • High stage
    • Adenosquamous cell type
    • Usually occurs within 3 years
  • Obesity is associated with worse outcomes
Endometrial cancer.docx
Microsoft Word document [15.8 KB]

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