Endometrial Cancer; Benign Uterine Disease

Front 1

most common gynecologic malignancy

Back 1

endometrial cancer

Front 2

Stage I survival for endometrial cancer

Back 2

95%

Front 3

Stage II/III survival for endometrial cancer

Back 3

25%

Front 4

Risk factors for endometrial cancer

Back 4

Obesity
Nulliparity
Unopposed estrogen (PCOS)
Tamoxifen use (weak estrogen)
Diabetes
Hypertension
Atypical Endometrial Hyperplasia
Family history

Front 5

What are the two types of endometrial cancer?

Back 5

Type I : Estrogen related
Type II: Non estrogen-related

Front 6

Characteristics of Type I Endometrial Cancer

Back 6

Estrogen-related

Disease of obesity

Younger, perimenopausal women

Heavier, associated with HTN and DM

Low grade tumor, low risk for extra-uterine disease

Generally early stage and surgically curable

Front 7

Characteristics of Type II Endometrial Cancer

Back 7

Unrelated to estrogen

Older and thinner women

African American

High grade, high risk for extra-uterine disease; Aggressive

Front 8

What genetic syndromes are associated with familial endometrial cancer?

Back 8

HNPCC: 60% lifetime risk of ovarian cancer (mismatch repair gene mutations)

(Lynch)

Front 9

What are the routes of endometrial cancer spread?

Back 9

Transperitoneal seeding

Lymphatic

Hematogenous: least common

Front 10

Key anatomic finding: vessels are (lateral; medial) while ureter is (lateral; medial)

Back 10

lateral; medial

Front 11

What nodes should be assessed to determine if lymphatic spread of endometrial cancer has occurred?

Back 11

pelvic and para-aortic nodes

Front 12

What should be assessed to determine is transperitoneal seeding has occurred?

Back 12

peritoneal cytology and omentum

Front 13

What are the different histological subtypes of adenocarcinoma of the endometrium?

Back 13

Endometrioid: Most common

Mucinous

Clear cell

Papillary serous (UPSC)

Carcinosarcoma or Mixed Malignant Mullerian: Very aggressive (included as adenocarcinoma rather than sarcoma)

Front 14

What is the most common histological subtype of adenocarcinoma of the endometrium?

Back 14

Endometrioid

Front 15

Which of the histological subtypes of adenocarcinoma of the endometrium are considered to be high risk / aggressive ?

Back 15

Clear cell; Papillary serous; Carcinosarcoma or Mixed Malignant Mullerian

Front 16

What is the most common chief complaint that will lead to evaluation for endometrial cancer?

Back 16

vaginal bleeding

Front 17

How is dx of endometrial cancer made?

Back 17

By endometrial biopsy obtained either in the office or in the OR via D&C

Front 18

T/F A preoperative CT scan is needed for endometrial cancer surgery

Back 18

F

Front 19

How is endometrial cancer stage?

Back 19

Surgically.
Stage I: Confined to uterus
Stage II: extension into cervix
Stage III: extension to pelvis: cytology, tubes, ovaries, nodes
Stage IV: distant disease, including omentum, lungs, upper abdomen

Front 20

In addition to surgery, what is adjuvant therapy?

Back 20

Radiation
Chemo
Sandwich therapy: radiation and chemo in sequence
Hormonal therapy

Front 21

What preop testing before endometrial cancer needs to be done?

Back 21

Chest xray
mammogram
electrolytes
CA-125

Front 22

What test performed at surgical workup correlates with depth of invasion, nodal spread, extra-uterine disease, and survival?

Back 22

CA-125

Front 23

T/F Radiation can be used as the primary treatment modality in extremely medically compromised patients BUT cure rates are lower

Back 23

T

Front 24

What is hormonal therapy?

Back 24

Advantage: Relatively non-toxic
Disadvantage: Never shown to be effective when used in the adjuvant setting
Progestins: Response rate of 25% in recurrence

Front 25

The majority of patients are diagnosed with early stage disease due to a recognizable presenting symptom-: ________

Back 25

vaginal bleeding

Front 26

T/F Surgery plus radiation and/or chemo is not performed if the patient has brain or lung mets in endometrial cancer.

Back 26

F

Front 27

leiomyoma are aka

Back 27

uterine fibroids

Front 28

Incidence of leiomyoma in women over age 30

Back 28

20-30%

Front 29

What is the racial difference in leiomyoma

Back 29

More common in AA than Caucasian

Front 30

What is the cell type of origin of leiomyoma?

Back 30

Smooth muscle of myometrium

Front 31

What is involved in the growth of leiomyoma?

Back 31

Many respond to estrogen; leiomyoma found almost exclusively during reproductive years

Other hormones, like GH, hPL, Progesterone, other growth factors

Front 32

How are leiomyomas classified?

Back 32

Based on location: intramural, subserosal, submucosal, intraligamentous, parasitic

Front 33

T/F Leiomyomas can progress to leiomyosarcomas

Back 33

F. They arise de novo as benign or malignant, they don't transform to malignant.

Front 34

Sx and clinical presentation of leiomyoma

Back 34

1) Abnormal uterine bleeding
2) Infertility
3) Recurrent pregnancy loss
4) Pain
5) Sx of pelvic "pressure"

Front 35

How are leiomyomas diagnosed?

Back 35

Pelvic exam
Imaging
Hysteroscopy

Front 36

What are indications for leiomyoma treatment?

Back 36

1) Symptoms: pain, ureteral obstruction, AUB, fertility considerations

2) Size: large ones above "comfort level"

3) Location - less impt now

4) Growth - if growth is rapid, or any growth in postmenopausal woman, concern that it's really a leiomyosarcoma

Any coexisting

Front 37

Tx of leiomyoma: medical

Back 37

1) Prostaglandin synthetase inhibitors
2) Progesterone therapy
3) GnRH agonists

Front 38

Tx of leiomyoma: surgical

Back 38

1) Hysteroscopy
2) Myomectomy
3) Hysterectomy

Front 39

What is uterine artery embolization a treatment for?

Back 39

Leiomyoma. It results in symptom improvement in up to 90%.
Leads to a reduction in myoma volume 35-50%.

Front 40

Uterine artery embolization is more useful in (pre, post) menopausal women.

Back 40

Pre

Front 41

Endometrial hyperplasia: what is "simple" hyperplasia?

Back 41

Endometrium with dilated glands, some outpouching, abundant stroma that's a variant of cystic hyperplasia

Front 42

Endometrial hyperplasia: what is "complex" hyperplasia?

Back 42

Glands are crowded with little stroma, complex gland pattern and outpouching formation; back to back glands; architectural but not cytologic atypia.

Front 43

Endometrial hyperplasia: what is "atypical hyperplasia?"

Back 43

there is <b>cytologic atypia</b>, with increased nuclear:cytoplasm ratio. There is irregularity in size/shape of nuclei. Precursor to adenocarcinoma in situ.

Front 44

What is pathophysiology of endometrial hyperplasia?

Back 44

There is chronic unopposed estrogen stimulation (anovulation or estrogen repalcement therapy) and the endometrium undergoes profression from proliferative to hyperplastic with eventual progression to carcinoma if untreated.

(Approx 30% of endometrial carcinoma occurs this way)

Front 45

What are risk factors for endometrial hyperplasia?

Back 45

1) Obesity
2) Anovulation
3) Exogenous estrogen
4) Estrogen producing tumors
5) Tamoxifen therapy
6) Epidemiology: nullipara, late menopause, HTN, diabetes, age between 50-60

Front 46

Postmenopausal bleeding: ____% have endometrial carcinoma

Back 46

10-20

Front 47

How will patient with endometrial hyperplasia present?

Back 47

Abnormal uterine bleeding

OR

Postmenopausal bleeding

Front 48

Mgmt of Simple hyperplasia or complex hyperplasia WITHOUT atypia

Back 48

Cyclic progestins

Resample endometrium 3-6 months

LNG IUD

Front 49

Mgmt of complex hyperplasia with atypia

Back 49

Should be considered pre-malignant.

Treat with hysterectomy OR progestin therapy if there are fertility concerns.

Front 50

What are endometrial polyps?

Back 50

Polypoid projections into endometrial cavity

Front 51

What is the clinical presentation of endometrial polyps?

Back 51

Abnormal Uterine Bleeding: usually perimenstrual spotting

Account for up to 25% of postmenopausal bleeding.

Most common in 5th decade of life.

Front 52

How are endometrial polyps dxed?

Back 52

Hysteroscopy is best.


Endometrial sampling is NOT reliable.

If prolapsed thru cervix, can be diagnosed that way.

Front 53

Endometrial polyps: Tx

Back 53

Removal of polyp: use hysteroscopy and resection

Front 54

Which type of leiomyoma is most likely to be associated with abnormal bleeding?

Back 54

submucosal myomas

Front 55

T/F Each leiomyoma arises from multiple cells

Back 55

F. Single cell

Front 56

indications for tx of myomas

Back 56

pain

persistent abnormal bleeding

rapid enlargement

repetitive spontaneous abortion or infertility in absence of other expalanation

Front 57

Endometrial polyps account for _____% of postmenopausal bleeding

Back 57

25