questions 2

Endometrial Cancer

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Topic updated on 06/15/17 1:25pm

Snap Shot
  • A 72-year-old woman was evaluated for post-menopausal bleeding. A fractional dilatation and curettage revealed endometrial carcinoma. Her cervical Pap smear was normal. She had not been on any hormone replacement therapy. An ultrasound is performed.
Introduction
  • Fourth most common malignancy in women after breast, colorectal, and lung cancer
  • Most common gynecologic malignancy
    • ovarian cancer is the leading cause of gynecological cancer deaths
  • It affects mainly postmenopausal women, with incidence peaking between ages 50 and 60
  • An estrogen dependent cancer. Sources can be from
    • ovary
    • extraglandular from peripheral conversion of androstenendione to estrone
    • exogenous from oral estrogen, patches, cremes.
  • Risk factors include
    • unopposed postmenopausal estrogen replacement
    • obesity, which increases risk by 3 to 10 times
    • hypertension
    • high fat diet as found in industrialized nations
    • nulliparity
    • late menopause (after 52)
    • anovulation
    • oligo-ovulation
    • polycystic ovarian syndrome
    • diabetes
    • estrogen-producing tumors
    • h/o of colon cancer, breast cancer, or ovarian cancer
    • h/o of cervical carcinoma in situ is not a risk factor
  • Endometrial hyperplasia usually precedes endometrial cancer
    • classified by the degree of cytologic atypia.
  • Histology
    • Adenocarcinoma accounts for > 80% of cases of endometrial cancer
    • Sarcomas account for about 5% of all uterine malignancies and include
      • mixed mesodermal tumors
      • leiomyosarcomas
      • endometrial stromal sarcomas
Presentation
  • More than 90% of patients with endometrial cancer have abnormal uterine bleeding
    • postmenopausal bleeding
      • 1/3 of women with postmenopausal bleeding have endometrial carcinoma
    • premenopausal
    • recurrent metrorrhagia
Evaluation
  • Any post-menopasual woman with uterine bleeding requires an endometrial biopsy
    • tissue biopsy is the definitive diagnostic procedure
    • procedure is > 90% accurate
  • Pap smears NOT RELIABLE (miss 60%) of endometrial carcinoma cases
    • AGCUS on Pap smear requires endometrial evaluation
  • Pelvic and abdominal CT may help if extrauterine or metastatic disease is suspected
  • FIGO staging

    Stage Description
    1A Limited to the endometrium
    IIB Invasion of cervical stroma
    IIIC, Grade 3 Pelvic lymph metastases
    IVA Invasion to the bladder and/or bowel mucosa
    IVB Distant metastasis including lungs, vagina, abdomen, bone,intrabdominal
Differential
  • Endometrial hyperplasia
Treatment
  • Simple or complex hyperplasia
    • progesterone to reverse hyperplastic process (e.g., Provera X 10 days)
  • Atypical hyperplasia
    • hysterectomy because of liklihood of invasion
    • progestin-only therapy if patient seeking to become pregnant
  • Stage I, grade 1 endometrial cancer without deep myometrial invasion
    • Probability of lymph node metastasis is < 2%.
    • TAH / BSO, and peritoneal cytologic examination
    • Accurate surgical staging enables 50-75% of patients with stage I disease to forego postoperative radiation therapy
  • For grades 2 and 3 and for grade 1 with deep myometrial invasion
    • TAH / BSO with pelvic and para-aortic lymphadenectomy
    • Extended-field radiation forextrapelvic cancer, depending on the site and extent
  • Stage IV disease are best treated with systemic chemotherapy
  • Valium to prevent spasms
  • Treatment for recurrence is high-dose progestins (Depo-Provera)
Prognosis, Prevention, and Complications
  • Very few patients with cancer confined to the uterus have recurrences
  • Histoligical grade is most important prognostic factor
  • Depth of invasion is second most important histological factor

 



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(M2.ON.250) A 65-year-old G0 postmenopausal female presents with vaginal bleeding of two days duration. The patient has diabetes mellitus type II and takes metformin. She has a 30-pack year history of smoking, but denies alcohol or illicit drug use. She denies any history of trauma to the pelvic area. Pelvic examination reveals no abnormalities. Endometrial biopsy and subsequent work-up reveals endometrial carcinoma. Which of the following is the most appropriate treatment for this patient? Topic Review Topic

1. Total abdominal hysterectomy
2. Radiation only
3. Total abdominal hysterectomy and bilateral salpingo-oopherectomy
4. High dose progestins
5. Fractional dilation and curettage

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