P03.007 Endometrial cancer

Endometrial cancer, arising from the lining of the uterus (endometrium), is the most common gynecological malignancy in developed countries. A strong understanding of this disease is crucial for the PLAB exam. Here’s a breakdown of key points:

Risk Factors:

• Unopposed Estrogen: Long-term exposure to estrogen without progesterone (e.g., obesity, polycystic ovary syndrome, tamoxifen use) is a major risk factor.
• Nulliparity: Never having children increases risk.
• Late Menopause: Later menopause is associated with a higher risk.
• Family History: A family history of endometrial cancer or Lynch syndrome increases risk.
• Obesity: Excess adipose tissue increases estrogen production.
• Type 2 Diabetes: Insulin resistance can contribute to endometrial hyperplasia, a precursor lesion.

Clinical Presentation:

• Abnormal Uterine Bleeding: This is the most common symptom, particularly postmenopausal bleeding.
• Vaginal Discharge: May be watery, blood-tinged, or mucoid.
• Pelvic Pain: Less common but can occur.

Types of Endometrial Cancer:

• Endometrioid Carcinoma (Type 1): Most common type (80%), usually well-differentiated with a good prognosis.
• Non-Endometrioid Carcinoma (Type 2): Less common (20%), more aggressive with poorer prognosis. Examples include serous carcinoma and clear cell carcinoma.

Diagnosis:

• History and Physical Exam: Pelvic examination may reveal an enlarged uterus or palpable mass.
• Endometrial Biopsy: Gold standard for diagnosis, usually performed in an outpatient setting through a pipelle or endometrial sampling device.
• Transvaginal Ultrasound (TVS): May be used to assess endometrial thickness and guide biopsy.
• Hysteroscopy: Direct visualization of the uterine cavity may be helpful in some cases.

Staging:

The FIGO staging system is used to determine the extent of cancer spread:

• Stage I: Confined to the uterus
• Stage II: Extends to the cervix
• Stage III: Involves lymph nodes or other pelvic structures
• Stage IV: Distant spread (e.g., lungs, bones)

Management:

Treatment depends on stage, grade (cell differentiation), and patient factors.

• Surgery:
  • Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy (TAH-BSO): Removal of the uterus, cervix, and ovaries is the mainstay of treatment for early-stage disease.
  • Lymph Node Dissection: May be performed depending on the stage to assess lymph node involvement.
• Adjuvant Therapy: May be recommended after surgery for high-risk features like advanced stage, deep myometrial invasion, or poorly differentiated tumors. Options include:
  • Vaginal Brachytherapy: Targeted radiation therapy to the vagina and surrounding tissues.
  • Pelvic or Adjuvant Pelvic and Para-aortic Lymphadenectomy: Removal of additional lymph nodes in the pelvis and abdomen.
  • Hormonal Therapy: Tamoxifen or aromatase inhibitors can be used in specific situations.

PLAB Exam Pointers:

• Be familiar with the risk factors and clinical presentation of endometrial cancer.
• Understand the importance of endometrial biopsy for diagnosis.
• Know the FIGO staging system and its implications for treatment.
• Recognize the different surgical options and adjuvant therapies used for endometrial cancer.
• Be prepared to discuss the management of endometrial cancer at different stages and in various patient scenarios.

Additional Resources:

• Royal College of Obstetricians and Gynaecologists (RCOG): https://www.rcog.org.uk/
• National Cancer Institute: https://www.cancer.gov/types/uterine/hp/endometrial-treatment-pdq