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Section II: Topics in Gynecology
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hyperplasia is a precancerous condition What characteristics are used to classify endometrial hyperplasia Which histologic feature of endometrial hyperplasia confers the greatest risk for cancer What are the four types of endometrial hyperplasia and what is the risk of cancer for each 1 Glandular/stromal architecture (simplex or complex) 2 Nuclear atypia (present or absent) Nuclear atypia
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1 Simple hyperplasia without atypia 1% (penny) 2 Complex hyperplasia without atypia 3% (nickel) 3 Simple hyperplasia with atypia 8% (dime) 4 Complex hyperplasia with atypia 40% (~quarter) If nuclear atypia is absent, treat with progesterone If nuclear atypia is present, hysterectomy is recommended A postmenopausal woman who is obese, nulliparous/infertile, diabetic, and hypertensive They are not diagnostic for endometrial cancer, but they do warrant an endometrial biopsy for further evaluation Complications of early pregnancy; other gynecologic neoplasms; leiomymata; endometrial hyperplasia/polyps; cervical polyps; Intrauterine device; hemophilias Atrophic vaginitis; exogenous estrogens; other gynecologic neoplasms; endometrial hyperplasia/polyps Hysteroscopy with dilation and curettage (D&C) In advanced disease, CA-125 may be elevated; however, it is not useful in the diagnosis or management 1 Endometrioid adenocarcinoma (80%)
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Describe your classic patient diagnosed with endometrial cancer How should atypical endometrial cells on a Pap smear be worked up
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What is the differential diagnosis for abnormal uterine bleeding in the premenopausal woman
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5: Gynecologic Oncology
2 Papillary serous carcinoma (5 10%) 3 Clear cell carcinoma (1 5%) How does endometrial cancer spread Most commonly through direct extension, but it can also spread transtubally, lymphatically, or hematogenously Pelvic and paraaortic lymph nodes By tumor histology (architecture and nuclear atypia) 1 Grade 1: Well differentiated (~95% glandular tissue, 5% solid pattern) 2 Grade 2: Moderately differentiated (~50 95% glandular tissue, 5 50% solid pattern) 3 Grade 3: Poorly differentiated (<50% glandular tissue, >50% solid pattern) Surgically (by the spread of the cancer) based on abdominal exploration, pelvic washings, total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO), and pelvic and periaortic lymph node biopsies See Table 5-5 TAH/BSO with lymph node dissection It is dependent on whether the patient is at low, intermediate, or high risk for disease recurrence Below are general guidelines for adjuvant postoperative treatment: 1 Low risk (Stage Ia, Ib): no adjuvant treatment warranted (Stage Ia, grade 3) Vaginal brachytherapy 2 Intermediate-risk (Stage Ic, Stage II): vaginal brachytherapy 3 High risk (Stage III, IV): pelvic/abdominal radiation therapy chemotherapy
What lymph nodes are involved in endometrial cancer metastases How is tumor grading for endometrial cancer determined What are the three different tumor grades for endometrial cancer
How is endometrial cancer staged
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Section II: Topics in Gynecology
Table 5-5 Stages of Endometrial Cancer
Stage Stage I: Involvement limited to the uterus Stage II: Extension to and involvement of the cervix Stage III: Local spread Description Ia: tumor limited to the endometrium Ib: invasion < half of myometrium Ic: invasion > half of myometrium IIa: extension to endocervical glands only IIb: cervical stromal invasion IIIa: invasion of serosa and/or adnexa, and/or positive peritoneal cytology IIIb: vaginal metastases IIIc: metastasis to pelvic and/or para-aortic lymph nodes IVa: invasion of the bladder and bowel IVb: distant metastasis including intraabdominal and/or inguinal lymph nodes Endometrial tumors 75% 5-Year survival 80 95%
65 75%
30 60%
Stage IV: Distant spread
5 20%
Name the chemotherapeutic agents used in endometrial cancer and their major toxicities
1 Doxorubicin (cardiotoxicity) 2 Cisplatin (ototoxicity, neuropathy, nephrotoxicity, nausea) 3 Paclitaxel (bone marrow suppression, allergic reaction) Trial of progestins after careful counseling Advanced stage; higher pathologic grade; histologic subtype; increase in myometrial invasion; lymph/vascular space invasion Monitor patients every 3 4 months for the next 2 3 years, then twice yearly with a comprehensive pelvic examination Without major adverse risk factors, treatment with a TAH/BSO may result in a 5-year survival greater than 95%
What is the recommended treatment for women who have early-stage disease and wish to preserve their fertility What factors worsen the prognosis for endometrial cancer
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