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ENDOMETRIAL CANCER (Histopathology findings in women with PMB (ATYPICAL…
ENDOMETRIAL CANCER
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HX
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• Drug history (COCP, HRT, tamoxifen, antihypertensives, oral hypoglycaemics).
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Examination
• Rule out other causes of bleeding (vulval, vaginal, and cervical pathology) with vulval, vaginal, and speculum examination.
• Bimanual examination: uterine size, mobility, adnexal masses.
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Imaging investigations
TVUSS: <4mm endometrial thickness/echo (ET) → very low risk of endometrial pathology in post-menopausal women (96% NPV)—no requirement for endometrial sampling.
CT chest/abdomen/pelvis: G3 disease for preoperative staging as ↑ risk of disease outside of uterus.
MRI pelvis: can be used to determine local extent of tumour and presence of grossly involved pelvic lymph nodes. Not routinely recommended as staging based on histology.
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Endometrial biopsy
Perform endometrial sampling if ET ≥4mm or persistent bleeding in woman with ET <4mm (in which case consider formal hysteroscopy).
TREATMENT
Surgery
TAH and BSO and pelvic washings: this can be performed via a transverse or midline incision. Increasingly, laparoscopic hysterectomy is gaining popularity and is approved by NICE, although longer-term survival data comparisons are lacking (no difference at 3yrs).
Pelvic lyphadenectomy
Role in low-grade early disease is controversial (and is debated fiercely across the Atlantic divide!). Two RCTs (and Cochrane systematic review) suggest no survival advantage in early disease
FIGO STAGING
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III = Extension to uterine serosa, peritoneal cavity, and/or lymph nodes
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IIIa = Extension to uterine serosa, adnexae, or positive peritoneal fluid (ascites or washings)
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Adjuvant radiotherapy
Adjuvant radiotherapy limited to vault brachytherapy, if intermediate risk (see below), EBRT ± vault brachytherapy boost for high risk (G3, stage Ib) or locally advanced disease.
PORTEC and ASTEC trials
• These trials compared adjuvant radiotherapy vs. no adjuvant radiotherapy in women with intermediate risk early endometrial adenocarcinoma: G1 with deep myometrial invasion (>50%); G2 with any myometrial invasion (stage Ia or Ib); and G3 with superficial invasion (stage Ia).
• Radiotherapy reduced pelvic recurrences, but gave no survival advantage to women with stage Ib endometrial cancer and intermediate risk histology.
• This was because pelvic recurrences were amenable to radiotherapy in previously non-irradiated patients.
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Hormonal
• Several RCTs have failed to establish a role for adjuvant progestagen therapy after primary treatment for endometrial cancer.
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Most commonly presents with PMB. Younger women present with menstrual disturbance (heavy or irregular periods). 1% are picked up on routine cervical smear tests.