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Questions and Answers
Which gene mutation is commonly associated with Cowden syndrome?
Universal screening for endometrial cancer is routinely conducted.
False
What is the most common histopathological type of endometrial cancer?
Adenocarcinoma
An annual endometrial biopsy is recommended starting at age _____ for individuals with hereditary cancer risk.
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Match the following cancer types to their characteristics:
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Which of the following is NOT a risk factor for endometrial cancer?
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Tamoxifen is associated with an increased risk of endometrial cancer.
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Name one protective factor against endometrial cancer.
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Lynch II syndrome is also known as _____ syndrome.
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Match the following conditions with their associated factors relating to endometrial cancer:
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Which layer of the cervix is lined by columnar epithelium?
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The exocervix is lined by columnar epithelium.
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What is the area where the columnar epithelium meets the squamous epithelium called?
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At puberty, Doderlein bacilli act on glycogen to produce ________ acid, changing the pH of the vagina.
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Match the following components of the cervix with their descriptions:
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Which type of endometrial carcinoma is characterized by adenocarcinoma grade 3 and has a bad prognosis?
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Type I endometrial carcinoma is primarily related to decreased estrogen levels.
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What is the most common complaint presented by patients with endometrial cancer?
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The first investigation in the diagnostic algorithm for endometrial cancer is ___ .
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Match the following characteristics with their corresponding types of endometrial carcinoma:
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What is the primary cause of endometrial hyperplasia (EH)?
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Endometrial sampling requires general anesthesia.
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What is the gold standard investigation for diagnosing endometrial hyperplasia?
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In endometrial hyperplasia, excessive bleeding is often reported by __________ females.
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Match the endometrial sampling instruments with their descriptions:
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Which of the following cancer stages is considered high risk for post-operative management?
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Radiotherapy is the only treatment option recommended for all patients with endometrial cancer.
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What is the most common cause of post-menopausal bleeding in India?
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If the endometrial thickness is greater than ___ mm, an endometrial biopsy is recommended.
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Match the following post-operative management options with their respective indications:
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What is the recommended next step for endometrial hyperplasia without atypia?
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The risk of malignancy in endometrial hyperplasia with atypia can be as high as 30%.
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What should be done if there is continued bleeding after initial management of endometrial hyperplasia with atypia?
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The risk of malignancy in endometrial hyperplasia without atypia is _____%.
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Match the management option with its appropriate indication:
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Which stage of endometrial cancer indicates involvement of pelvic and para-aortic lymph nodes?
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Which of the following mutations is associated with a good prognosis in gynecologic oncology?
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Stage 4B of endometrial cancer is characterized by regional metastasis to the bladder or bowel.
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What is the best investigation method for assessing myometrial and parametrium involvement in endometrial cancer?
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Microsatellite instability indicates a bad prognosis in gynecologic oncology.
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Endometrial cancer stage that involves the cervix is Stage _____
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What is the surgical procedure recommended for Stage 1 gynecologic tumors?
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Match the following endometrial cancer stages with their respective features:
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A patient with a p53 abnormality is expected to have a __________ prognosis.
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Match the following stages with their surgical approach:
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What is a primary advantage of fractional curettage (FC)?
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Hysteroscopy is primarily used for generalized endometrial conditions.
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What medication is commonly used for managing metropathia hemorrhagica?
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The risk of malignancy associated with cystic glandular hyperplasia is _______.
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Match the following management strategies with their corresponding conditions:
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Study Notes
Endometrial Cancer
- Most common type: Adenocarcinoma
- Most malignant type: Clear cell
- Grading based on percentage of undifferentiated solid component
- Risk Factors: Family history, hypertension, obesity (most common), late menopause, early menarche, diabetes, atypical endometrial hyperplasia, unopposed estrogen, PCOS, estrogen-only HRT, estrogen-secreting tumors (Granulosa cell tumors), nulliparity, Tamoxifen (most common), corpus cancer syndrome
- Protective Factors: Multiparity, pregnancy, OCPs (progesterone downregulates estrogen receptors on endometrium), physical exercise and green tea
- Familial syndromes: Lynch II syndrome (AKA HNPCC syndrome), Cowden syndrome
- Lynch II syndrome cancers: colon cancer (most common), endometrial cancer
- Increased risk of endometrial cancer in Lynch II syndromes.
- Best prevention method in familial syndromes: TAH + BSO (TAH prevents endometrial cancer, BSO prevents ovarian cancer)
- Indication for TAH + BSO: Completed family by 40 years of age
- Staging based on FIGO 2009 classification
- Superficial lymph node involvement: Stage 4B
- Spread to cervix: Stage I → II
- Spread to uterus: Stage does not change
- Staging investigation: MRI (myometrial & parametrium involvement), CT (omental & lymph node involvement), PET-CT (lymph node status), surgical staging + histopathological examination + molecular classification (used in 2023 staging)
- Treatment of choice: Radiotherapy
- Molecular classification: Good (POLE mutation), Intermediate (MMRD, msi), Bad (p53 abnormality)
- Surgical staging based on stage: Stage 1: TAH + BSO, Stages 2 & 3: Wertheim's Hysterectomy, Stage 4: Debulking surgery
- In papillary serous tumors/Carcinoid sarcoma: Intracolic omentectomy (due to increased chances of micrometastasis of omentum)
- In mucinous tumors: TAH + BSO + Appendectomy (due to association with appendix cancer)
- Lymph node dissection: Stage IA – Size of tumor, All other stages – All lymph nodes
Types of Endometrial Carcinoma
- Type I: Most common, Adenocarcinoma grade 1, 2, good prognosis, increased estrogen, endometrial hyperplasia, 50-60 years old, obese, PTEN, KRAS
- Type II: Adenocarcinoma grade 3, clear cell, papillary serous, poor prognosis, decreased estrogen, endometrial atrophy, 60-70 years old, thin, p53 gene
- Age group: Most common: 50-70 years, Median: 60 years
Presentation
- Irregular vaginal bleeding/AUB (most common)
- Postmenopausal bleeding (PMB): most specific
- Most common causes of PMB: Polyp (37%), Endometrial atrophy (30%), Dirty vaginal discharge, Pelvic pressure/pain
- 10% of PMB cases are endometrial cancer
Spread
- Most common route: Direct
Management
- First investigation: TVS
- Endometrial thickness ≥ 24 mm -> Endometrial biopsy (10C)
- Malignancy positive -> Fractional curettage + Hysteroscopy (Gold standard)
- Gatekeeper gene: PTEN
Endometrial Hyperplasia
- Histopathology diagnosis
- Cause: Increased estrogen (Hyperestrogenic state)
- Presentation: Perimenopausal female with excessive bleeding
- Classification: Abnormal uterine bleeding (AUB) - most common
- Investigations: TVS with increased endometrial thickness (suspect EH), Endometrial biopsy (10C)
- Gold standard for diagnosis: Fractional curettage + Hysteroscopy
Endometrial Sampling
- AKA: Endometrial biopsy/endometrial aspiration cytology
- Done in: OPD
- Anesthesia: Not required
- Instruments used: Karma's cannula (India), Pipelle, Vabra aspirator
- Indications: Reproductive age (suspect EH, amenorrhea), Postmenopausal
Fractional Curettage (FC)
- Procedure: Done in OT, General anesthesia, Endocervical curettage followed by endometrial curettage
- Advantages: Diagnosis of generalized endometrial pathology
- Disadvantages: Not suitable for localized pathology
Hysteroscopy
- Diagnostic tool for localized pathology
EB Report Interpretation & Management
- Outcomes: Normal, Metropathia hemorrhagica, Endometrial hyperplasia ± Atypia
- Management of Normal: Use first-line medications for abnormal uterine bleeding (AUB)
- Management of Metropathia Hemorrhagica: Tranexamic acid (medication), FC + Hysteroscopy (procedure).
- Patient Profile: Perimenopausal female with anovulatory cycles and heavy menstrual bleeding (HMB) for 2-3 months. Pathology report mentions possible amenorrhea
- Histopathological Examination (HPE): Findings: Swiss cheese pattern, proliferative endometrium, Equivalent: Cystic glandular hyperplasia, Risk of malignancy: 1%
- Treatment options: Oral, Progesterone, Mirena
- Single best investigation for diagnosis: Fractional curettage
Post-op Management
- Low risk: Adenocarcinoma grade 1/2 + Stage IA
- High risk: Stage 3/4 or Papillary serous/Clear cell tumor
- Intermediate risk: All others
- Treatment: No treatment, Chemotherapy + Radiotherapy (Carboplatin + Paclitaxel), Radiotherapy
Postmenopausal Bleeding
- TVS for endometrial thickness: ≤4 mm (normal), >4 mm -> Endometrial biopsy
- Causes: Tranexemic acid, Bleeding, Suspect type 2 endometrial cancer -> Fractional curettage + Hysteroscopy, Polyp (most common), Endometrial atrophy (most common), HRT, Endometrial cancer (10%)
- Most common cause of PMB in India: Cancer cervix
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Description
Dive into the critical aspects of endometrial cancer, focusing on its most common type, adenocarcinoma, and the various risk and protective factors involved. Understand the familial syndromes associated with increased risk, particularly Lynch II syndrome, and explore prevention strategies such as TAH + BSO. This quiz will enhance your knowledge about the complexities of this malignancy.