Endometrial Cancer (Delic 11/8/2023)

A link to a recording of this presentation is available HERE. 

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Many, many thanks to our speaker this week, Dr. Lejla Delic, a local gynecologist-oncologist, who works with our local oncologists and gynecologists to care for patients in our community with gyn cancers. Her presentation was excellent -- so good, in fact, that we we want her back for a Part 2, on ovarian cancer. Stay tuned. We will get her scheduled in the winter/spring.

In the meantime, my notes:

Gynecological cancers occur in the uterus (most common, aka endometrial cancer), cervix, fallopian tubes, ovaries, peritoneal cavity, vulva and vagina.

In the US, there are ~65,000 new cases of uterine cancer  per year --> 12,000 deaths

In the US, there are ~19,000 new cases of ovarian cancer per year--> 12,000 deaths

Unfortunately, mortality from uterine/endometrial cancer is on the rise

Endometrial cancer, the most common type of gyn cancers, has a lifetime prevalence of 3%. Women are average age 60 years old at the time of diagnosis and, because endometrial cancer typically presents with post-menopausal bleeding, 75% are diagnosed in the early stage (stage I and II). When it does metastasize, endometrial cancer typically spreads via local lymphatics to the pelvic nodes and then to the aortic lymph nodes. 

Unfortunately, black women in this country are dying at disproportionate rates of endometrial cancer and are diagnosed with more aggressive cancers, younger than white women. 

Risk factors for endometrial cancer:

• Obesity (endogenous unopposed estrogen). In fact, every 5 points of BMI increases your risk of being diagnosed with endometrial cancer by 50%. 
• Chronic anovulation (obesity, PCOS)
• Nulliparity, infertility, early menarche, late menopause
• Exogenous unopposed estrogen (e.g. HRT without progesterone)
• Tamoxifen (2x risk of uterine cancer)
• Hereditary: these present earlier than sporadic cancers, more typically in non-obese younger women (<50 years old), including genetic syndromes like Lynch Syndrome and MLH1, 2, 6, etc. 

Risk reduction for endometrial cancer:

• OCPs (combined)
• Weight loss
• Hysterectomy (offered to women with Lynch syndrome after age 45 or when fertility is accomplished)

NEJM: Association with race and BMI and endometrial cancer

Historically, endometrial cancers have been divided in two groups: Type 1-- or non-aggressive, more excess estrogen type--  and Type 2, more aggressive, poorly differentiated, frequently metastasize (40% of women with Type 2 have +LN at time of diagnosis. Increasingly, however, new molecular characterization studies are changing the way we think about and treat endometrial cancer and are being integrated into the categorization. This is because prognosis is variable depending on these molecular characteristics.

90% of women with endometrial cancer present with post-menopausal (PMP) uterine bleeding. All cases of PMP bleeding should be investigated but it is important to note that only 9-14% of women with PMP bleeding have cancer.  Abnormal uterine bleeding (AUB) in premenopausal women may present more like "intermenstrual" bleeding.

Evaluation of AUB:

1) Pelvic ultrasound: in PMP women, >4mm endometrial stripe necessitates and EMB. Of note, endometrial stripe thickness in premenopausal women is totally useless. Also, in someone with repeated bleeds, even a thin stripe should not prevent you from getting an EMB.

2) Endometrial biopsy (EMB)

Of note, Type 2 Endometrial cancers, an EMB has a 25% false negative rate.

If the patient has recurrent bleeding, even if they have a normal EMB, refer for hysteroscopy and D&C

Treatment of endometrial cancer:

1) Surgery

All gyn cancers (except for cervical, trophoblastic and vaginal) need surgery to be staged.

Surgery includes hysterectomy, bilateral salpingectomy, and lymph node assessment (sential LN mapping).

Stage I: cancer confined to uterus

Stage II: cancer extends to cervix

Stage III: LN involvement/ovaries/tubes

Stage IV: distant mets (omentum, lungs)

Robotic/minimal invasive surgery has best outcomes (but NOT in cervical cancer). With robot, conversion to open only happens 3% of the time (whereas its 20% of the time with typical surgery). This is really important for patients with elevated BMI who have a much better/easier recovery with minimally invasive surgery and way less bad outcomes.

2) Immunotherapy may be indicated for Stage III or IV or recurrent endometrial cancer 

Historically, chemo was used (Carboplatin and paclitaxil) but with new molecular studies, immunotherapy is showing increasing promise.

Fertility preservation in young women with endometrial cancer is important to many women! 14% are pre-menopausal at diagnosis and may not be done building their families. Low Grade (1) and non-invasive cancers (as determined by MRI) can sometimes be treated temporarily with high dose progesterone (either oral Megace 80mg BID or Mirena IUD). Informed consent is important. About 50% respond, but 20-30% will either progress or return. Some women hate the side effects of high dose progesterone, which include increased appetite, weight gain, and blood clots. 

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On a final note, Dr. Delic recommends TWO passes with your EMB pipelle when doing an EMB to ensure you get a good amount of tissue. And without a tenaculum whenever possible. 

Stay tuned for the spring for Part 2: Ovarian cancers