No Disclosures Endometrial Intra-epithelial Neoplasia Jocelyn S. - - PowerPoint PPT Presentation

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Endometrial Intra-epithelial Neoplasia

Jocelyn S. Chapman, MD Gynecologic Oncology Assistant Professor, Division of Gynecologic Oncology University of California San Francisco

No Disclosures

Objectives

• What is endometrial intra-epithelial neoplasia (EIN)
• Symptoms
• Diagnosis
• What are the management options?
• Fertility sparing
• Non-operative candidates
• Surgical management
• Sentinel Lymph node evaluation

Endometrial Intra-epithelial Neoplasia

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ACOG – Committee Opinion May 2015 ACOG – Committee Opinion May 2015 Prognostic accuracy of EIN Risk factors for EIN

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• OBESITY
• 21-50lb overweight – 3x incidence
• >50lb weight - 10x incidence
• Nulliparity – incidence increased 2x
• Late Menopause - incidence increased 2.5x
• Diabetes, hypertension, hypothyroidism are associated

with endometrial cancer

Risk factors for EIN

• Bleeding
• Present in 90% of all cases
• 15% of patients with postmenopausal bleeding will have endometrial cancer
• Other Signs/Symptoms
• Vaginal Discharge
• Pelvic Pain, Pressure
• Referred Leg Pain
• Change in Bowel Habits
• Pyometria/Hematometria

Signs & Symptoms Diagnosis

• Pap Smear
• Only 30-50% patients with cancer will have an abnormal result
• AGUS predictive of carcinoma in post-menopausal women
• Endometrial Biopsy
• False negative rate of 5-10%
• Trans-vaginal Ultrasound
• Not for routine screening or diagnosis (unless Lynch)
• Suspicious findings include endometrial stripe >5mm, polypoid mass, or fluid

collection in uterus

Management of EIN

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• Candidates
• Benign endometrial hyperplasia
• EIN PLUS
• Desired fertility
• No evidence of concomitant carcinoma
• Non-operative candidates

Non-surgical management Consider MRI

• Non-pharmacologic interventions
• Removal of source of unopposed estrogen
• Correct ovulatory dysfunction
• Weight loss
• Estrogen producing neoplasms (i.e. granulosa cell

tumors)

• Progestin therapy

Non-surgical management Progestins

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LNG-IUD compared to MPA

SH = simple hyperplasia, CH = complex hyperplasia, ACH = atypical complex hyperplasia

Orbo A, Vereide A, Arnes M, Pettersen I, Straume B. Levonorgestrel-impregnated intrauterine device as treatment for endometrial hyperplasia: a national multicentre randomised trial. BJOG. 2014 Mar;121(4):477-86.

• Repeat EMB q3-6 months until regression
• If menses resumes (for pre-menopausal patients), no further

biopsy necessary

• If EIN persists – add megace to LNG-IUD

If EIN persists despite dual agent therapy, patient has failed conservative management and should be recommended for hysterectomy

Monitoring & Regression

Role of Sentinel Lymph Node Evaluation

Risk of Lymph Node Metastases

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Sentinel Lymph Node Mapping with ICG

Abu-Rustum. Sentinel Lymph node mapping https://doi.org/10.6004/jnccn.2014.0026

SLN Mapping in Uterine Cancer

Sentinel lymph node (SLN) mapping algorithm. Abbreviation: LND, lymph node dissection.From Barlin JN, Khoury-Collado F, Kim CH, et al. The importance of applying a sentinel lymph node mapping algorithm in endometrial cancer staging: beyond removal of blue nodes. Gynecol Oncol 2012;125:534; with permission.

SLN Algorithm

Risks associated with lymphadenectomy

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Lymph node assessment risk for EIN

• 43% with EIN will have cancer on hysterectomy

specimen.

• 12% of cancers diagnosed pre-op as EIN will have

deeply invasive, high-grade tumors

• 7% of patients staged at the time of hysterectomy with a

pre-operative diagnosis of EIN have nodal metastatic disease

• Cancer. 2006 Feb;106:812-9.

Int J Gynecol Cancer. 2005 Jan-Feb;15:127-31.

Proposed protocol for EIN management with GYN and GYNONC

• EIN or FIGO grade 1 endometrioid

adenocarcinoma

• Pre-operative CT A/P and CXR (for FIGO grade 1)
• Pre-operative ultrasound (for EIN)
• CXR
• If BMI > 40 must refer to GynOnc

Review Questions

What is one advantage of the endometrial intraepithelial neoplasia (EIN) diagnostic schema over the WHO94 schema?

• A. EIN classification is more reproducible
• B. EIN classification has been used longer
• C. EIN classification is preferred by

pathologists

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78% 16% 6%

Review Questions

Which of the following describes a patient who can be

• ffered non-operative management of her EIN?
• A. A 47 year old woman who has had 4

endometrial biopsies over 2 years with persistent EIN while on progestin therapy.

• B. A 28 year old woman who desires

pregnancy and has an MRI without evidence

• f invasive carcinoma.
• C. A 66 year old woman with class 3 obesity.

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3% 2% 95%

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Review Questions

Which of the following progestins appears to be most efficacious in regression of EIN?

• A. Medroxyprogesterone acetate
• B. Levonorgesterol intra-uterine device
• C. Megace 180mg BID

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2% 8% 90%

Review Questions

What is the risk of lymphedema after a pelvic lymphadenectomy?

• A. 5%
• B. 10%
• C. 20%

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7% 85% 8%

Questions? Thank you!

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