Chapter 18: The headmistress’ family

A 62-year-old headmistress developed post-menopausal vaginal bleeding and was referred urgently by her GP under the “2-week wait” pathway for suspected endometrial cancer. Her body mass index mass/height2 (BMI) was 32. The gynaecologist sent her for an urgent transvaginal ultrasound (TVUS) which showed a thickened endometrium of 8 mm depth. Hysteroscopic biopsy was performed and confirmed a moderately differentiated endometrioid adenocarcinoma of the endometrium (type I). She had an MRI scan for staging.

• 1. What does the MRI scan show?

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  Correct answer:
  The tumour stage is IC with extension into the outer half of the myometrium.
  

She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by adjuvant pelvic radiotherapy and vaginal brachytherapy.

She composed a family tree as she remarked that her aunt had died of endometrial cancer and gave it to her oncologist.

• 2. What inherited cancer predisposition does the family tree suggest?

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  Correct answer:
  Lynch syndrome/hereditary non-polyposis colon cancer.
  Her family history is suggestive of Lynch syndrome (HNPCC) and fulfil the Amsterdam II clinical criteria.
  Criteria for establishing Lynch family (all must be met):

  • Three or more relatives with an associated cancer (colorectal, endometrial, small intestine, ureter or renal pelvis cancer)
  • Two or more successive generations affected
  • One or more relatives diagnosed before the age of 50 years
  • One should be a first-degree relative of the other two
  • FAP should be excluded in cases of colorectal carcinoma
  • Tumours should be verified by pathologic examination