Genital Tract Malignancies Flashcards
What is endometrial cancer?
Most common genital tract cancer
Very rare pre-menopausal
Adenocarcinoma
Adenosquamous carcinoma (poor prognosis)
What is the aetiology of endometrial cancer?
High ratio of oestrogen to progesterone
What are the risk factors for endometrial cancer?
Exogenous oestrogens w/o progestogen
Obesity (conversion of androgens to oestrogens)
PCOS - prolonged amenorrhoea
Nulliparity
Late menopause
Ovarian granulosa cell tumour (ovarian secreting)
Tamoxifen
What is the premalignant syndrome of endometrial tissue?
Oestrogen causes cystic hyperplasia of the endometrium -> atypical hyperplasia
PMB and is premalignant
How does endometrial cancer present?
Postmenopausal bleeding
IMB
Abnormal cervical smear
How does endometrial cancer spread?
Directly through myometrium into cervix and upper vagina
Lymph -> pelvic and para-aortic lymph nodes
-> bladder or bowel
How is endometrial cancer treated?
Most present with Stage 1
Hysterectomy and bilateral salpingo-ooepherectomy
External beam radiotherapy - follows surgery in high risk/lymph node involvement patients
also used for pelvic recurrence
What is the 5 year prognosis of endometrial cancers?
Stage 1 - 85%
Stage 2 - 70%
Stage 3 - 50%
Stage 4 - 25%
Overall - 75%
What uterine sarcomas exist?
Leiomyosarcoma
Endometrial stromal tumours (perimenopausal)
Mixed mullerian tumours (old age)
When does cervical cancer peak?
During 30s and 80s
What are the histologies of cervical cancer?
90% squamous cell carcinoma
10% adenocarcinoma (worse prognosis)
How does cervical cancer present?
Occult - picked up on biopsy or LLETZ
PCB
Offensive discharge
PMB
Later stages: uraemia, haematuria, rectal bleeding, pain
Where does cervical cancer spread?
Stage 1 - confined to cervix
Stage 2 - invasion into vagina or parametrium
Stage 3 - Invasion of pelvic wall/ureteric obstruction
Stage 4 - Invasion of bladder/rectal mucosa
How are cervical cancers investigated?
Confirm diagnosis - biopsy
Stage - vaginal and rectal exam, MRI, cystoscopy
How are microinvasive cervical cancers managed?
Cone biopsy (-> post-op haemorrhage or preterm labour) Simple hysterectomy in older women
How are cervical carcinomas treated?
1a - cone biopsy/simple hysterectomy
1aii-1bi - laparoscopic lymphadenectomy and radical trachelectomy
1aii-2a - radical abdominal hysterectomy (LN -ve) or chemo-radiotherapy
> 2b or LN positive - chemo-radiotherapy alone
What is the prognosis of cervical cancer?
Stage 1 - 95%
Stage 2 - 60%
Stage 3-4 - 10-30%
Overall - 65%
What is the follow up for cervical cancer?
R/V at 3+6 months
then every 6 months for 5 years
What is ovarian cancer?
Rates increase with age
90% are epithelial carcinomas Serous cystadenocarcinoma Endometrioid carcinoma Mucinous cystadenocarcinoma (raised CEA) Clear cell carcinoma 10% other
What genes are linked to ovarian carcinomas?
BRCA1 - breast
BRCA2 - breast
HNPCC - bowel and endometrial
2 relatives + BRCA1 = 50% risk
How does ovarian cancer present?
Vague - 70% present with stage 3/4 Bloating Feeling full Increased urgency and frequency Breast/GI mass
What are indicator of malignant ovarian mass?
Rapid growth >5cm Ascites Advanced age Bilateral masses Solid mass Increased vascularity
Where does ovarian cancer spread?
Within pelvis and abdomen (transcoelomic spread) - omentum, small bowel, peritoneum
What investigations are done for ovarian cancer in primary care?
CA 125 levels
If >35 then USS of abdomen and pelvis is done
If USS identifies ascites/mass then urgent referral done
What investigations are done for ovarian cancer in secondary care?
If 250 then referred to MDT for CT pelvis and abdo
How is RMI calculated?
RMI = U x M x CA 125
USS result
- multilocular cysts
- solid areas
- metastases
- ascites
- bilateral lesions
Menopausal status
- premenopausal = 1
- postmenopausal = 3
What is the management of ovarian cancer?
Midline laparotomy with total hysterectomy, bilateral salpingo-ooepherectomy and partial omentectomy
Biopsy of peritoneal deposits
Retroperitoneal lymph node assessment/removal
Assessment of upper abdomen
What chemotherapy is given for ovarian cancer?
Platinum agent carboplatin/cisplatin +/- paclitaxel
What is the follow-up and prognosis of ovarian cancer?
CA 125 levels monitored
Death commonly from bowel obstruction or perforation
What is vulval cancer?
More common >60yrs
Mainly SCC
Others: melanoma, BCC, adenocarcinoma
Associated with lichen sclerosis, immunosupression, smoking and Paget’s disease of the vulva
How does vulval cancer present?
Pruritus Bleeding/discharge Mass Ulcer on labia majora or clitoris Enlarged inguinal lymph nodes
How is vulval cancer investigated and treated?
Biopsy
Local excision +/- groin lymphadenectomy
Where does secondary vaginal cancer arise from?
Cervix
Endometrium
Vulva
GI tissue
How does primary vaginal cancer present?
Older women
SCC
Bleeding/discharge
Mass/ulcer
Tx: intravaginal radiotherapy
What is clear cell adenocarcinoma of the vagina?
Late teenage years
Daughters of women prescribed DES during pregnancy
Tx: radical surgery and radiotherapy
What is the initial management of PMB?
History and examination
TV USS
Hysteroscopy
Pipelle
