Gyn Cancer NM Flashcards
Corpus uteri N
10% in stage I
Pelvic or paraaortic - - 50% reduced 5-year survival
2/3 lower drain like cervix
1/3 upper drain directly to paraaortic
Corpus uteri M
Lung - - hormonal therapy
Liver
Bone
Skin
Inguinal LN (above renal pelvis)
Peritoneal implants
Malignant ascites
Stage IVB
Corpus uteri cancer
Risk
Hyperestrogenism - - nullipara, anovulation, premature menarche, late menopause, polycystic ovaries, tamoxifen therapy, HRT
Obesity
Comorbidities - - arterial hypertension, DM, Lynch
Corpus uteri cancer
Endometrioid type 80%
Estrogen - dependent
Type 1
Earlier - - Better prognosis
Precede - endometrial hyperplasia
Ass with chronic estrogen exposure
Mutations of PTEN, PIK3CA, K-Ras, beta-catenin genes
Corpus uteri cancer
Non Endometrioid
Estrogen independent
Type 2
Papillary and clear cell
Aggressive, extrauterine
serous (prototype of type 2)
clear cell carcinoma (features of type 1 and 2)
No ass with estrogen exposure, no premalignant disease
Corpus uteri treatment
TAH + BSO
High risk - - grade 3, >50% myometrial invasion, papillary serous, carcinosarcoma and clear cell carcinoma - - radical pelvic and paraaortic lymphadenectomy
Corpus uteri sarcoma
Leiomyosarcoma - - rare LN
Endometrial stromal sarcoma
Adenosarcoma
Leiomyosarcoma
15-40% smooth muscle tumor
>40 y
Large, 6-10 cm
>5 cm - - poor prognosis
Recurrence in lungs 40%
FDG avid in primary tumor and MTS
CT - enlarged uterus with areas of necrosis
Endometrial stromal sarcoma
10-25% mesenchymal tumor
>35-55 y
Large mass with myometrial component
Spreads along fallopian tubes, uterine ligaments, pelvic veins
Often sensitive to hormones
High rate of recurrence
CT - - enhancing mass, loss of pelvic fat planes
Adenosarcoma
6% benign epithelium and malignant stroma
Polypoid mass with septa, lattice like appearance, expands endometrial cavity
Large, up to 9 cm
May protrude through dilated cervical canal
Recurrence in vagina and pelvis
CT - large solid mass, regions of necrosis, small cystic areas
Corpus uteri sarcoma
Risk
Risk - - tamoxifen therapy or long term COCs, previous pelvic radiation
Aggressive - - intense FDG uptake
Endometrial cancer
Uterus PET indication
Evaluation of extrauterine disease
Patient selection and surgical planning
Response to therapy, recurrence
Early stage only if high risk
Not for primary staging, early carcinomatosis, microMTS, low grade, serous or mucinous
PET MRI - - infiltration in surrounding tissue
PET false
False negative:
Lesion <1 cm
Grade I endometrial cancer
Well-diff mucinous ovarian cyst adenocarcinoma
Small pelvic tumor adjacent to bladder or ureter
Peritoneal carcinomatosis
Uterus benign PET
Uterine fibroid
Adenomyosis
Endometriosis
Cyclic activity of uterus or ovary in premenopausal women
Oral metformin PET
Diffuse uptake in bowel
Stop 48h
PET after treatment
Cancer of uterus
After surgery or chemo - - 2 weeks
After radio - - 6-12 weeks
Cervical cancer FIGO
Ia2 - stromal invasion 3-5 mm
Ib1 - stromal invasion >5 mm
Ib2 - visible lesion 2-4 cm
IIa1 - visible lesion <4 cm
Cervical cancer N
Drain to parametria, external iliac, obturator LN (most common SLNB)
1/3 of locally advanced - - paraaortic LN MTS
Cervical cancer M
Liver
Lung
Bone (spine)
Adrenal
Mediastinal LN
Supraclavicular LN
Cervical cancer origin
Squamocolumnar junction (ectocervix intra vagina) - - moves to endocervix with age - - cancer arise in transformation zone between old and new SCJ
Cervical cancer type
SCC 70% - - cavitary lung MTS - - highest FDG SUV
Adenocarcinoma - - 25%, aggressive
Small cell - - 2%, PAP smear not sensitive, aggressive
Clear cell adenocarcinoma - - exposure to diethylstilbestrol in utero
Adenoma malignum - - from columnar epithelium of endocervical canal, history of copious watery discharge, poor prognosis, ass with Peutz-Jeghers
Cervical cancer risk
90% HPV16, 18
Early sex
Multiple partners
STD
Multiparity
Smoking
Long use of COC
Postcoital bleeding
Anemia
Peritoneal seeding
Sister Mary Joseph’s LN (umbilical)
Cervical cancer
Paraneoplastic sy
Cushing
SIADH
Carcinoid
Hypoglycemia
Cervical cancer
Paraaortic LN
Predictor of recurrence
Important for treatment strategy
Surgical staging
Cervical cancer
PET MRI
Useful for IB2, soft tissue and Parametrial involvement
Hysterectomy
Only if N0
Conization
Depth of tumor invasion <3 mm
N0
Wertheim - Meigs operation
TAH
Upper 1/3 of vagina
Parametrial and uterosacral ligament
Pelvic and paraaortic LN
Cervical cancer
CT
92% accurate for stage IIIB-IVB
Not for Parametrial invasion
Cervical cancer
MRI
Ideal for local staging
Accurate in selecting operative candidates
Superior soft tissue contrast
Cervical cancer
FDG PET
100% sensitivity and 99% specificity for LN >5 mm and for MTS
>MRI and CT in adenopathy
Higher SUV on primary lesion or metastatic pelvic/paraaortic LN - - increase risk of adverse events and death
NCCN - - IB2 or higher
ACR - - IB1 or higher
When paraaortic LN found at surgery
Incidental invasive cervical cancer at hysterectomy
To define targets for radiotherapy planning
Suboptimal for early stage
3 - 6months after chemo radio
Not for routine unless proven recurrence
Cervical cancer
Cervical cancer
Cervical cancer
Ovarian cancer M
Liver:
Perihepatic - - smooth, elliptic - - stage III - - resectable
Parenchymal - - less defines, surrounded by parenchyma - - stage IV, non resectable
Lung
Pleural effusion
Adrenal
Spleen
Bone
Intestine - - morbidity
Ovarian cancer epithelial 90%
High grade serous 70% - - precursor - - serous tubal intraepithelial carcinoma, TP53 and BRCA
Low grade serous 5% - - precursor - - ovarian surface epithelial inclusion cysts, KRAS and BRAF
Clear cell
Endometrioid - - endometrial hyperplasia
Mucinous - - variable density
Ovarian cancer non epithelial 10%
Germ cell
Calcification in cysts
Serous
Suspicious malignancy ovary
Solid mass with necrosis
Non fat nodular components in cystic lesion
Irregular thick wall or septa >3 mm
Vascularity
Enhancement
Ascites, peritoneal MTS, lymphadenopathy
CA 125 > 30 U/mL
Premenopausal Endometriosis
Cystadenoma
Pelvic inflammatory disease
Peritoneal dissemination of non ovarian cancer
Malignant ascites
Peritoneal MTS
Omentum
Primary peritoneal carcinona
Poor prognosis
Biopsy to confirm
Partially solid/cystic mass separate from ovary associated with hydrosalpinx
No hydrosalpinx - - sausage shaped solid adnexal mass
At least stage II
Latzko classic triad
Primary peritoneal cancer
Intermittent profuse serosanguinous Vaginal discharge
Colicky pain relieved by discharge
Adnexal mass
Ovarian cancer
Mature cystic teratoma
Ovarian cancer
Ovarian cancer MRI
Problem solving
When CT is contraindicated
Better in DD benign vs malignant
Local extension
Local recurrence
Ovarian cancer PET CT
Tumor characterisation, local extent, nodal involvement, MTS
>US, CT, MRI in staging of epithelial cancer, regional LN, peritoneum esp in right upper abdomen and small bowel mesentery, residual
SUV at staging predict survival
Locally advanced epithelial cancer treated with neoadjuvant therapy - - responders vs non responders
Corpus luteum cyst - - high uptake in premenopausal
Not optimal for lesions <5 mm
Vaginal cancer
30-50% had prior hysterectomy
90% SCC - - HPV, post menopause
10% adenocarcinoma - - exposure to DES, congenital T-shaped uterus, young
FDG useful in recurrence
Vulvar Stage
Ib - T1b - lesion <2 cm
II - T2 - any size, adjusent perineal structures
Vulvar cancer
LN
Inguino-femoral
Labia - - superficial inguinal
Midline - - deep inguinal bilateral
Vulvar cancer risk
Smoke
Lichen sclerosis
Intraepithelial neoplasia
HPV 60%
Vulvar cancer
Unilateral dissection
Unifocal tumor <2 cm
Lateral lesion >1 cm from midline
No palpable adenopathy
Vulvar cancer
Bilateral dissection
Tumor >2 cm
Central lesion
Nodal MTS
Complications - - better SLNB
Vaginal cancer
Vulvar cancer PET CT
Staging
Recurrence
Treatment planning
SLNB still required
PET MRI
Management of patients with cervical and ovarian cancer
Less useful in endometrial carcinoma
PET MRI > PET CT
Superior for detecting small metastatic LN and for distinguishing LN from anatomic structures
2 on the right
1 on the left
External iliac bilaterally
