gynae oncol Flashcards
what are the layers of the uterus? (Brief) How is the uterus supported within the pelvis?
Serosa (peritoneum) which covers the anterior + posterior surfaces.
Myometrium (Fibroids derived from this layer) - smooth muscle (3 layers upper segment, 2 layers lower segment)
Endometrium (Glandular tissue, site of endometrial hyperplasia/ ca)
Supported by cardinal ligaments (lateral from cervix/ lower portion of uterus to lateral pelvic wall) which also contain the uterine arteries + uterosacral ligaments (to the sacrum)
Round ligament is remnant of gubernaculum and attaches to the labia majora.
What is the blood supply to the uterus? Where does lymph drain to? What is the most imp structure to ID when performing hysterectomy?
Uterine arteries that anastamose at superior + inferior portions with ovarian a supply + vaginal a respectively. Uterine a get blood from intern iliac, ovarian supp from aorta.
Drain mainly to internal + ext iliac nodes.
URETERS!! Uterine a should travel sup to them lateral to the uterus.
What is endometrial carcinoma? What is the peak incidence and what are RF for its development?
two subtypes:
Adenocarcinoma Type 1 (most common) less aggressive, E sensitive, low grade, associated with obesity. often atypia preceeds.
Type 2: aggressive, tend not to be E sensitive/ associated with obesity.
Highest prevalence at 60 years old.
RF: endogenous + exogenous E. PCOS/Obesity, DM, early menarche, nulliparity, late menopause, unopposed E HRT, older age, tamoxifen (antagonist in breast, agonist in uterus), familial non-polyposis (collection of ca- ovarian, breast, colon, endometrial).
Protective: COCP, Progestogens
How does endometrial carcinoma present? How is it staged?
Main symptom is PMB- 10% chance ca postmenopausal discharge - 50% chance ca pelvic pain If pre-menopause, IMB and occassionally new onset HMB Exam: Lymphadenopathy/ organomegaly, abdo, speculum +/- smear, PV. FIGO Staging 1. confined to uterus (endometrium + myometrium) a/ endometrium only b/+ <50% myometrium c/ + >50% myometrium 2. Cervical stroma invaded but not beyond uterus 3. Invades through uterus into: a/ serosa/ adnexae b/ vaginal/ parametrial involvement c/ Pelvic/ para-aortic nodes 4. further spread a/ bladder or bowel b/ distant mets
How is endometrial ca investigated and managed?
- TV - USS to assess endometrial thickness + regularity. Normal in postmenopause <4mm and between 8-16mm in women of reproductive age.
- Endometrial biopsy with Pipelle (may require hysteroscopy to first visualize the endometrium); sometimes, Dilation + curettage in order to access the endometrium).
- Pre-op Investigations- FBC, U+E, CXR for pulm mets, MRI for myometrial invasion + extra-uterine spread.
Management: - Surgery: TAH BSO (open) or lap + Washings + LN sample (possibly) + Omental biopsies for rare types (clear cell). Enables staging.
- Radiotherapy- either for those unfit for surgery/ distant mets/ adjuvant to surgery if > stage 1. Can use brachytherapy.
- Medical
Progestogens Medroxy-progesterone acetate / Mirena as primary tx for : Complex hyperplasia, Grade 1 endometrial cancer, Unfit patients, Advanced disease + recurrent disease.
Overall survival all stages 74% at 5 years.
how might Vulval malignancy/ neoplasia present? what are the RF? How is it investigated + managed?
Pruritis, bleeding or discharge, or may have distinct mass.
solitary plaque with irregular shape, structure, surface and colour. Firm or hard consistency and/or ulceration and bleeding are particularly concerning.
o/e: ulcer/ mass on clitoris, or labia majora and inguinal LN may be enlarged, hard or immobile.
associated with lichen sclerosus, older age, smoking, immunosuppression.
Ix: wedge biopsy (scc likely). Tx: radical local resection/ vulvectomy + dissection of local LN if req. Adjuvant radiotherapy if multiple LN involved.
what is endometrial hyperplasia? How is it diagnosed? How does it present?
classified as either hyperplasia w. atypia or w/o atypia. Atypical has a much higher chance of developing carcinoma. w/o atypia have <5% chance develop into carcinoma in 20 years, many regress.
Dx pipelle biopsy, may require hysteroscopy to get the sample.
PC: PMB, If pre-menopause, IMB and occassionally new onset HMB
How should endometrial hyperplasia be managed?
Hyperplasia w/o atypia: observation is fine but more will regress with IUS/ Oral P (continuous) such as methylprogesterone acetate but IUS is slightly more effective. min 6 months, up to 5 years. Good option for those who continue to have abnormal uterine bleeding. Aim to reverse RF such as obesity, HRT. surveillance OP biopsies, at 6/12 intervals.
Lap Hysterectomy +/- BSO can be done if med tx fails (after 12/12), progresses to atypical hyperplasia, persistent bleeding + no desire to conceive.
Atypical Hyperplasia: First line is hysterectomy +/- BSO (depends if premenopausal). If pt wishes to conceive, IUS/ Oral methlyprogresterone acetate until finished family + then Hysterectomy.
what is CIN? How is it staged? What are the primary investigations for its presence?
Presence of atypical cells within squamous epithelium of cervix. They cells are dyskaryiotic with large nuclei and frequent mitoses. Smears identify dyskaryosis (normal-borderline-high grade)
Smears done at 3yr intervals between 25-49. 50-64 every 5yr. Smear sample taken via speculum with cytobrush over external os - cells looked at using cytology.
CIN is a histological dx ie requires biopsy via colposcopy and is graded based on the depth of the atypical cells within the sample. CIN I- confined to lower third of epithelium. CIN II- lower 2/3 of epithelium. CIN III- full thickness of epithelium without invasion (not spreading past BM).
Colposcopy: cervix visualised via speculum w/ 10-20x magnifier + acetic acid - appearance of white dense areas particularly if arise quickly- CIN likely. Biopsy taken.
What are the causes/ RF of CIN? What are the symptoms?
HPV : types 16, 18, (strains in the vaccine, cause 75% ca) 31 most oncogenic strains.
Many sexual partners, early age of first intercourse, oral contraceptive (COCP), smoking, immunosuppressed e.g. HIV
peak ages: 35-44, 55-64
There are no symptoms and CIN cannot be detected by the naked eye by visualising the cervix.
How are smear results managed?
Normal: pt to have another smear in 3y/5y depending on age
Borderline/ low grade: if no HPV present, pt to be routinely screened in 3/5y depending on age
Borderline/ low grade + HPV present: Colposcopy
High grade: Colposcopy
How is CIN managed? What is the likelihood of developing cervical cancer from CIN? What are the main types of cervical cancer?
CIN I 60% regress within 3y
CIN II/III 30-70% progress to ca within 10y
CIN II/ III: LLETZ procedure (large loop excision of TZ). Diagnostic + tx procedure.
Ca types: squamous cell due to squamous cell metaplasia (75%), adenocarcinoma (10%)
what are the signs + symptoms of cervical cancer?
post-coital bleeding/ PMB
Intermenstrual bleeding
abnormal vaginal discharge
Advanced disease: anaemia, Lower limb oedema, haematuria, pelvic pain, rectal bleeding. May be visible mass on cervix.
how is cervical cancer investigated?
Smear + colposcopy (acetowhite + iodine negative, abnormal blood vessels)
Examination under anaesthesia (spread to vagina, parametrium, groin nodes).
Biopsy
MRI + Cytoscopy +/- sigmoidoscopy for staging
Fitness for surgery: FBC, CXR, U + E
Briefly outline the stages of cervical ca?
I: confined to cervix
II: invasion into vagina +/- parametrium (ie ligaments supporting uterus)
III: invasion to lower vagina, or ureteric obstruction (hydronephrosis), or pelvic side wall
IV: invasion of bladder/ rectum/ beyond true pelvis.
