Gynaecological Flashcards
Anatomy of Uterus
- Upper 2/3 of uterus is the body
- Lower 1/3 of the uterus is the cervix
- Upper 2/3 of cervix = columnar glandular epithelium
- Lower 1/3 of cervix = stratified squamous epithelium
- Internal Os is the opening between cervix and corpus, external os is the opening between cervix and vagina
Regional LNs of the Uterus
paracervical, parametrial, presacral, sacral, external iliac, common iliac, hypogastric (obturator), internal iliac.
Endometrium epidemiology
4th most common cancer in women, common in menopausal women
Diagnosis of Gynae cancers
Papanicolaou test
Cancer of endometrium staged surgically
- Pathology review
- EUA
- Chest X-ray
CT/MRI for disease extent
Patterns of spread
- May extend and involve greater proportion of endometrial surface readching cervix, extension in myometrium occurs simultaneously
- Lymph: Fundus -> para aortic
- Lymph: Middle/lower uterus -> broad ligament -> pelvic nodes -> round ligament -> inguinal nodes
- Direct invasion of serosa to bladder, colon or extension into abdominal cavity
- Small tumour fragments into peritoneal cavity by traversing the Fallopian tubes
- Blood borne spread common
Endometrium/Cervix histology
Adenocarcinoma
Adenocanthoma
Adenosquamous carcinoma
Leiomyosarcoma
Endometrial cancer staging
Using FIGO
Stage I - The tumour is confined to the uterine fundus (the body of the uterus).
• Stage II - The tumour extends to the cervix (the lower part of the uterus).
• Stage III - There is regional tumour spread.
• Stage IV - There is bulky pelvic disease or distant spread.
Prognostic indicators
- Pelvic or paraaortic LN spread
- Tumour grade or cell type
- Depth of myometrial invasion
- Tumour extension to the cervix
- Tumour vascularity
- LVSI
- Peritoneal mets
Distant mets
RT treatment technique - endometrium
- Stage 1 brachytherapy alone (16Gy in 4# or 22Gy in 4#)
Stage 1-3 EBRT generally 45Gy in 25# +8 Gy in 2# in brachytherapy
Clinical management endometrium
Surgery is most common for Ca Endometrium
- Stage 1A- surgery alone
- Stage 1B - Surgery and brachytherapy
- Stage 1C - surgery +EBRT+BT
Stage 2-3 - Surgery + EBRT +BT
CT simulation
1-3mm slices
Scan length - lower border T10 - inferior border of ischial tuberosities
Ant tattoo - ML and 2 Lateral tattoos
Organ motion: 60-80% tumour regression possible during RT
Tumour shrinkage can affect position of OARs
Also affected by bladder and rectal filling
Acute side effects
vaginal dryness, fatigue, diarrhoea, nausea, erythema, desquamation.
Acute side effects
vaginal dryness, fatigue, diarrhoea, nausea, erythema, desquamation.
Late side effects
Dysuria, vaginal stenosis, fibrosis
Endometrial cancer symptoms
Bleeding and vaginal discharge
Vulva symptoms
Palpable mass but early diagnosis important
Vulva management
- Early invasion - wide local excision (WLE)
- Stage 1 with 1mm larger tumour - WLE +lymph node assessment
- Large Stage 1 and 2 tumours = WLE +partial or complete vulvectomy +node dissection
Sentinel node biopsy - 25-35% of patients with stage 1 or 2 disease will have lymph node metastases
Vulva rt technique
Nodal involvement > irregular volumes > increased conformality with IMRT/VMAT
Vulva Cancer staging
TNM
Surgical staging
• Depth of invasion important indicator of nodal involvement
and prognosis
Vulva cancer epidemiology
accounts for 5-6% of all gynae cancers, uncommon in women under 50 - mean age of 70
Increased risk associated with HPV and smoking
Epidemiology of cervical cancer
7th most common cancer, high incidence in developing countries
Cervical cancer staging
FIGO
Stage I: carcinoma strictly confined to the cervix
Stage II: carcinoma that extends beyond the cervix but has not
extended onto the pelvic wall; the carcinoma involves the vagina,
but not as far as the lower-third section
Stage III: carcinoma that has extended onto the pelvic sidewall and/or
involves the lower third of the vagina; all cases with hydronephrosis
or a non-functioning kidney should be included, unless they are
known to be due to other causes
Stage IV: carcinoma that has extended beyond the true pelvis or has
clinically involved the mucosa of the bladder and/or rectum
Cervix RT technique
- EBRT 50.4Gy in 28# over 5.5 weeks
14Gy in 2# brachytherapy
Cervix clinical management
Stage 1A1 and 1A2 - surgery alone
1A1 - cone biopsy for clear margins but simple hysterectomy is indicated if fertility is not an issue
1A2 - radical trachelectomy and node dissection to help maintain fertility
1B1 - fertility may be preserved if tumour is less than 2cm, choice between hysterectomy or chemo radiation
1B2- Iva - RT +concurrent chemo (cisplatin)
Ivb- treated palliatively with chemo +RT
Ovary Symptoms
asymptomatic, symptoms are vague until patient presents with locally advanced cancer.
Lower abdominal pain, bloating, anorexia. Compression of adjacent structures - urinary frequency, constipation, pelvic discomfort, sensation of heaviness
Ovary Management
Surgery and chemotherapy (cisplatin, carboplatin), RT may be use for recurrent or palliative disease
Ovary epidemiology
6th most common female cancer. 75% women present when disease has spread beyond ovaries
Vagina epidemiology
rare accounts for 2% of gynae malignancies, post menopausal women, linked to HPV infection, previous hysterctomy or prolapsed uterus
Vaginal cancer treatment
Surgery and RT
Pre treatment prep
radio opaque markers
empty bladder
endometrial treatment field
4 field box
Treatment considerations for cervix
60-80% tumour regression during RT
can affect OAR positioning
