Gynecologic Cancers Flashcards
Anatomy of the Vulva
The outermost portion of the female genitalia.
Three major parts:
- labia majora
- labia minora
- clitoris
Anatomy of the vagina
Extends 6 to 8 inches from the cervix to the vulva. Surrounded by the rectum, urethra and bladder. The vaginal wall consists of smooth muscles and lined with stratified squamous cell epithelium.
Three layers of vaginal walls:
- mucosa
- muscularis
- adventitia
Anatomy of uterus
The uterus is a pear-shaped structure divided into two main parts:
- cervix
- fundus
Three layers of the wall of the uterus are:
- inner endometrium (mucous membrane)
- middle myometrium (smooth muscles)
- outer perimetrium (parietal peritoneum)
Anatomy of the cervix
Part of the uterus extends into the superior vaginal wall. The cervix is a firm rounded structure.
Endocervix is the part of the cervix closest to the uterus
Exocervix is the part of the cervix closest to the vagina.
Cell types of the cervix
The cervical os is the opening of the cervix (vagina end) is lined with squamous cell epithelium.
Squamous cell epithelium connects with the columnar epithelium of the endocervix.
Where they connect is called the squamocolumnar junction of the transformation zone.
Squamous cell carcinoma of the cervix usually originates at this junction.
Epidemiology of cervical cancer
The third most common malignancy diagnosed in women.
High incidence rates in found in Hispanic and black communities.
Most cases are diagnosed in women under 50 but it is uncommon to be diagnosed under 20.
Women in lower socioeconomic status may not have access to screening and are therefore have higher rates of cervical cancer
Pathology of cervical cancer
Two primary types of cervical carcinomas:
- squamous cell carcinoma most common and account for 80-90% of cancer
- adenocarcinoma account for 10-20% are typically worse prognosis
- 3-5% of cervical cancers have components of both called adenosquamous carcinomas.
Etiology of cervical cancer
The strong correlation between multiple sexual partners and sexual intercourse at an early age is some behaviours that increase the risk of developing cervical cancer.
Also, a strong correlation between sexually transmitted diseases and cervical cancer. Specifically herpes simplex type 2 and HPV.
HPV is the most common sexually transmitted infection and is responsible for 99% of all cervical cancer. Specifically the HPV 16 and 18.
Other risk factors include oral contraceptives with estrogen alone, smoking, hormonal factors, obesity, low-socioeconomic status, nulliparity and immunosuppression.
Clinical presentation of cervical presentation
Cervical cancers are typically slow-growing and develop over decades before clinically evident, therefore the early-stage cervical cancer is asymptomatic.
More advanced stages may present with:
- abnormal vaginal discharge
- pelvic or back pain
- painful urination
- hematuria
- hematochezia (bright-red stools): may suggest invasion into the rectum.
The most common presenting symptom is abnormal vaginal bleeding.
Screening for cervical cancer
The primary screening test for cervical cancer is a Pap smear, which identifies abnormal cells that may develop into cancer. The pap smear is sensitive, specific and cost-effective.
Recommendations are being tested every 3 years beginning at 21 if sexually active.
Women aged 30-65 should be tested every 5 years.
Women with risk factors may need to be screened more often and
Colposcopy
Performed on women with abnormal pap smear results.
This test uses a magnifying microscope to examine the cervix for abnormalities.
Abnormal areas can be excised with a punch biopsy
Cervical intraepithelial neoplasm (CIN)
Precancerous condition in which squamous cells that line the cervix become dysplastic.
Endocervical cutteage
For cases where the transformative zone cannot be seen under the microscopic. Cutteage removes tissue from the endocervical canal.
Cone biopsy
A cone-shaped piece of tissue is removed from the cervix (exocervix and endocervix) and examined by a pathologist.
T1 cervical cancer
Cervical carcinoma confined to the cervix.
T1a of cervical cancer
T1a: invasive carcinoma diagnosed only with microscopy
T1a1: measured stromal invasion <3.0mm in depth and <7.0mm in the horizontal spread.
T1a2: measured stomal invasion is >3.0mm but <5.0mm with horizontal spread <7.0mm
T1b of cervical cancer
T1b: clinically visible lesion confined to the cervix
T1b1: clinically visible lesion <4.0cm in greatest dimension
T1b2: clinically visible lesion >4.0cm in greatest dimension
T2a stage of cervical cancer
Tumour without parametrial invasion.
T2a1: clinically visible lesions <4.0cm in greatest dimension
T2b2: clinically visible lesion >4.0cm in greatest dimension
T2b stage of cervical cancer
Tumour with parametrial invasion
T3 stage of cervical cancer
Tumour extends to the pelvic wall or involves the lower third of the vagina or causes hydronephrosis or non-functional kidneys.
T3a: tumour involves lower 1/3 of vagina no extension to the pelvic wall
T3b: tumour extends pelvic wall or causes hydronephrosis
T4 stage of cervical cancer
T4a: tumour invades mucosa of bladder or rectum
T4b: tumour extends beyond the true pelvis
Prognostic factors in cervical cancer
The most significant prognostic factor is staging.
Other factors include age, race, socioeconomic status, tumour size, location and lymph node involvement.
Patients without lymph node involvement showed improved 5-year survival compared to those with para-aortic or pelvic lymph node metastasis.
Metastasis of cervical cancer
Direct extension into the uterus, vagina, parametrium, the abdomen, the pelvis, the rectum and the bladder.
Spread via hematogenous routes. The most common distant sites include lung, liver and bone.
Lymphatic spread
The lymphatic spread of cervical cancer
Parametrial nodes
obturator
common iliac
peri-aortic
superclav nodes
Treatment for carcinoma in situ and Ia1 cervix cancer
The typical treatment is total abdominal hysterectomy (TAH) with or without a small amount of vaginal tissue (vaginal cuff). After this treatment patients can no longer conceive children and menstruation ceases.
May undergo brachytherapy alone because the risk of nodal spread is very low.
Or radical trachelectomy in which the cervix is removed but the uterus stays in place. Therefore patients keep their fertility.
The survival outcomes of these three treatment options are very similar.
Treatments for stage Ib1 or IIa
Controversial because surgery and RT both yield similar results.
Because of the preservation of vaginal pliability and ovarian function surgery is suggested for younger women.
Radiation is used for women who have a higher risk of surgical complications.
Post-op radiation is given to patients with pelvic nodes positive for a tumour or positive surgical margins. Also for patients with a combination of deep stromal invasion, lymphovascular space invasion, or large tumour diameter.
Treatment for advanced-stage cervical cancer
Treated with radiation with or without chemotherapy
Both EBRT and brachytherapy are used.
Total tumour doses of 70Gy for low-volume doses and 85Gy for bulky tumours are used.
Typically 45Gy is given by EBRT and the rest by brachytherapy
TDF goals of cervical cancer treatment
50 to 60Gy to microscopic disease
60 to 70Gy to small macroscopic disease
70-90Gy to large macroscopic disease
Limit the volume and dose to bladder, colorectal tissue and small intestine.
Point A prescription point cervical cancer
2cm superior to cervical os 2cm lateral to endocervical canal where the uterine artery crosses the uterer
Point B prescription point cervical cancer
3cm lateral to point A.
Borders for RT treatment of cervical cancer
Inf border: obturator foramen unless the vagina is involved then it is 4cm past the lowest extent of disease.
Sup border: usually at the top of L5 or may be extended up to L4
Lats: 2.0cm lateral to pelvic sidewall in the AP/PA plane
Ant: either at or anterior to the symphysis
Post: include S3
Epidemiology of endometrial cancer
Most common gynecologic malignancy
The fourth most common cancer diagnosed in women
Most cases of endometrial cancers occur in post-menopausal over the age of 55
Incidence is higher among white women although black women have a higher mortality rate.
Anatomy of the uterus
The uterus is located in the pelvis between the bladder and rectum.
Divided into two parts
- cervix
- fundus (body)
Three layers of the uterus
The endometrium (mucous membrane) is the most inner layer of the uterus. Where cancers of the endometrium originate.
The myometrium (smooth muscle)
The serosa (pariteal peritoneum)
Pathology of endometrium cancers
Adenocarcinomas account for 80% of diagnoses
Less seen pathologies are:
- clear cell: highly malignant
- papillary serous: usually highly malignant usually spreads throughout the abdomen
- mucinous
- squamous cell
Uterine sarcoma is rare but the most malignant
Risk factors of endometrial cancer
Hormone-related cancers so risk factors result from the female hormone estrogen.
The major risk factor is the high cumulative exposure to estrogen that is not hindered by progesterone.
Other risk factors include:
- estrogen replacement therapy: without progesterone
- obesity: obese women have a 3-5 times higher risk of developing endometrial cancer
- nulliparity
- late menopause
- early menarche
- irregular menstruation
- diabetes
- history of infertility
- women taking tamoxifen are at higher risk
- or women with hereditary colon cancer
Clinical presentation of endometrial cancer
The most common presenting symptom is postmenopausal bleeding. 1/3 of postmenopausal bleeding is cancer-related.
Most endometrial cancers are diagnosed in stage I.
More advanced disease may present with hematuria, hematochezia, constipation, lower extremity edema, pain, abdominal distension.
Poor prognosis factors for endometrial cancer
- higher grade
- increased depth of invasion into the myometrial muscle
- lymph node involvement
- lymphatic space invasion
- size of the tumour
Screening for endometrial cancer
No screening test for endometrial cancer is recommended.
A biopsy can be done but is not recommended for screening.
If women are at high risk they may receive a biopsy every year after the age of 35.
Education for post-menopausal women is important in the detection of endometrial cancer.
Stage 1A of endometrial carcinoma
Tumour is only in the inner layer of the uterus (endometrium) and has grown less than halfway through the muscle layer of the uterus wall (myometrium)
Stage Ib of endometrial cancer
Tumour has grown more than halfway through the myometrium.
Stage II of the endometrial cancer
The tumour has grown into the cervix.
Stage IIIA stage of endometrial cancer
The tumour has grown to the outer surface of the uterus (serosa) or the fallopian tubes, ovaries or supporting ligaments.
Stage IIIb of endometrial cancer
The tumour has grown into the vagina or the tissues next to the uterus and cervix (parametria)
Stage IIIC
Cancer has spread to the lymph nodes in the pelvis or to the lymph nodes around the aorta.
Stage IVa of endometrial cancer
Tumour has grown into the lining of the bladder or intestines.
Stage IVb of endometrial cancer
Cancer has spread to other parts of the body including lungs, liver and bones.
The spread of endometrial cancer
Spread to the pelvic and para-aortic nodes is common in endometrial cancer.
Lymph spread of endometrial cancer
Spread usually occurs initially to the internal and external iliac pelvic nodes.
Surgical management of endometrial cancer
Total abdominal hysterectomy and bilateral salpingo-oophorectomy with or without lymphadenectomy.
salpingo-oophorectomy
Removal of the fallopian tubes and ovaries.
Radiation treatment for endometrial cancer
Commonly used in combination with surgery, or as the only treatment for patients who cannot undergo surgery.
Most cases are seen after surgery and include a combination of both EBRT and brachytherapy.
For lower stages, 60Gy is given by brachytherapy
For higher stages, EBRT is used to treat the pelvis and lymph nodes.
Pelvic nodal doses of 45Gy are recommended with a boost of up to 65Gy for gross tumour.
Field borders are similar to that of cervical cancer.
