O&G JC107: Abnormal Vaginal Bleeding: Gynaecological Cancer Flashcards
Common cause of abnormal vaginal bleeding
Benign causes:
Uterine (PALM):
1. Endometrial polyps
2. Adenomyosis
3. Fibroids
4. Endometrial hyperplasia
5. Pregnancy-related
6. Dysfunctional uterine bleeding (i.e. without identifiable cause)
Ovarian:
1. Anovulation
Cervical:
1. Cervical polyps
2. Cervical erosion
Vaginal:
1. Atrophic vaginitis
2. Lacerations
Malignant causes:
- Can occur at any part of genital tract
How to tell source of bleeding: History taking
- Age + ***Stage of reproductive life
- Pre-menarche
- Pregnant
- Peri-menopausal
- Post-menopausal - Bleeding pattern / Menstrual history
- **Amount
- **Regular / Irregular
- **Abnormal bleeding
–> **Intermenstrual bleeding (Endometrial cancer)
–> **Post-menopausal bleeding (Endometrial cancer)
–> **Post-coital bleeding (Cervical cancer)
–> Clots - Provoking factors
- **Coitus
- **Trauma (vaginal lacerations)
- ***Stress (e.g. medical students) –> Hypothalamic amenorrhoea - Associated symptoms
- **Abdominal pain
- **Urinary / Bowel symptoms (e.g. Uterine fibroids may cause pressure symptoms on urinary bladder –> urinary frequency) (also rule out **haematuria / **blood in stools mistaken as vaginal bleeding)
- Anaemic symptoms
***記: COC (Contraceptive, Obstetrics, Cervical smear)
5. Contraceptive history
- possibility of pregnancy?
- on hormones e.g. OC pills?
- Obstetric history
- Cervical smear history
- smear up to date?
- have regular smear?
- smear results - Drug history
- **Anticoagulation (cause menorrhagia)
- **HRT (cause abnormal uterine bleeding)
- **OC pills
- **Herbal medications (may contain estrogen) - Family history
- CA ovary, breast, colon
Physical examination
General examination
1. Pallor
2. Bleeding tendency (e.g. easy bruising)
3. Constitutional symptoms (e.g. cachexia)
Abdominal examination
1. Inspection
- Scars
- **Distension (e.g. ovarian mass, ascites, pregnancy)
- **Signs of pregnancy (e.g. linea nigra, fetal movement in advanced gestation)
- Palpation
- Mass
- Tenderness (e.g. elicit rebound, guarding for peritoneal signs) - Percussion
- Ascites - Auscultation
- Fetal heart
Pelvic examination
1. Inspection
- Vulva
- Vagina / Cervix (by Speculum examination)
—> **Lesions / Bleeding sites
—> **Atrophic changes
—> ***Genital prolapse (cause ulcers)
- Bimanual examination of Uterus
- Position (Anteverted, Retroverted, Axial)
- Size
- Mobility
- ***Adnexal masses (estimate size) - Rectal examination
- Endometriosis (nodularity in PoD)
Investigations
Cervix
1. **Cervical smear
- collect cells from cervix for cytological diagnosis
- for cervical cancer screening, effective in picking up abnormal cells from cervix before obvious lesion / cervical cancer become apparent
- abnormal smear –> proceed to **Colposcopy
- Colposcopy
- examination of cervix with Colposcope
- apply Acetic acid –> Lugol’s iodine to cervix to visualise abnormal lesions
- lesions seen –> proceed to Cervical biopsy for histological diagnosis - ***Cervical biopsy
- punch biopsy
- obvious lesion / mass at cervix
- histological diagnosis
Uterus
1. ***Endometrial aspirate (biopsy)
- Pipelle aspirator (can be performed in clinic)
- ***Hysteroscopy (Diagnostic)
- visualise uterine cavity -
**Hysteroscopy + **Curettage (H+C)
- can be performed during Hysteroscopy to ascertain any endometrial pathology - USG
- Transvaginal / Transabdominal
- readily available
- look at endometrial ***thickness, other pathologies
- sagittal view of uterus: Trilaminar layer of endometrium
–> outer echogenic basal layer
–> middle hypoechoic functional layer
–> inner echogenic stripe at the central interface
Common gynaecological cancers
- Cervical cancer –> cause abnormal vaginal bleeding
- Endometrial cancer –> cause abnormal vaginal bleeding
- Ovarian cancer
Epidemiology of gynaecological cancers
Endometrial cancer (Corpus uteri cancer)
- 4th most common female cancer
- 11th in mortality
- Median age at diagnosis: 55
- ↑ incidence in HK (associated to risk factors e.g. obesity)
- 70% presents at stage 1 (∵ mostly symptomatic)
Ovarian cancer
- 6th
Cervical cancer
- 7th
- 8th in mortality
- Median age at diagnosis: 54
- 25% presents at stage 1, 25% stage 2, 40% stage 3+4 (advanced stage)
***Risk factors for Cervical cancer
- ***HPV
- Early sex
- Multiple sex partners
- STD
- Smoking
- Lower socioeconomic class
- OC pills
- Immunosuppression
***Clinical features of Cervical cancer (SpC OG + Felix Lai)
- Asymptomatic
- Bleeding
- Irregular menstrual bleeding
- Heavy menstrual bleeding
- Intermenstrual bleeding
- ***Post-coital bleeding (most specific presentation of cervical cancer, DDx: cervicitis) - Vaginal discharge
- Blood stained or unpleasant smell - Metastatic symptoms
- Bowel and urinary changes (invasion into bladder / rectum)
—> Haematuria, Haematochezia
- Constitutional symptoms
- Dyspnea
- Jaundice
- Pelvic or low back pain (bone pain)
History taking of Cervical cancer
- Age
- Median 54 - Bleeding pattern
- ***Post-coital bleeding - Associated symptoms
- Early disease: ***not much (usually picked up during cervical screening)
- Late disease: Back pain, Leg edema - Contraceptive / Sexual history
- OC pills
- ***Sexually active? (or Had been?) - Cervical smear history
- Regular screening?
- Last one?
- Results? - Obstetric history
- Parity - Family history
- ***not related
Physical examination of Cervical cancer
General examination
Pelvic examination
1. Normal appearance cervix in early stage + ***Asymptomatic (∴ cervical cancer screening is effective)
- Growth on cervix
- **Exophytic (cauliflower, contact bleeding)
- **Endophytic (infiltrative, barrel shape cervix)
- ***Ulceration
–> must take cervical biopsy to confirm nature of lesion - PV + PR examination (SpC Revision)
- ***Clinical staging: Assess extent of vaginal + parametrial spread
Investigations of Cervical cancer
Diagnosis
1. Punch biopsy
Plan of management
1. Blood test
- CBP
- LRFT
- Tumour markers
- SCC: SCC Ag level
- Adenocarcinoma: CA125 (SpC OG) - Imaging
- CT
- MRI abdomen + pelvis
- PET-CT
- PET-MRI
–> assess renal tract / extent of spread / LN involvement
(SpC OG
4. Cystoscopy / Sigmoidoscopy (for invasion into bladder / rectosigmoid area
- seldom done now)
- Examination under anaesthesia (EUA)
- for difficult P/E / biopsy
- seldom done now)
Spread of Cervical cancer
- Local
- laterally to parametrium
- downward to vagina
- anteriorly to bladder
- posteriorly to rectum, PoD, sacrum - Distal
- via LN chains to Pelvic / Para-aortic LN
***Staging of Cervical cancer
FIGO staging
1. Clinical
2. Pathological (新加)
3. Imaging (新加)
Stage 1: Cervix only (5-year survival 85%)
- 1A: Microscopic
—> 1A1: <3mm deep (SpC Revision)
—> 1A2: >=3 to <5mm
- 1B (1-3): Macroscopic, Confined to cervix (1-3 depend on size of mass)
—> 1B1: <2cm in greatest dimension
—> 1B2: >=2 to <4cm
—> 1B3: >=4cm
Stage 2: Upper vagina / Surrounding structures (e.g. parametrium) (5-year survival 75%)
- 2A: Upper 2/3 vagina
- 2B: Parametrium
Stage 3: Lower vagina / Pelvic wall / Pelvic/Para-aortic LN / Hydronephrosis/Non-functioning kidney (5-year survival 50%)
- 3A: Lower 1/3 vagina
- 3B: Pelvic sidewall / Hydronephrosis
- 3C: Pelvic / Para-aortic LN
Stage 4: Bladder / Rectum / Distant metastasis (5-year survival 25%)
- 4A: Bladder, Rectum
- 4B: Distant metastasis
- Add notation (r: imaging, p: pathology) to indicate findings that are used to allocate case to the stage
Treatment modalities in Cervical cancer
- Surgery
- for early stage (e.g. Stage 1)
- Stage 1A1: Cone biopsy / **Simple hysterectomy: very very early (microscopic **<3mm deep)
- Stage 1A2: **Wertheim’s hysterectomy (Radical hysterectomy + Pelvic lymphadenectomy)
–> remove uterus + upper vagina + parametria + pelvic LN
–> **laparotomy (tend to use) / laparoscopic route (↑ recurrence risk + poorer overall survival?)
- advantages:
–> preserve Ovarian function (less chance of osteoporosis / heart disease associated with early menopause)
–> avoid long-term morbidities of Radiotherapy (e.g. bladder, bowel, vaginal stenosis)
- Stage 1B1, Early 2A: **Radical hysterectomy + Pelvic lymphadenectomy / RT
- Stage 1B2, Late stage 2 / above: **Chemoradiation
(SpC OG
Advantages of Cone vs Hysterectomy:
- preserve fertility
- less invasive / complications
Disadvantages of Cone vs Hysterectomy:
- more difficult to monitor for recurrence after procedure (e.g. in endocervix —> difficult to brush)
- need for re-procedure if margin positive)
- ***Radiotherapy
- for early stage if surgery not suitable / high risk (e.g. elderly with comorbidities)
- for late stage (e.g. >= Stage 2)
- External beam + Brachytherapy - ***Chemotherapy
- in combination with Radiotherapy (Chemoirradiation)
- to ↑ sensitivity of Radiotherapy
- for recurrence
- e.g. Cisplatin - Targeted therapy (Bevacizumab) / Immunotherapy (Pembrolizumab)
- in combination with Chemotherapy
- to prolong progression-free survival + overall survival
Prognostic factors in Cervical cancer
- Stage
- LN metastasis (i.e. Stage 3)
- Histology
- common histology (e.g. SCC, Adenocarcinoma, Adenosquamous carcinoma): better prognosis
- rarer histology (e.g. Neuroendocrine small cell carcinoma): poorer prognosis
SpC Revision:
4. Parametrial involvement
5. Size + Depth of stromal invasion
6. Lymphovascular permeation
7. Age (Controversial)
