Time of the month Flashcards
What are the 3 layers of the uterus
Serosa- outermost layer, thin,
Myometrium – smooth muscle, thickest layer, contracts during menstruation
Endometrium – the layer that is shed
What are the lymph nodes that drain the the female pelvis
paracervical parametrial presacral & sacral external illiac common illiac hypogastric (obturator) internal illiac
What age group does endometrial cancer mostly effect.
It is most common in MENOPAUSAL women
55-85 years old
What are the risk factors of endometrial cancer?
- Early menarche
- Late menopause
- Obesity – too much adipose tissue can secrete -
hormones - Nulliparity (having no children)
- Infertility
- Oestrogen-producing ovarian tumours
- The use of tamoxifen for breast cancer
- Family history (immediate family gets disease before 50)
What are the symptoms for endometrial cancer?
- vaginal discharge (90%)
- bleeding
Not common in post-menopausal therefore is picked up earlier
What is the common pathology of Endometrial Cancer
- Adenocarcinoma
- Adenocanthoma
- Adenosquamous carcinoma
- Leiomyosarcoma – muscle
What are the patterns of spread for endometrial cancer
- Blood borne spread is uncommon
- Cervix, myometrium, serosa to the bladder, colon, abdominal cavity and Fallopian Tubes
- Lymph drainage from the fundus empties into the para‐aortic nodes.
- From the middle and lower portions of the uterus lymph passes through the broad ligament to the pelvic nodes.
- Some lymphatics course through the round ligament to the inguinal nodes.
What level do the paraaoritc nodes finish
T12
What are the prognostic indicators for endometrial cancer?
Spread to the regional nodes is the most important prognostic.
Pelvic or paraaortic LN spread
Tumour grade or cell type
Depth of myometrial invasion
Tumour extension to the cervix
Tumour vascularity
LVSI (Lymphovascular space invasion)
Peritoneal metastases
Distant organ metastases
Low grade tumours have a better prognosis
Why is prognosis not always good in younger women (endometrial cancer)?
Prognosis is not always good in younger women because it is not picked up early (bleeding from the uterus is normal).
In older women who are post-menopausal it is usually diagnosed earlier (bleeding is abnormal).
What are the recurrence rates of deep and superficial invasion (endometrial cancer)?
Patients with superficial invasion have a 10% recurrence risk.
Patients with deep invasion have a 25% recurrence rate.
What is stage 1 of endometrial cancer?
Stage 1 – the tumour is confined to the uterine fundus (body of uterus)
- A: Tumour limited to endometrium
- IB: Invasion to no more than half the myometrial thickness.
- IC: Invasion to more than half the myometrial thickness
What is stage 2 of endometrial cancer?
Stage 2- The tumour extends to the cervix (lower part of uterus)
IIA: Invasion to the mucosa of the cervix.
IIB: Invasion to cervical stroma
What is stage 3 of endometrial cancer?
There is regional tumour spread
- IIIA: Tumour invades serosa and/or adnexa, and/or positive peritoneal cytology
- IIIB: Vaginal metastases
- IIIC: Metastases to pelvic and/or para‐aortic lymph nodes.
What are the staging method for Endometrial cancer?
• Cancer of the Endometrium staged surgically
o Pathology review
o EUA (Examination Under Anesthesia)
o Chest X ray
• CT/MRI may be used to define extent of disease
What is the clinical management of Endometrial cancer?
Primary therapy is surgery
- Abdominal hysterectomy
- bilateral salpingo-oophorectomy
(removal of the ovaries and Fallopian tubes)
What is the treatment for each stage of cancer? (Endometrial)
Stage 1A – surgery alone
Stage 1B – surgery + brachytherapy
Stage 1C – surgery + EBRT + BT
Stage II‐III – surgery + EBRT + BT
Role of RT in early stages is questionable
What are the pre-treatment steps for endometrial cancer?
Full bladder ( pushes small bowel superior) Mostly supine
What are the pre-treatment steps for endometrial cancer?
Full bladder ( pushes small bowel superior) Mostly supine Are fiducial markers required Oral contrast - for lymph nodes Daily verification
What are the doses for endometrial cancer?
Brachytherapy alone:
16Gy in 4# or 22Gy in 4#
EBRT: 45Gy in 25# + 8Gy in 2# brachytherapy
Pelvic EBRT usually given for Stage 3 and above.
Acute side Effects of Endometrial cancer (RT treatment)?
Acute:
Diarrohoea
Nausea and vomiting para-aortics involved
Abdominal pain and cramping
Erythema and Desquamation in the inguinal folds
Rectal dysfunction
Urinary frequency and dysuria (less common)
Late Side effects of endometrial cancer (RT treatment)?
Chronic fatigue
Vaginal Stenosis
Rectal and urinary frequency
What is epidemiology of the cervix?
- Seventh most common cancer overall worldwide
- Second most common cancer in women worldwide
- Incidence is highest in developing countries
- Regular screening has reduced the incidence in developed countries
- Vaccination = Gardasil
What is the aetiology of of cervical cancer?
HPV 16 –Squamous Cell carcinoma
HPV 18–Adenocarcinoma (associated with a worse prognosis)
- HPV 11 (associated with benign) malignancies
What are early detection methods of cervical cancer?
Pap testing/ cytology testing
HPV DNA testing
What is the lymphatic spread of cervical cancer?
Tumor spreads from the primary lesion sequentially to the pelvic lymph nodes, para-aortic lymph nodes (PAN) and supraclavicular lymph nodes
paracervical parametrial presacral sacral external iliac common iliac hypogastric (obturator) internal iliac
What are the staging methods for cervical cancer?
Cutterage of the cervix to examine abnormal cells
- Pathology review
- EUA (Examination under Anaesthesia)
- Chest X-Ray
- IVP (intravenous pyelogram)
- MRI useful for determining the extent of the tumour in the cervix and parametrial extension
What is the clinical management of cervical cancer?
Stage 1A1 and 1A2 – surgery alone can be curative
1A1 – cone biopsy may achieve clear margins but simple hysterectomy is indicated if fertility not an issue
1A2 – radical trachelectomy and node dissection if required may help to maintain fertility, but simple hysterectomy is indicated if this is not an issue
Trachelectomy – surgical remove of lower part of the uterus and the cervix
1B1 – fertility may still be preserved if tumour <2cm, otherwise patient has a choice between hysterectomy or chemo radiation
1B2 – IVa – primary treatment is radiation therapy with concurrent chemo (cisplatin)
IVb – treated palliatively with chemo and radiation
Chemotherapy – might be possible for the patient to preserve fertility
What are the CT scan considerations?
- L1 to 5cm beyond the vaginal introitus
- IV contrast to outline the pelvic blood vessels and nodes
What is the dose for cervical cancer?
50.4Gy in 28# over 5.5 weeks
14Gy in 2# Brachytherapy
What is the Aetiology Vaginal cancer?
- Occurs mainly in post-menopausal women
- HPV infection
- previous hysterectomy
- prolapsed uterus
What are the symptoms of Vaginal Cancer
- A watery, bloody or malodourous discharge
- Bleeding and pain during intercourse
What is the clinical management of vaginal cancer?
Surgery
- Useful in early superficial disease
- Radical surgery may cause loss of function of the bladder and rectum
EBRT and brachytherapy is the main option
45 Gy in 25# EBRT
21-28Gy in 3- 4# of brachytherapy
What is the aeitology of Vulval cancer?
- Uncommon in women under 50 – mean age of 70
- Increased risk associated with HPV and smoking
- Although often seen in post-menopausal women there is an increasing number of young women with the disease
What are the symptoms of Vulval cancer?
Bleeding
Pain
Dysuria
Pruritus - pus filled lesion
How is vulval cancer staged?
Surgical staging - biopsy performed
Depth of invasion important indicator of nodal involvement and prognosis
- 1% nodal involvement in invasion of less than 1mm
- 28% nodal involvement in invasion 1-5mm
What is the clinical management of vulval cancer (Surgery)?
Surgery is the primary intervention
Early invasion – tumours < 2cm + ≤ 1mm invasion = WLE (wide local excision)
- Stage I with > 1mm invasion = WLE + lymph node assessment
- Larger stage I and II tumours > 2cm = WLE + partial or complete vulvectomy + node dissection
What is the clinical management of vulval cancer (RT)?
Can also be used for those who are unfit for surgery
Bolus brings dose to the skin
Treated with large fields, (Ideally, treated in lithotomy position, but not all patients can do this )
Concurrent chemo being investigated
45Gy in 25# to vulva alone and an electron boost of 15Gy in 8# to the perineum and to the nodal sites involved
What is the patient care (Vulval cancer)?
Very painful skin reactions for the vulva
RT side effects are similar for all gynae patients
Patients diagnosed with vulva cancer may experience psychosocial issues before RT
Vaginal Dilators (for stenosis)
What are the signs and symptoms of ovarian cancer?
- Anorexia
- Urinary frequency
- Sensation of heaviness
- Growth into peritoneal cavity leads to abdominal pain
What is the clinical management of ovarian cancer?
Surgery is treatment of choice
- In early stages 5-year survival is 95% for surgery alone
- Later stage disease – Debulking based surgery followed by platimum based chemo
Chemotherapy
- Used after surgery
- Carboplatin
- Paclitaxel
- Cisplatin
