Genital Tract Malignancies

Question 1

What is endometrial cancer?

Answer 1

Most common genital tract cancer
Very rare pre-menopausal
Adenocarcinoma
Adenosquamous carcinoma (poor prognosis)

Question 2

What is the aetiology of endometrial cancer?

Answer 2

High ratio of oestrogen to progesterone

Question 3

What are the risk factors for endometrial cancer?

Answer 3

Exogenous oestrogens w/o progestogen
Obesity (conversion of androgens to oestrogens)
PCOS - prolonged amenorrhoea
Nulliparity
Late menopause
Ovarian granulosa cell tumour (ovarian secreting)
Tamoxifen

Question 4

What is the premalignant syndrome of endometrial tissue?

Answer 4

Oestrogen causes cystic hyperplasia of the endometrium -> atypical hyperplasia
PMB and is premalignant

Question 5

How does endometrial cancer present?

Answer 5

Postmenopausal bleeding
IMB
Abnormal cervical smear

Question 6

How does endometrial cancer spread?

Answer 6

Directly through myometrium into cervix and upper vagina
Lymph -> pelvic and para-aortic lymph nodes
-> bladder or bowel

Question 7

How is endometrial cancer treated?

Answer 7

Most present with Stage 1
Hysterectomy and bilateral salpingo-ooepherectomy

External beam radiotherapy - follows surgery in high risk/lymph node involvement patients
also used for pelvic recurrence

Question 8

What is the 5 year prognosis of endometrial cancers?

Answer 8

Stage 1 - 85%
Stage 2 - 70%
Stage 3 - 50%
Stage 4 - 25%

Overall - 75%

Question 9

What uterine sarcomas exist?

Answer 9

Leiomyosarcoma
Endometrial stromal tumours (perimenopausal)
Mixed mullerian tumours (old age)

Question 10

When does cervical cancer peak?

Answer 10

During 30s and 80s

Question 11

What are the histologies of cervical cancer?

Answer 11

90% squamous cell carcinoma

10% adenocarcinoma (worse prognosis)

Question 12

How does cervical cancer present?

Answer 12

Occult - picked up on biopsy or LLETZ
PCB
Offensive discharge
PMB

Later stages: uraemia, haematuria, rectal bleeding, pain

Question 13

Where does cervical cancer spread?

Answer 13

Stage 1 - confined to cervix
Stage 2 - invasion into vagina or parametrium
Stage 3 - Invasion of pelvic wall/ureteric obstruction
Stage 4 - Invasion of bladder/rectal mucosa

Question 14

How are cervical cancers investigated?

Answer 14

Confirm diagnosis - biopsy

Stage - vaginal and rectal exam, MRI, cystoscopy

Question 15

How are microinvasive cervical cancers managed?

Answer 15

Cone biopsy (-> post-op haemorrhage or preterm labour)
Simple hysterectomy in older women

Question 16

How are cervical carcinomas treated?

Answer 16

1a - cone biopsy/simple hysterectomy

1aii-1bi - laparoscopic lymphadenectomy and radical trachelectomy

1aii-2a - radical abdominal hysterectomy (LN -ve) or chemo-radiotherapy

> 2b or LN positive - chemo-radiotherapy alone

Question 17

What is the prognosis of cervical cancer?

Answer 17

Stage 1 - 95%
Stage 2 - 60%
Stage 3-4 - 10-30%

Overall - 65%

Question 18

What is the follow up for cervical cancer?

Answer 18

R/V at 3+6 months

then every 6 months for 5 years

Question 19

What is ovarian cancer?

Answer 19

Rates increase with age

90% are epithelial carcinomas
Serous cystadenocarcinoma
Endometrioid carcinoma
Mucinous cystadenocarcinoma (raised CEA)
Clear cell carcinoma
10% other

Question 20

What genes are linked to ovarian carcinomas?

Answer 20

BRCA1 - breast
BRCA2 - breast
HNPCC - bowel and endometrial

2 relatives + BRCA1 = 50% risk

Question 21

How does ovarian cancer present?

Answer 21

Vague - 70% present with stage 3/4
Bloating
Feeling full
Increased urgency and frequency
Breast/GI mass

Question 22

What are indicator of malignant ovarian mass?

Answer 22

Rapid growth >5cm
Ascites
Advanced age
Bilateral masses
Solid mass
Increased vascularity

Question 23

Where does ovarian cancer spread?

Answer 23

Within pelvis and abdomen (transcoelomic spread) - omentum, small bowel, peritoneum

Question 24

What investigations are done for ovarian cancer in primary care?

Answer 24

CA 125 levels
If >35 then USS of abdomen and pelvis is done
If USS identifies ascites/mass then urgent referral done

Question 25

What investigations are done for ovarian cancer in secondary care?

Answer 25

If 250 then referred to MDT for CT pelvis and abdo

Question 26

How is RMI calculated?

Answer 26

RMI = U x M x CA 125

USS result

• multilocular cysts
• solid areas
• metastases
• ascites
• bilateral lesions

Menopausal status

• premenopausal = 1
• postmenopausal = 3

Question 27

What is the management of ovarian cancer?

Answer 27

Midline laparotomy with total hysterectomy, bilateral salpingo-ooepherectomy and partial omentectomy
Biopsy of peritoneal deposits
Retroperitoneal lymph node assessment/removal
Assessment of upper abdomen

Question 28

What chemotherapy is given for ovarian cancer?

Answer 28

Platinum agent carboplatin/cisplatin +/- paclitaxel

Question 29

What is the follow-up and prognosis of ovarian cancer?

Answer 29

CA 125 levels monitored

Death commonly from bowel obstruction or perforation

Question 30

What is vulval cancer?

Answer 30

More common >60yrs
Mainly SCC
Others: melanoma, BCC, adenocarcinoma
Associated with lichen sclerosis, immunosupression, smoking and Paget’s disease of the vulva

Question 31

How does vulval cancer present?

Answer 31

Pruritus
Bleeding/discharge
Mass
Ulcer on labia majora or clitoris
Enlarged inguinal lymph nodes

Question 32

How is vulval cancer investigated and treated?

Answer 32

Biopsy

Local excision +/- groin lymphadenectomy

Question 33

Where does secondary vaginal cancer arise from?

Answer 33

Cervix
Endometrium
Vulva
GI tissue

Question 34

How does primary vaginal cancer present?

Answer 34

Older women
SCC
Bleeding/discharge
Mass/ulcer

Tx: intravaginal radiotherapy

Question 35

What is clear cell adenocarcinoma of the vagina?

Answer 35

Late teenage years
Daughters of women prescribed DES during pregnancy

Tx: radical surgery and radiotherapy

Question 36

What is the initial management of PMB?

Answer 36

History and examination
TV USS
Hysteroscopy
Pipelle