Female Reproductive Cancer Objectives
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List three categories of organs in the female reproductive system and give examples of each.
- 1)Primary: Ovaries
- 2)Internal Accessory:fallopian tubes, uterus, vagina
- 3)External:(the vulva) labia majora, labia minora, clitoris, vestibule, and vestibular glands
Describe the Ovaries, give their location and state where lymph drainage from the ovaries goes.
The ovaries are solid, ovoid structures the size of unshelled walnuts and are located on the lateral walls of the pelvic cavity(one on either side). Lymphatic drainage goes almost exclusively to the pariaortic lymph nodes(lumbar chain of nodes).
Locate and describe the broad, suspensory and round ligaments.
- 1)The largest of the ligaments is is the broad ligament which is formed by a fold of peritoneum. It is attached to the fallopian tubes and uterus.
- 2)The ovary is held in place at the upper end by a small fold of peritoneum called the suspensory ligament. The suspensory ligament contains ovarian blood vessels and nerves.
- 3)A flattened band of tissue within the broad ligament,called the round ligament, connects the upper end of the uterus to the pelvic wall.
State the function of the uterine tubes and give another name for them.
Uterine tubes, also called fallopian tubes, convey egg cells toward the uterus.
Describe the infundibulum and the fimbriae of the uterine tube.
Near the ovary, the fallopian tube expands to form a funnel shape called a infundibulum.The infundibulum bears a number of irregular, branched, extensions, called fimbriae.Although the infundibulum does not generally touch the ovary, the fimbriae are directly connected to it.
Describe how the movement of the egg from the ovary to the uterus if accomplished.
Transport of the ovary to the uterus is facilitated by the uterine tube cilia, which sweep the egg towards the uterus. In addition, peristaltic contraction help force the egg along.
Describe the uterus and state its function
The uterus, whose function is to receive the embryo and sustain its life during development, is a hollow, muscular organ shaped somewhat like a pear.
State the significance of the retrouterine pouch.
A posterior ligament forms a deep pouch between the uterus and rectum. This pouch helps prevent the spread of uterine cancer to the rectum.
Describe and locate the parts of the uterus, including the: fundus, body, corpus, cervix, internal os, external os.
The upper 2/3 of the uterus is the body or corpus and has a dome shaped top and is joined by uterine tubes that enter its wall. The fundus is the rounded portion above the entrance of the uterine tubes. The junction of the uterine cavity is the the cervical canal is called the internal os. The lower end of the cervical canal opens into the vagina and is termed the external os. The cervix surrounds the opening through which the uterus communicates with the vagina.
Describe the location of the vagina and identify the following parts: vault, fornices.
The vagina is located posterior to the urinary bladder and urethra and anterior to the rectum. The part of the vagina that surrounds the cervix is known as the vault and the recesses that occur between the vaginal wall and the cervix are termed fornices.
List the structures that make up the vulva:
labia major, labia minor, clitoris, vestibule, and vestibular glands
Discuss the importance of early screening methods for gynecologic cancers.
State what tool is most effective for early screening methods for gynecologic cancers.
State the most common histological type of cancer of the cervix and where they are more likely to arise.
squamous cell, posterior lip of cervix
State the chemical clear cell carcinoma is most closely linked
List the risk factors for cancer of the cervix and give the peak age of incidence.
- Peak age 50-60
- lower socioeconomic status(lack of health care)
- Early sexual activity, multiple partners, and multiple pelvic infections(HPV, herpes, and genital warts)
- DES daughters
State the most common method of spread for cancer of the cervix.
Direct extension-uterus, vagina, bladder, rectum
Describe the pattern of lymphatic spread usually followed by cancers of the cervix.
- Lymph nodes are orderly:
- paracervical, parametrial, pelvic, common iliac, para-aortic, and even SCV nodes
List some common metastatic sites for cervical cancer.
lungs, bone, liver
Discuss and describe pap smear classification, class I-class IV
- Class I-Normal
- Class II-atypical
- Class III-dysplasia
- Class IV-carcinoma in situ
Describe a complete diagnostic workup for cervical cancer.
H&P including pelvic and rectal exams, CT, MRI, PET, cystoscopy, and proctoscopy are used to asses metastastic disease.
List the most common symptoms of carcinoma of the cervix.
postcoital bleeding, increased menstrual bleeding, discomfort with intercourse, *malodorous discharge, pelvic pain, and urinary or rectal pain may accompany more advanced disease
List factors upon which clinical staging is based
How far the cancer has extended-
Discuss and describe the staging for cancer of the cervix.
- Tis-Carcinoma in situ
- T1-Confined to Cervix
- T2-Extenion into the vagina upper 2/3/parametrium
- T3-Extension into lower 1/3 of vagina/parametrium/pelvic wall
- T4-extension to bladder/rectum/beyond true pelvis
Discuss the two primary treatments for cervical cancer.
- TAH with a small amount of vaginal tissue called a cuff(or even more for later stages)
- RT-Tandem and Ovoid implant
Discuss the the treatment fr precancerous lesions of the cervix.
The cervix is viewed with a colposcope and any suspicoius areas are biopsied. The precancerous areas are removed with a laser or cryosurgery.
Discuss internal vs. external radiation for cervical cancer.
- internal radiation only is used when not trying to cover lymph nodes. Early stages-1a1-1a2: are treated with a TAH OR brachy(tandem and ovoids.
- Stage 1b1 and 2a:are treated with a choice of TAH or external beam RT(for nodes) AND and implant.
- Stage 2b-4: RT and Chemo because the cancer has spread there is no need to do a TAH. RT treats the pelvis and chemo treats systemically to get any disease that has spread.
Describe the external RT port for cervical cancers.
- 4 field box
- Border AP/PA
- -Bottom-Below obturator foramen unless the vagina is involved then 4 cm below
- -Lateral-2cm lateral to pelvic side walls
- Borders Lats
- -Top and bottom same as above
- -Anterior at pubic symphysis
- -Posterior includes S3
Describe an afterloading system
Low dose brachytherapy using Cesium where the physicist or the RT loads the source into the tandem and ovoids/etc.
Define tandem, ovoids, colpostats, give the purpose and positioning of each. Also give the three sizes of ovoids.
- The tandem is a curved rod that is inserted into the uterus, and the ovoids/colpostats(different manufactures call them different things) are the hemispherical pieces that flank the cervix in the fornices. Ovoids are one piece and look like golf clubs. The colpostats are the hemispherical pieces that fit on the end of the rod.(so each side has 2 pieces unlike the ovoids)They are used to administer brachytherapy
- Ovoids,basically come in sizes S,M,L
Describe the Manchester System, locate point "A" and point "B" and state what each point represents.
The Manchester system is either a ring and ovoids or tandem and oviods used for brachytherapy of the cervix or uterus.Point A-2cm superior and 2 cm lateral to the external os-associated with dose to the uterusPoint B- 2 cm superior and 5 cm lateral to the external os-associated with dose to the nodal areas
Describe the side effects of XRT treatment for cervical cancer
- (FOR ALL RT FOR GYNECOLOGIC CA)
- Anal irritation
- vaginal fibrosis
- bowel obstruction
Discuss the overall prognosis for cervical cancer
- The overall prognosis is good because it is slow growing, however if it is caught to late it is still deadly. (overall its 49% for 5 year survival)
State what stage ovarian cancer usually presents.
III or IV
List risk factors and peak age for ovarian cancer.
- Risk factors:(uninterrupted ovulation for many years)
- late or few pregnancies, late menopause, lack of oral contraceptive use
- family history
- personal history of breast, endometrial, or colon cancer
- diet high in animal fat
Discuss connection between ovarian and breast cancer
BRCA1 and BRCA2 have been shown to increase the risk of getting ovarian cancer. Genes associated with colon cancer have also been linked to ovarian cancer.
Most common histological type of ovarian cancer
Serum marker associated with ovarian cancer
4 methods of spread for ovarian cancer and which is most common
direct, through the blood, lymph nodes, and seeding
Most common- seeding
Main lymphatic drainage for the ovaries
Organs which are most common extra-pelvic metastatic sites for ovarian ca
Main modality for the treatment of ovarian cancer.
- Surgery is main modality
- chemo is also used
Which is most common gyn cancer in US women?
Endometrial(50% of gyn cancers in the US)
State whether the incidence of endometrial cancer is increasing or decreasing
Discuss the cure rate for endometrial cancer and give the peak age of incidence.
- overall 5 year survival is 75 %
- Peak age is 58
Describe the most common symptoms for each of the cancers discussed.
- Endometrial: post menopausal bleeding
- Ovarian: abdominal/pelvic pain
- Cervical: post coital bleeding
- Vulvar: subcutaneous lump on labia
- Vaginal:abnormal bleeding/painful intercourse
Most common histological type for each cancer
- Cervical: squamous cell
- vaginal: squamous cell
State the definitive procedure for diagnosing carcinoma of the endometrium.
aspiration and curettage
Give the most reliable prognostic factor for endometrial cancer
depth of myometrial penetration
Discuss treatment of the various cancers.
- Cervical:combinations of TAH /Brachytherapy/ external beam RT .
- for stage IIb-IV:RT and chemo (no TAH or brachy)
- Endometrial:TAH, brachy and external beam RT added for later stages.
- Stage 3-4-external beam RT alone
- Ovarian:Surgery is main mode of treatment, chemo is also used. RT for mets and palliation
- Vaginal-RT is treatment of choice for AP/PA fields. For superficial lesion-brachy 60 Gy.Deeper lesions -whole pelvis external beam RT 45-50Gy boosted and vagina boosted with brachy 65-80Gy
- Vulvar-Surgery and RT, chemo for stage 3
The cure rate for endometrial cancer:
State whether the incidence of endometrial cancer is increasing or decreasing.
Discuss treatment for precancerous lesions of the cervix
Colposcopy is used in order to magnify the cervix so that any suspicious areas can be viewed and biopsied. After the results come back, any abnormal areas can be removed with cryosurgery or a laser.
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