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____ helps prevent the spread of uterine cancer to the rectum.
Rectouterine
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The ____ is located medially within the anterior portion of the pelvic cavity, above the ____ and usually bent forward over the urinary bladder.
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The upper 2/3 of the uterus (____ or ____) had a dome shaped top and is joined by the ____ ____that enter it's wall.
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____ is the rounded portion above the level of the entrance of the uterine tubes.
Fundus
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The ____ changes greatly during pregnancy.
uterus
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The lower 1/3 of the uterus is the ____ ____ , which extends ____ into the upper portion of the ____.
- tubular cervix
- downward
- vagina
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The junction of the uterine cavity w/ the cervical canal is called the ____ ____
internal os.
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The lower end of the cervical canal which opens into the vagina is termed the ____ ____.
external os
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The cervix surrounds the opening through which the ____ communicates w/ the ____.
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The three distint layers of tissue of the uterus are ____, ____, and ____. (outermost, middle innermost)
perimetrium, myometrium, endometrium
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The ____ is a fibromuscular tube about 9cm in length, extending from the uterus to the ____.
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The part of the vagina which surrounds the cervix is known as the ____ and the recesses that occur between the vaginal wall and the cervix are termed ____.
- vault
- fornicies (singular:fornix)
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Why are the fornicies clinically important?
because they allow the internal abdominal organs to be palpated during a physical examination.
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The vaginal orfice opens into the ____. This orfice allows ____ and ____ ____ to pass to the outside.
- vestibule
- uterine
- vaginal secretions
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What structures, as a group, surround the openings of the urethra and vagina and compose the vulva?
labia majora, labia minora, clitoris, vestibule and vestibular glands (Bartholin's glands)
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Most common incidence of female cancers?
Endometrial (50%)
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Most common death rate of female cancers?
ovarian (56%)
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What is the importance of early screening methods?
screening is when a test is used to look for a disease before there are any symptoms. Cancer screening tests are effective when they can detect disease early. Detecting disease early can lead to more effective treatment.
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Most effective tool in screening for gynecologic cancers?
pap smear
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Most common histologic type of cancer of the cervix?
squamous cell
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Most cervical cancer lesions are in the ..?
posterior lip of the cervix.
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Risk factors for cancer of the cervix?
- Risk factors:
- -smoking
- -Women whose mothers used DES during pregnancy (clear cell)
- -wives of men w/ penile ca
- -multiple partners, early sexual activity, and multiple pelvic infections(HPV, herpes, genital warts)
- -women of lower socioeconomic staus
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Peak age for cervical ca?
50-60
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Par smear: 2/3 of cancers are diagnosed in ____ stage.
noninvasive
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Most common method of spread for cervical ca?
- local invasion
- *lymphatic
- vascular embolization
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Chemical to which clear cell carcinoma is closely linked?
DES
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The pattern of lymphatic spread?
- paracervical
- parametrial nodes
- pelvic
- common iliac
- para-aortic
- SCV nodes
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Common meststatic sites for cervical cancer.. direct extension? and hematogenous?
- direct extension: uterus, vagina, bladder, rectum
- hematogenous: lungs, bone, liver
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Describe Pap smear classifications. Class I-class IV?
- Class I- normal
- Class II- atypical
- Class III- dysplasia
- Class IV- carcinoma in situ
- Class V- invasive carcoinoma
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Most common symptom of carcinoma of the cervix?
postcoital bleeding
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Diagnostic workup for cervical ca?
- history and physical
- pelvic and rectal exams
- CT, MRI, PET
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Two primary treatments for cervical ca?
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____ is used for staging.
FIGO
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Clinical staging is based on Tis, T1, T2, T3, T4. Describe each?
- Tis-Carcinomain situ
- T1-confined to cervix
- T1a – micro invasive: depth of penetration 3mm or less
- T1b – invasive: depth of penetration greater than 3mm
- T2-extension into the vagina (upper 2/3 / parametrium
- T2a – extension to vagina
- T2b – extension to parametrium (not pelvic wall)
- T3-extension to lower third vagina/parametrium/pelvic wall
- T3a – extension to lower third of vagina
- T3b – extension into parametrium and pelvic wall
- T4-extension to bladder/rectum/beyond true pelvis
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Manchester system: point "A" and point "B". What does each point represent?
- Point A- 2cm superior and 2cm lateral to external os (dose to uterus)
- Point B- 2cm superior and 5cm lateral to external os (dose to nodal areas)
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Overall prognosis for carcinoma of the cervix?
the overall (all stages combined) 5-year survival rate is about 72%
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Side effects for XRT treatment for cervical ca?
Common side effects of radiation therapy include tiredness, upset stomach, or loose bowels. Pelvic radiation therapy may cause scar tissue to form in the vagina. The scar tissue can make the vagina more narrow (called vaginal stenosis) or even shorter, which makes vaginal intercourse painful. Vaginal dryness and painful intercourse can be long-term side effects from radiation. Pelvic radiation can damage the ovaries, causing premature menopause. Radiation can irritate the bladder and problems with urination may occur. Radiation to the pelvis can also weaken the bones, leading to fractures. Hip fractures are the most common, and may occur 2 to 4 years after radiation.
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treatment of precancerous lesions of the cervix?
When a precancerous lesion requires treatment, cryosurgery (freezing), cauterization (burning, also called diathermy), or laser surgery may be used to destroy the abnormal area without harming nearby healthy tissue.Abnormal tissue also can be removed by LEEP or conization.
Choice of treatment for a precancerous lesion of the cervix depends on a number of factors. These factors include whether the lesion is low or high grade, whether a woman wants to have children in the future, her age and general health, and her preference and that of her health care professional.
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internal vs external radiation of cervical cancers?
External radiation therapy uses a machine outside the body to send radiation toward the cervical cancer. Internal radiation therapy uses a small amount of radioactive material that is delivered directly to the tumor using implants.
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what is an "afterloading" system used for cervical cancer
In use, the end of the tandem would be positioned next to the tumor. Next, the colpostat would be inserted and into the uterus and then locked at the appropriate diameter. The shielding provided by the tungsten ovoids reduced the dose to the rectum - a limiting factor in treating cervical cancer. Finally, the radium source, loaded into the end of the plastic tube, is inserted into the tandem.
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Isotopes: low dose and high dose?
- low dose: Cesium
- HDR: Iridium 192
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Fletcher apparatus: Tandum is inserted in ____. Ovoids lie in the ____ ____ on each side of the cervix.
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peak age for ovarian ca?
50-70
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Risk factors for ovarian ca?
- older age
- late or few preg.
- late menopause
- lack of oral contraceptive use
- family history of ovarian cancer
- personal history of breat, colon, or endometrial ca
- diets high in meat or animal fat
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Radiation field for cervical ca?
- Borders AP/PA
- Top – L4-L5
- Bottom – Below obturator foramen unless the vagina is involved and then it is 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
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most common symptoms for ovarian cancers are?
abdominal and or pelvic pain, and ascites, abdominal distention
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CA-125 marker is a ..?
useful prognostic indicator for ovarian ca
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blood spread of ovarian ca is to the ____ and the ____.
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Ovarian ca can ____ in the abdomen.
seed
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Ovarian cancer usually presents itself at what stage?
Ovarian cancer is often caught in the late stage and survival isn’t that promising.
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Connection between breast, ovarian, and colon cancer is ..?
Symptoms of ovarian cancer are not specific to the disease, and they often mimic those of many other more-common conditions..
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Most common histologic type of ovarian cancer?
epithelial (90%)
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Four methods of spread for ovarian cancer?
- pelvis
- abdominal cavity
- lymph nodes (para-aortic)
- blood (liver and lungs)
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main lymphatic drainage for the ovaries?
para-aortic lymph nodes
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overall 5 year survival for ovarian cancer is?
30%
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Primary treatment for ovarian ca is?
surgery then chemotherapy. RT is not usually used, but if so, it includes the whole abdominal and doses are 25-28Gy. Renal blocking at 18Gy.
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Overall 5 yr. survival for endometrial ca is?
75%
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most common spread for ovarian ca?
spreads to the pelvis
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Which GYN cancer is most commonly occurring in the US?
endometrial
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incidence of endometrial cancer increasing or decreasing?
increasing
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Peak age of endometrial ca is ?
58
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Risk factors for endometrial cancer?
- family history
- postmenopausal women
- diabetes
- hypertension
- women who are 50lbs overweight have 9x the risk
- prolong estrogen use
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Most common symptoms for GYN cancers?
- bleeding
- back pain
- discharge
- bloating
- frequent urination
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Most common histological type of cancer for each of the areas discussed..?
- cervical, vaginal, and vulvar=squamous
- ovarian=epithelial
- endometrial= adenocarcioma
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procedure for diagnosing carcinoma of the endometrium?
History and physical, chest xrays, blood counts and chemistries, and a urinalysis, pelvic ultrasound, CT, and MRI
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most reliable prognostic factor for endometrail ca?
lymph node status, histological type of carcinoma, and depth of invasion.
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Endometrial cancer lymph spead is to the ____ and ____ ____.
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____ ____ can spread along surface of uterine cavity.
Endometrial cancer
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Women who have taken the drug tamoxifen may develope ____ ____.
endometrial cancer
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Treatment options for endometrail cancer. Stage Ia, Ib, Ic, Stage II, III, and IV?
- -Stage Ia – TAH
- -Stage Ib- TAH and vaginal cuff brachytherapyStage
- -Ic – Stage II – TAH and external beam RT and brachytherapy
- -Stage III and IV – RT alone
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____ cancer is usually on the labia majora.
Vulvar
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What GYN cancer usually causes patients to have a subcutaneous lump or mass or more advanced disease will be a ulcerative exophytic mass?
Vulvar cancer
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Which GYN cancer starts w/ inguinal nodes, then deep femoral nodes, and eventually pelvic nodes?
Vulvar ca
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Prognostic factors for vulvar ca?
- size of lesion
- depth of invasion
- histologic subtype
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Diagnostic work up for vulvar ca?
biopsy, H&P, blood counts, chemistries, urinalysis, chest xrays, and CT
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overall 5 yr survival rate for vulvar ca?
70%
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Treatment options for vulvar cancer?
- -Stage I and II – Surgery and RT 50-60Gy
- -Stage III – Surgery and RT 60Gy to gross disease and 45-50Gy to the inguinal nodes and Chemotherapy
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RT field for vulvar cancer is.. ?
- AP/PA
- top:L5
- pelvic inlet is covered and wide enough to cover the inguinal nodes
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What GYN cancer is the patient sometimes treated in the frog leg position, and bolus is used.
vulvar ca
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____ ____ accounts for cancers that have not reached the cervix or vulva
Vaginal cancer
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median age for vaginal ca?
65
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DES (morning sickness drug) is the only known cause for which GYN cancer?
vaginal cancer
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Presenting symptoms of vaginal cancer?
- Abnormal bleeding
- painful intercourse
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Most common location for vaginal tumor is ..?
posterior upper third of vagina.
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Lymph drainage for vaginal ca is similar to ____ with the exception of the lower lesion draining to the ____ nodes
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Direct extension for vaginal ca is along the ____ ____ to cervix or vulva. It may also spread to the ____ ____,bladder, and ____.
- vaginal wall
- pelvic wall
- rectum
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Vaginal cancer work up includes?
- biopsy
- H&P
- blood
- chemistry
- urinalysis
- chest xray
- CT
- cystourethroscopy
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For vaginal ca ____ is the treatment of choice.
RT
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Side effects from radiation therapy?
- Fatigue
- Diarrhea
- Dermatitis
- Dysuria
- N & V
- Anal Irritation
- Menopause
- Vaginal fibrosis and dryness
- Bowel obstruction
- Dry and moist desquamation
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____ is used for recurrent or persistent vaginal ca.
Surgery
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*note* Vaginal Cancer
For superficial lesions only the vaginal tissues are treated via brachytherapy60Gy. For deeper lesions, the wholepelvis to include inguinal nodes is treated with external beam 45-50Gy andvagina is boosted with brachytherapy to 65-80Gy.
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