O+G CANCERS
Ovarian Lumps Uterine Lumps Cervical Lumps Vulva (2-5%)
Epithelial derived: 1. Endometrial cancer (MOST common = 1. Mainly SCC (75%) - Transformation zone • Mainly SCC
1. Serous carcinoma (most common) 80% are AC ® PTEN 10%) more sensitive to RT (better prog.) • Also: melanoma, BCC,
® from fallopian tubes (ciliated 2. Serous carcinoma (2nd) from ciliated Paget’s
epithelium) usually due to tubular tubular epithelium of fallopian tubes 2. AC (25%) - Mucinous carcinoma (goblet
occlusion – papilla (gravestones) (Tubal metaplasia in endometrium) cells = endocervix)
Malignant 2. Mucinous carcinoma (derived from 3. Mucinous carcinoma (from endocervix) [AC = less sensitive to RT (poorer prog.)]
cervix) – occurs slowly
3. Endometrial carcinoma – 2o to 4. Rare: Mesothelioma (peritoneal lining of HPV inhibits tumour suppressor genes
endometriosis usu. in POD (recto uterus) ® ?asbestos • E6 oncoprotein – inhibits p53
uterine pouch) 5. Uterine sarcoma (mets fibroid) • E7 oncoprotein ® inhibits Rb
Ø DERMOID cysts (teratoma from germ Ø Leiomyomas (fibroids) – single fibroids • Teratomas / dermoid cysts • Cysts – Bartholin
Benign cells) – assoc. w/ ovarian torsion have higher risk of malignancy • Corpus albicans (white blobs) – corpus gland
(hemorrhagic necrosis) (leiomyosarcomas) than multiple fibroids luteum becoming scar tissue • Genital Herpes
Ø Adenomyosis (endometriosis invading into • Ovarian stroma • Genital warts (HPV)
Ø Sex cord-stromal tumours = e.g.
muscle layer)
granulosa cell, Sertoli-leydig cell • Abscesses
tumours (check inhibin levels) Ø Teratomas (dermoid cysts)
• Angiomas
o struma ovarii (only produce T3/T4)
Ø Krukenberg tumours (signet ring • Fibromas
o Immature teratoma (++ recur and mets)
cells) –Ovarian Ca 2nd GI cancer • Lipomas
Ø Inflammation = Infection = TORCHsv è
Ø Struma Ovarii (mature thyroid tissue) [endometriotis + vaginitis 60-80%]
Ø Ovarian fibroma (stroma) / cysts Ø Ectopic Pregnancy
Ø Choriocarcinoma (B-HCG) Ø Tubo-ovarian cysts
Ø Embryonal cell tumour (AFP , B-HCG)
Ø Obesity Non-modifiable: HPV related (16,18) • Advanced age
Ø Smoking Ø Cancer (lynch, bowel, breast, p53 mutant) Ø Early Sexual activity, • Lichens sclerosis (5%)
Non-modifiable Ø P53 mutations Ø multiple partners, • Immunosuppressed
Ø BRCA1/2 Modifiable (XS estrogen exposure): Ø UPSI • HPV infection (esp.
Ø Lynch syndrome Ø Old age Ø Immunosuppression (HIV) post-menopausal)
Ø FHx of Breast, uterine, bowel cancer Ø Obesity + T2DM • Hx of Vulvar or
Ø Advanced age (60yo) Ø early menarche + Late meno Non HPV related cervical intraepithelial
RF neoplasia, cancer
Increased # of ovulations Ø Nulliparity, no BF Ø Mid-50s - Lower SE status,
Ø Early menarche , late menopause Ø PCOS, HRT/COCP, anovulation Ø FHx • Smoking
Ø Nulliparous or endometriosis Ø Tamoxifen Ø OCP for > 5 years
Protective factors: Protective factors: Ø Smoking
Ø breastfeeding Ø Smoking Ø High number of full-term pregnancies
Ø Multiparious / pregnancy Ø Multiparious / pregnancy (multiparious)
Ø COCP Ø Mirena coil or POP (progestogens)
Asymptomatic + non-specific Sx Asymptomatic (esp. for fibroids) Asymptomatic but: Asymptomatic,
• Abdo pain ® shoulder tip pain 1. PV bleed – IMB, HMB, post-coital • Irregular bleed or HMB • Itchy - candida, trichom
• Palpable mass / bloating / LoA (esp. post-menopausal – endometrial • Post-coital bleed • Palpable vulva lump
Sx cancer until proven otherwise) w/ ulcer + Pain +
• Meig’s syndrome = ascites, ovarian • Vaginal d/c (watery, mucous, pus,
cancer, pleural effusion 2. Pelvic Pain +/- smelly vag discharge smelly) bleeding
• Irregular periods 3. Abdo distension / pelvic pressure
• VAG spec + bimanual – adnexal Ø Bloods = anaemia, raised plt 1. VAG spec + swabs Clinical exam
mass Ø UA = visible or microscopic haematuria [ulceration, inflammation, bleeding, Ø Irregular mass usu in labia
• CA-125 - epithelial cell tumour Ø VAG spec + bimanual visible tumour] majora
marker Ø TVUS - (> 5mm thick endometrium = 2. Colposcopy + Biopsy (HPV + LBC) ® Ø Fungation lesion
• TVUS -abdo pelvis and ovarian abnormal post-menopause) cervical intraepithelial neoplasia Ø Ulceration
• Diagnosis ONLY via biopsy Ø Pipelle Aspiration biopsy +/- pap smear (grading dysplasia) ® CIN 1, 2 and 3 Tests
(HPV 16/18) [CIN 1 – mild dysplasia – returns normal]
• Swabs
[CIN 2 - mod dysplasia – pre-cancerous
FIGO (surgical) staging Ø CT ® PET® MRI ® Hysteroscopy/D&C • Colposcopy + Biopsy
if not treated]
Ø Stage 1 = confined to ovary FIGO (surgical) staging [more specific] [CIN 3 – sev dysplasia – highly likely anything suspicious
Ix Ø Stage 2 = spreads past ovary but Ø Based on nuclear atypia + gland cancer] (not ALL lesions –
within pelvis architecture 3. [FIGO (clinical) staging] • Sentinel node biopsy
Ø Stage 3 = spreads past pelvis but Stage 1 = confined to uterus • CT + CT-PET (staging)
Stage 1 = confined to cervix
within abdomen Stage 2 = invades cervix
Stage 3 = invades ovaries, LN, vagina and Stage 2 = invades uterus or upper 2/3rd FIGO staging Vulva
Ø Stage 4 = OUTSIDE abdomen (distant vag intraepithelial neoplasia (VIN)
fallopian tubes
mets) Stage 3 = invades pelvic wall or lower
Stage 4 = invades bladder, rectum or Ø High-grade squamous
beyond pelvis 1/3rd vag intraepithelial lesion =
Ø Poor prognosis: LN-vascular invasion, Stage 4 = invades bladder, rectum or HPV infection (35-50yo)
Tumour Grade 3, older age, stromal beyond pelvis Ø Differentiated VIN =
involved Lichen sclerosis (>50yo)
• OCP • Decrease E2 exposure (reduce HRT, • 2x HPV vaccines (free for 10-15 yo • HPV vaccination
COCP, usage, pregnancy, breastfeeding) boys/girls in school) – ideally before • Minimise sexual
• Healthy weight (Wt loss) + PA sexually active activity
1o Prev ® 2x free catch up doses before 20
• Smoking cessation
• Condoms + minimise sexual activity
• CA-125 (>35 IU/mL is significant) • Adequate progestin supp. • Cervical screening program (from age DDx: lichen sclerosis,
• Pelvis USS OR CT +/- Histology (progesterone) to slow progression 25 ® every 5 years) pigmented or ulcerated
2o Prev • Urgent cancer referral for post-meno Now can be self-collected lesions
• Paracentesis (ascitic tap) – test for
cancer cells bleeding (> 12 mths since last period) • Colposcopy
Gynaecology-oncology MDT Young pt • CIN and early stage 1A = LLETZ or cone Rx depends on stage:
• Laparoscopic Oophorectomy = • High dose PG therapy to preserve biopsy • Stage 1A = Radical wide
Removing ovaries does not always uterus • Stage 1b -2a = radical hysterectomy and local excision +/- groin
prevent cancer • If responsive ® advise fertility ® local LN chemo and RT LN excision
3o Prev • May need Pelvic + para-aortic hysterectomy after fertile completion • Stage 2b – 4A = chemo + RT • Stage 3 = Chemo + RT for
lymphadenectomy Older pt (for stage 1 and 2) • Stage 4B = MDT (Chemo, RT, surg, +ve node
• Debulk ® Adjuvant Chemo • TAH-BSO = Total hysterectomy + palliative)
BILATERAL salpingo-oopherectomy • Recurrent/mets cancer ®
(neoadj. Chemo-RT) Bevacizumab (Avastin) (anti-VEGF) Lifetime surveillance of
remaining vulvar tissue
5-year survival decreases w/ higher • 5 year survival decrease w/ higher • Most recurrences within 3 years
stage grades • Early stage (I and II) ®
• Early or advanced disease ® Monitor 3-
Ø 75% (stage 1) (stage 1 = 80%, stage III/IV = 20%) every 6/12
4/12
Ø 60% (stage 2) Complications • Advanced (III and Iva)
• Palliative if ureamia present
F/U Ø 23% (stage 3) • Surgery = SSI, lymphodema ®every 3/12
Complications w/ LLETZ and cone-biopsy
Ø 11% (stage 4) • RT = RT fibrosis, cystitis, proctitis Ø Infection, bleeding, pain
Ø Scar forms – cervical stenosis
Ø +++ risk of M/C and premature labour
, Gynaecological Surgery and Gynaecology Oncology
LN group Females Male
Lumbar/para-aortic LN Ovary, uterine tube, uterine fundus Testes Gonadal CANCERS
Internal iliac nodes Ø Bladder, uterus body, cervix, Prostate, CC, Bladder, Cervical
Ø upper and middle vagina bladder (exc. OR Prostate Cancer
fundus)
External iliac Ø lower body of uterus & cervix Deep inguinal STD or 2nd mets
Ø Upper vagina Fundus of bladder
Superficial inguinal Ø Superolateral aspect uterus Scrotum, penis (exc. Ø STD
(round ligament) glans) Ø Melanoma
Ø Vulva, skin of perineum, Perineum Ø Cellulitis
clitoris (exc. glans)
Deep inguinal Glans of clitoris Glans of penis
Sacral nodes Inferior vagina
SURGICAL Mx Surgeries in office:
Ø Biopsy (cervix, endometrium)
1) Surgical vs non-surgical alternatives Ø IUCD insertion (mirena)
a. (+ urgency of surgery? – ED, semi-urgent vs elective) Ø D+C
2) What surgery? (e.g. myomectomy/hysterectomy or cystectomy/oophorectomy) Ø Colposcopy
a. ?further pregnancy plans
Counselling Surgeries in OT:
3) Approach (explain need to convert) (robotic/laparoscopic ® open)
& Consent 4) Anesthesia (regional vs general) Ø Hystero-/cysto-/ oopherotectomy
5) Risks, complications (general vs specific) Ø Tubal ligation
6) Post-op recovery expectations Ø Ectopic pregnancy
a. Length of stay, catheter removal and next meal
General Ix General Advice Medication Advice
1. FBC ® Anaemia evaluation 1. Diet - previous day (last meal 4-6 hrs 1. Anti-HTN = optimise dosage before
2. ABO + Group + Hold prior to surgery) morning of surgery
3. EUC / CMP 2. Hydration = Fasting/fluid Status 2. Anti-coags = stop 3-5 days ® convert to
4. BSL; HbA1C 3. DVT prophylaxis clexane (bridging therapy)
Preoperative 5. Coags INR 4. Bowel Prep (laxatives vs enema) 3. Anti-DM = stop SGLT2i and OHA days
preparation 6. Viral Screen (HIV, HBsAG, HCV)- 5. Anaesthetics (drug reactions, previous before surgery
COVID 19 RT-PCR issues) 4. Thyroid = stop on morning of surgery
7. CXR / CT Chest COVID 19 screening 6. Abx (since Clean Contaminated surgeries 5. OCP = stop 4 weeks prior
Protocol as vagina is not sterile) 6. Epilepsy = individual Mx
8. ECG Single dose- (Cefazoline 1-2gm IV)
Repeat- >3 h; Blood Loss >1.5L
1) Anaesthesia (NBM, anaphylaxis)
Intra- 2) Fluid and temp management
operative 3) Surgery
N/V XS pain Inflammation Sepsis Haemorrhage
Ø Electrolyte Expect progressive Ø Catabolism Ø 4-5 days post-op Ø Blood within or OUTSIDE
imbalance improvement Ø water Ø Fever, chills, tachycardia, hypoTN peritoneal cavity
Ø Paralytic ileus Ø Bowel = ileus, injury, retention Ø confusion Ø Hypovol. Shock (hypoTN,
Ø RF = anxiety, constipation Ø Diffuse distension +/- rebound tender tachycardia)
obesity, Motion Ø GU = urinary retention, Ø Severe vaginal bleed
General sickness, previous injury Risk factors
Comp. post-op N/V Ø Sepsis Ø Extensive tissue injury and necrosis
Ø Haemorrhage Ø Prolonged operation time
Ø Anti-emetics = Step-wise analgesia Ø Hydration Ø IV empirical ABx Ø eFAST or MRI to confirm
ondansetron, (Panadol ® NSAID ® Ø nutrition Ø ED surgery Ø Hysterectomy (no
metoclopramide, codeine) pregnancy plans) OR
dex Ø Embolization of uterine
artery (uterus preserving)
Paralytic ileus Subacute intestinal Remnant CO2 in Bladder Reflex Bladder vs ureter leakage
obstruction bowel Retention (thermal injury)
(Dx: portal site hernia)
Ø Passing urine but no flatus DDx: paralytic ileus Ø Laparoscopic Ø Suprapubic tenderness Ø 10 days post-op following
Ø AXR = distended bowel Ø Day 3-5 post-op = Abdo surgery uses CO2 Ø Right shoulder pain hysterectomy
Specific and fluid-gas levels in pain persists despite NGT Ø XS CO2 left Ø Dull percussion Ø Spec exam = watery vaginal
Comp. small bowel Limits oral aspiration behind causes Ø Normal bowel sounds discharge (smells like urine)
intake Ø Emergency laparotomy – irritation to + tolerating oral fluid worse w/ cough
Ø IVF ® correct electrolytes drain fluid in peritoneal phrenic nerve = and solids Ø DDx: CT pyelogram w/
Ø NGT aspiration cavity and resect areas of shoulder tip pain Ø Post-op removal of methylene blue in bladder (is
Ø +/- enema (if refractory bowel necrosis Ø Normal BS and endometriosis is a bladder or ureter leak?)
ileus) Ø Dx: portal site hernia UO Ø Rx: stent
