Gynaecological malignancy

Presentations

• Can be very non-specific with abdominal pain/bloating, nausea and vomiting, PV bleeding, fatigue, obstructive uropathy, failure to thrive and paraneoplastic syndromes
• Complications of surgery can include post-operative bleeding, bowel/urologic/vascular injury, VTE
• Chemotherapy complications may arise
• Radiation injury

Ovarian cancer

• 90% are epithelial ovarian tumors
• Germ cell tumors, stromal, mixed cell type tumors all rare
• >70% of cancer are detected at late stage
• Recognition of early symptoms and early diagnosis has huge effect on survival
• Consider in any woman with:
  • Bloating, increased abdominal size, urinary urgency/frequency, early satiety, abdo/pelvic pain
  • A woman who presents to ED with unexplained ascites has gynaecological malignancy until proven otherwise

• 2nd most common gynaecological malignancy but highest mortality
• Risk factors
  • Low parity
  • Infertility
  • Early menarche, late menopause
  • HRT
  • Smoking
  • Obesity
  • FHx
• Protective factors
  • Multiparity
  • Tubal ligation
  • Hysterectomy
  • Breast feeding
• US is most useful for adnexal mass
• Aspiration of ascitic fluid is not recommended due to risk of seeding
• All women with masses suspicious for ovarian malignancy need consult or referral to gynae oncology

Uterine cancer

• Most common gynaecological cancer
• Mostly caught early with good prognosis
• Adenocarcinoma of endometrium is most common
• Sarcomas have worse prognosis
• Risk factors
  • Oestrogen-only hormone replacement
  • Chronic anovulation
  • Tamoxifen use
  • Obesity
  • Diabetes
  • HTN
  • Nulliparity
  • Early menarche/late menopause
  • Hereditary non-polyposis colorectal cancer
  • Family history

• Abnormal uterine bleeding is the most common presentation (90% of cases)
• Postmenopausal woman with bleeding has 5-20% chance of endometrial cancer
• All women with abnormal bleeding need follow-up
• Endometrial biopsy is initial test of choice OR hysteroscopy/D&C
• Post-menopausal women
  • Post-menopausal women with endometrial stripe <4-5mm on TVUSS have low risk of endometrial malignancy
• Pre-menopausal
  • USS less useful

Cervical cancer

• Risk factors
  • Multiple partners
  • Exposure to HPV
  • Smoking
  • High parity
  • Immunosuppression
  • Low SES
  • Prolonged COCP use
  • STI
  • Vulval or vaginal squamous dysplasia
• Squamous cell carcinoma is the most common (80%)
• Adenocarcinoma is less common
• Symptoms include abnormal vaginal bleeding, postcoital bleeding, vaginal discharge and leg swelling

Vaginal cancer

• Uncommon (0.3% of all female genital tract cancer)
• Metastatic disease to the vagina is not uncommon from endometrium, cervix, vulva, ovary, breast, rectum and kidney
• Embryological rhabdomyosarcomas seen in girls <5yo as grapelike mass from vagina
• Risk factors
  • Multiple sexual partners
  • Early age at first intercourse
  • DES exposure in utero
  • Chronic irritation
  • Immunosuppression 
  • Smoking

• Present with vaginal bleeding, post-coital bleeding, water/bloodtinged discharge, urinary symptoms or GI complaints
• Many patients are asymptomatic

Vulvar cancer

• Mostly vulvar plaque, ulcer or mass
• Pruritis, dysuria, bleeding, discharge, inguinal lymphadenopathy • Mostly squamous cell

Gestational trophoblastic disease

• Encompasses
• Hydatidiform mole (partial or complete)Persistent/invasive gestational trophoblastic neoplasia
• Choriocarcinoma
• Placental site trophoblastic tumors
• May be malignant or non-malignant

Hydatidiform mole

• Benign, localised form from aberrant fertilisation event
• May be complete or partial (contains fetal material)
• Present with vaginal bleeding, missed period, lower abdo discomfort and positive hCG
• Complete moles have markedly elevated hCG and large uterus for dates
• Complications
• Theca lutein cysts
• Hyperemesis gravidarum
• Early pre-eclampsia
• Hyperthyroidism

Malignant gestational trophoblastic disease

• Can develop after molar or non-molar pregnancy
• Persistent/invasive gestational trophoblastic disease occurs after a molar pregnancy and found in routine follow-up
• Occurs in 15% of cases of hydatidiform moles
• May have ongoing vaginal bleeding
• Can progress to malignancy and death if untreated
• Common sites for metastases are lungs and vagina
• Highly responsive to chemo
• Malignant gestational trophoblastic disease
• If occurs after a normal pregnancy, almost always = choriocarcinoma
• 1/16 000 normal pregnancies and 1/60 complete hydatidiform moles
• Usually irregular vaginal bleeding
• Cough, chest pain, haemoptysis, GI/urologic/intracerebral bleeding suggest metastasis

Radiation complications

• Acute
  • GI: Nausea, vomiting, diarrhoea
  • GU: nephritis
  • Pulmonary: Pneumonitis
  • Haematologic: Myelosuppression that resolves with cessation of treatment
• Chronic
  • GI – Radiation enteritis is most common after 6 or more months with nausea, diarrhoea, weight loss, bowel perforation/obstruction
  • GU – Bladder fibrosis fistulas, incontinence, haemorrhagic cystitis
  • Pulmonary – Chronic pulmonary fibrosis
• Always consider secondary malignancy

Last Updated on September 29, 2021 by Andrew Crofton