FIGO Staging cervical cancer:
1: confined to cervix:
2: Beyond uterus, no extended to lower third vagina or pelvic side wall.
- 2A: involvement of upper 2/3 vagina without para metrial involvement. (SURGERY)
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- 2B: invovlement upper 2/3 vagina with parametrial involvement, but not up to pelvic side wall.
(CHEMO / RAD ONC PRIOR TO SURGERY)
3: Involved lower third vagina and / or extends to pelvic wall and / or causes hydronephrosis, and / or pelvic / para aortic nodes.
- 3A: involves lower third vagina, no extension to pelvic side wall.
- 3B: extension to pelvic side wall and/or hydroneprhosis.
- 3C: involvement pelvic and / or para aortic nodes regardless of tumour size.
4: carcinoma extended beyond true pelvis, or involved bladder, rectum.
TNM Staging Cervical Cancer:
T1: confined to uterus
T2: invades beyond uterus but not to pelvic side wall or lower third vagina.
- T2A: tumour without para metrial invasion
- T2B: tumour with parametrial invasion.
T3: tumour extends to pelvic side wall and or lower third vagina and or hydronephrosis.
- T3A: lower third vagina, no pelvic wall extension
- T3B: extends to pelvic side wall and or causes hydronephrosis
T4: invades bladder or rectum, or extends beyond true pelvis.
N1: regional nodes
M1: distant mets, including peritoneal spread, supraclavicular / mediastinal / para aortic nodes)
Ovarian lesion with low T2 signal intensity
T2 signal isointense relative to pelvic muscles:
- Endometrioma
- FIbroma
- Cystadenofibroma
- Struma ovarii
T2 signal hypointense to pelvic muscles:
- Haemorrhagic cyst
- Krukenburg tumour
- Mucinous cystic neoplasm
Solid:
- fibroma / fibrothecoma
- Krukenburg tumour
- Adenofibroma
Cystic:
- Endometrioma
- Haemorrhagic cyst
- Mucinous cystic neoplasm
Cystic and solid:
- cystadenofibroma
- Struma Ovarii
Solid Adnexal Mass:
Leiomyoma Ectopic pregnancy Mature teratoma (Dermoid) Adnexal torsion Ovarian Mets Ovarian Fibroma Ovarian primary carcinoma - usually mixed cystic solid. Ovarian lymphoma.
Extra ovarian Adnexal Mass:
Tubal:
- tubal ectopic
- Hydrosalpinx
- Pyosalpinx
- Haematosalpinx
Non tubal Gynaecological:
- Endometriosis
- Subserosal leiomyoma
- Paraovarian / paratubal cysts
Other:
- Peritoneal inclusion cyst
- Lymphocele
- Bowel loop
- Appendicitis
Enlarged Uterus DDX:
Leiomyoma:
- Focal well defined mass
- Can be multiple
- Lobulated uterine contour.
Adenomyosis:
- Asymmetric myometrial thickening
- Cystic spaces in endometrium
- Alternating bands of increased through transmission and shadowing - Veneitan blinds.
Cervical stenosis:
- FLuid in endometrial cavity
- No lesion, thin endometrium.
Endometrial cancer:
- bleeding
- Diffuse uterine enlargement
- Ill defined endometrium.
Uterine leiomyosarcoma.
Abnormal Uterine Bleeding DDX:
PALM-COEIN P: polyp A: adenomyosis / Atrophy L: leiomyoma M: malignancy and hyperplasia
C: coagulopathy O: ovulatory dysfunction E: endometrial I: iatrogenic N: not yet classified
Endometrial polyp
Endometrial atrophy:
- post menopausal, <4mm thick
Leiomyoma:
- shadowing
Pregnancy related
Adenomyosis:
- Enlargement, shadowing and increased transmission.
Hyperplasia:
- diffuse or focal thickening
- Pre menopausal > 15mm secretory phase. <6mm allows exclusion.
- Post menopausal > 5 / 8mm abnormal (unless on tamoxifen).
Endometrial cancer:
- poor definition endometrium
- irregular thickened heterogenous.
Anechoic Cystic Adnexal Mass DDX:
Physiologic cyst
Para ovarian / para tubal cyst
Serous cyst adenoma:
- usually unilocular, thin septations.
Hydrosalpinx
Peritoneal inclusion cyst
Mature cystic teratoma:
- Ca++ in wall or echogenic nodule.
Serous cystadenocarcinoma.
Complex Cystic Adnexal Mass:
Haemorrhagic Cyst:
- strands of internal echogenicity.
Dermoid / Mature cystic teratoma:
- Echogenic mass, Dot Dash appearance, echogenic nodule with shadowing.
Endometrioma:
- Chocolate cyst, diffuse homogenous low level echoes.
Serous cyst adenoma
Mucinous cystadenoma
Cystadenocarcinoma:
- Thick irregular wall with internal septations.
- Solid elements, flow suggests malignancy
- Ascites, mental thickening, liver / spleen mets.
Granuloma Cell Tumour:
- Estrogen secretion.
- Post menopausal bleeding, precocious puberty.
Endometroid ovarian carcinoma:
- Bilateral 30%, endometrial lesion 15-20%.
Hydrosalpinx
Tubo ovarian complex
Peritoneal inclusion cyst
Adnexal torsion
Theca Lutein cyst:
- Increased BHCG, fertility drugs, trophoblastic disease.
Endometrial cancer staging:
1: tumour confined to uterus
- A: less 50% myometrial invasion
- B > 50% myometrial invasion.
2: spread to cervical stroma but tumour still contained within uterus.
3A: spread to adnexa / uterine serosa
3B: spread to vagina / parametrium
3C: spread to lymph nodes.
4A: spread to bladder / bowel
4B: distal mets / inguinal nodes.
Features of malignant ovarian neoplasm on ultrasonography include:
solid tumour mass >10 cm with loculation mural nodule thick and irregular walled cyst cyst with thick septae (>3 mm) poorly defined margins adherent bowel loops ascites resistive index (RI) <0.4-0.8 pulsatility index (PI) <1.0
Predominantly cystic ovarian neoplasm:
serous cystadenoma mucinous cystadenoma mature cystic teratoma serous cystadenocarcinoma mucinous cystadenocarcinoma
Predominantly solid ovarian neoplasm:
Brenner tumour thecoma fibroma endometroid granulosa cell tumours dysgerminoma endodermal sinus tumour (yolk sac tumour) metastatic
Ovarian tumour markers:
Serological tests:
- CA-125 levels: elevated in most ovarian malignancies (~80% in general); some mucinous and germ cell tumours may not secrete this marker
- AFP levels: elevated particularly with immature ovarian teratomas (~50% of cases) and ovarian yolk sac tumours
- β HCG: in a small number of dysgerminomas
- human epididymis protein 4 (HE4): elevated in malignant ovarian diseases, being helpful to complement the Ca-125 in premenopausal women
Simple ovarian cyst management plan: Premenopausal
< 3cm, dont need to mention / no follow up
3 -5cm: describe as benign, no follow up
5 - 7cm: describe as benign but annual follow up
>7cm: MRI or surgical evaluation
Simple ovarian cyst management plan: Post-menopausal
< 1cm: benign and not reported / no follow up
1 - 7cm: likely benign, describe, annual follow up
> 7cm: MRI or surgical evaluation
Theca lutein cysts:
Multi fetal pregnancy
Gestational trophoblastic disease
Ovarian hyperstimulation syndrome
Ovarian mass and endometrial thickening:
Endometrioid uterine cancer with endometriod ovarian metastases.
Granulosa theca cell tumour with endometrial hyperplasia
