Cancer of the Female Genital Tract

1. CANCER of the FEMALE
GENITAL TRACT

2. Anatomy

3. Ultrasound
• Ultrasound of the pelvis can be carried out two
ways: either by scanning through the abdominal
wall or transvaginally with a specialized
ultrasound probe inserted directly into the
vagina. With the transvaginal route the pelvic
organs are nearer the ultrasound probe so image
quality is much improved. Moreover it is not
necessary for the patient to have a full bladder.
• When abdominal scanning is undertaken it is
essential for the patient to have a full bladder to
act as a 'window' through which the pelvic
structures can be seen. Scans are usually made
in the longitudinal and transverse planes

4. On a midline longitudinal scan
the vagina can be recognized
as a tubular structure, with a
central linear echo arising from
the opposing vaginal surfaces.
The uterus lies immediately
behind the bladder, and the
body of the uterus can be seen
to be in continuity with the
cervix and vagina. The
myometrium shows low level
echoes, whereas the
endometrial cavity gives a high
amplitude linear echo. The
precise appearances of the
uterus depend on the age and
parity of the patient and also
on the lie of the uterus. The
normal fallopian tubes are too
small to be visualized
sonographically.
Normal uterus and vagina. Longitudinal section. The central echo of
uterus (U) corresponds to the endometrial cavity; the uterus itself has
a homogeneous echo texture; V, vagina; B, bladder

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6. MRIThe pelvic anatomy is very
well demonstrated because
of the excellent soft tissue
contrast afforded by MRI.
Images are usually taken in
the transverse and sagittal
planes but may be
supplemented by coronal
images, particularly for
examining the ovaries.
Images in the transverse
plane give appearances
similar to CT. The sagittal
plane shows the vagina and
cervix in continuity with the
body of the uterus which can
be readily recognized on a
T2-weighted scan because
the endometrium has a high
signal. The ovaries and
broad ligaments can also be
identified
Normal uterus, sagittal T2-weighted MRI
scan. There is a high signal from the
endometrium (arrows). B, bladder; V,
vagina

7. Normal Anatomy

8. Pelvic masses
CT, ultrasound and MRI will be abnormal in
virtually any patient in whom a mass can be felt
on physical examination. With ultrasound, it is
possible to tell whether the mass is cystic or
solid. Unfortunately, there is no clear association
of cystic with benign disease, or of solid
characteristics with malignant disease. A
limitation of imaging is that it is sometimes not
possible to determine from which organ the
mass arises; an ovarian mass which lies in
contact with the uterus may appear similar to a
mass arising within the uterus and vice versa.

9. Cancer of the Female genital tract
• Cancer of the Cervix
• Cancer of the VULVA
• Cancer of the VAGINA
• Cancer of the UTERUS
• Cancer of the FALLOPIAN TUBES
• Cancer of the OVARY

10. Colposcopy
а в
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11. Conization of the cervix

12. Werthaim operation

13. Endometrial Hyperplasia and Polyps
Endometrial hyperplasia occurs under conditions that
produce a constant stimulus of estrogen, which prevents
the progestational or secretory phase of the menstrual cycle
to take place. The gross appearance of endometrial
hyperplasia is a thickened and edematous mucosa.
Estrogenic stimulation produces an overgrowth of glands,
stroma, and microvessels. In long-standing cases, the
glands show irregular cystic dilatation with a lining of low
cuboidal epithelium, which leads to the "Swiss cheese"
pattern. The exuberant growth may be difficult to distinguish
from well-differentiated adenocarcinoma. Atypical
hyperplasia is defined as complex glandular crowding and
cytologic atypia. Endometrial hyperplasia may give rise to
single or multiple endometrial polyps. The diagnosis of
endometrial hyperplasia usually is made from pathologic
examination of endometrial curettings from a woman with
abnormal uterine bleeding. Occasionally, examination
reveals an infectious process, including tuberculosis.

14. Endometrial Hyperplasia and Polyps

15. Leiomyoma (Fibroid)Uterine myomata, the most
common tumors in the female
pelvis, have an incidence of
approximately 4% to 11% in adult
women. Commonly called
fibroids, these tumors are
composed of benign proliferations
of uterine smooth muscle cells with
a typical whorled pattern on
histologic examination and are,
therefore, leiomyomata. The
tumors, which vary in size,
location, and position (intramural,
subserous, or submucosal), occur
most frequently in the fifth decade
of life and are more common in
black women. Leiomyomata also
are found in the cervix and broad
ligament (intraligamentary
myoma). The most common
symptom, profuse or prolonged
uterine bleeding, occurs in
approximately 50% of cases. The
uterine bleeding and the growth of
the leiomyomata may have a
common cause in excess estrogen
stimulation, so that excision of the
leiomyoma may or may not cure
the uterine bleeding.

16. Leiomyoma: Secondary Changes
The evaluation of infertility should take uterine
leiomyomata into account, particularly if there are
submucous myomas. Indications for surgery,
either removal of the leiomyoma (leiomyectomy) or
hysterectomy, include recurrent uterine bleeding,
pelvic pressure, pelvic pain, and rapid growth
suggesting sarcomatous transformation.
Pedunculated submucous leiomyomas are prone
to torsion of the pedicle, cutting off the blood
supply and causing sloughing and necrosis.
Occasionally, a myoma on a long pedicle can
prolapse through the cervix and cause complete
inversion of the uterus. Large leiomyomas
sometimes exceed their blood supply, leading to
cystic degeneration and calcification. Leiomyomas
may not affect a successful pregnancy but, if
located in the cervix, may obstruct the passage of
the fetal head through the birth canal. During
pregnancy, the vascular supply to an interstitial
leiomyoma may be compromised, leading to
necrosis and hemorrhage, so-called red
degeneration, which may become a serious
complication.

17. Uterine tumours Fibroid
• Leiomyomas (fibroids) are common in women over 30
years of age. They are often asymptomatic but may
cause menorrhagia or present as a palpable mass. When
sufficiently large, a fibroid can be seen on a plain film as a
mass in the pelvis and may show multiple irregular but
well-defined calcifications. Ultrasound and CT both show
a spherical or lobular uterine mass. At ultrasound, the
mass may be either sonolucent or echogenic, whereas at
CT, fibroids are usually the same density as the adjacent
myometrium. Magnetic resonance imaging can readily
identify fibroids as they have a different signal
characteristic from the normal uterus. Degenerating and
non-degenerating fibroids can also be distinguished

18. Uterine tumour, (a) CT scan
showing enlarged uterus
(arrows) which was due to
fibroids. It is not possible to
distinguish this appearance
from adenocarcinoma
confined to the uterus. B,
bladder; R, rectum.
(b) Transverse ultrasound
scan showing a large fibroid
in the uterus. Its extent is
indicated by the arrows. B,
bladder.

19. Carcinoma of the cervix and uterus
Neither CT, MRI nor ultrasound play much part in the initial
diagnosis of these conditions, which is normally made by
physical examination and biopsy or cytology.
Carcinoma of the cervix may be staged by CT or preferably by
MRI because the stage determines whether the patient is
managed with surgery, radiotherapy or a combination of
treatments. In essence the observations to be made are
whether the tumour is confined to the cervix or whether it
extends into the parametrium, rectum or pelvic side walls.
Computed tomography and MRI also enable detection of
enlarged lymph nodes and dilatation of the ureters in cases
where the tumour has caused ureteric obstruction.
Endometrial carcinoma is usually treated by surgical removal of
the uterus, ovaries and pelvic lymph nodes. Therefore the use
of imaging to stage the tumour at presentation is limited.
Magnetic resonance imaging can predict the depth of
myometrial invasion by tumour, and both CT and MRI can
demonstrate lymph node involvement.

20. Carcinoma of cervix, (a) CT
scan showing a large
tumour of the cervix (T)
invading the parametrium
(arrows) and extending into
the rectum (R) posteriorly,
(b) Sagittal MRI scan
showing a tumour confined
to the cervix (arrows). B,
bladder; R, rectum.

21. Sarcoma
Sarcoma of the uterus accounts for
approximately 3% to 4% of malignancies
of the female genital tract. Uterine
sarcomas, whether primary or secondary
to a preexisting fibroid (rate of
sarcomatous degeneration is
approximately 1%), grow rapidly and
have a grave prognosis. Sarcomas
arising in a fibroid appear grossly as soft,
meaty areas, often with foci of central
necrosis or hemorrhage due to an
inadequate blood supply. The size and
extent of tumor are more important for
prognosis than is location or histologic
characteristics. Histologically, the
sarcoma cells may be spindle-shaped or
round and show nuclear pleomorphism
and mitoses. Occasionally, uterine
polyps show sarcomatous degeneration.
Sarcoma botryoides ("grape" sarcoma)
is a rare and almost invariably fatal
condition that occurs only in young
children.

22. Ovarian tumours
The commonest ovarian tumours are the cystadenoma and the
cystadenocarcinoma. Ovarian tumours can be cystic, solid or a mixture
of the two. Those that are cystic may be multilocular. Evidence of
invasion of neighbouring structures or metastasis indicates a malignant
tumour. Although ultrasound, CT and MRI are reliable at showing the
size, consistency and location of an ovarian mass, it is often not possible
to say whether the mass is benign or malignant unless there is evidence
of local invasion or distant spread. A malignant nature is suggested if the
septa are thick and there are coexisting solid nodules within or adjacent
to the cyst. With disseminated malignancy, ascites may be visible, but
frequently omental and peritoneal metastases are difficult to detect due
to their small size. Computed tomography, MRI and ultrasound may
show hydronephrosis from ureteric obstruction by the tumour and may
also demonstrate enlarged lymph nodes and liver metastases.
Treatment of ovarian carcinoma is usually by hysterectomy,
oophorectomy and surgical removal of all macroscopic tumour and
staging is carried out during surgery. The main role of imaging is for
follow-up to assess response to treatment and disease recurrence.

23. Ovarian carcinoma, (a) Longitudinal ultrasound scan showing a very large multilocular
cystic tumour containing septa (S) and solid nodules (N). The lesion was a
cystadenocarcinoma. (b) CT scan showing large partly cystic, partly solid ovarian
carcinoma (arrows). The tumour, which contains irregular areas of calcification, has
invaded the right side of the bladder (B). The rectum is indicated by a curved arrow, (c)
MRI scan showing a partly solid (arrows) and partly cystic tumour. The cystic component
shows as a high signal on this T2-weighted scan. B, bladder.

24. Ovarian cyst, (a) Longitudinal ultrasound scan to right of midline showing a
5 cm cyst (C) in right ovary with no internal echoes. B, bladder, (b) CT scan
of same patient showing the cyst in the right ovary (arrows). Note the
uniform water density centre of the cyst, (c) Coronal T2-weighted MRI scan
showing a left sided ovarian cyst (arrows) in a patient with an enlarged
uterus due to adenomyosis. B, bladder; U, uterus