Endometriosis, Benign and Malignant Tumours Flashcards

Basic Definitions and Anatomical Sites

• Tumour: Refers to an abnormal growth or swelling without inflammation, caused by an abnormal growth of tissue, whether benign or malignant.

• Benign: A non-cancerous growth.

• Malignant: A cancerous growth.

• Borderline: A mixture of benign and malignant characteristics.

• Sites of Tumours:

  • Vaginal.

  • Cervical.

  • Uterine.

  • Fallopian Tube.

  • Ovarian.

  • Broad Ligament.

  • Pouch of Douglas.

Endometriosis: Pathophysiology and Clinical Manifestations

• Overview: A common condition affecting $1-2\%$ of reproductive-aged women. The etiology remains unknown.

• Definition: The presence of endometrial tissue outside of the endometrial cavity.

• Common Locations:

  • Peritoneal cavity.

  • Pelvis.

  • Uterosacral ligament.

  • Umbilicus, abdominal scars, nasal passages, and the pleural cavity.

• Physiological Response: The ectopic tissue responds to cyclical hormonal changes, resulting in bleeding and a local inflammatory reaction.

  • This lead to a cycle of repeated bleeding and healing, which results in adhesions, pain, and infertility.

  • Endometrial tissue grows outside uterus, responds to estrogen, thickens and prepares like normal uterine lining during menstrual cycle. When menstruation occurs the tissue bleeds but cannot exit the body. Trapped blood irritates surrounding tissues which leads to inflammation, swelling and pain. Scar tissue and adhesions form, repeated cycles form fibrosis, adhesions. Adhesions + inflammations cause dysmenorrhea, dyspareunia, chronic pelvic pain and infertility.

• Clinical Manifestations:

  • Severe cyclical non-colicky pelvic pain occurring around the time of menstruation.

  • Associated heavy menstrual loss (menorrhagia).

  • Deep dyspareunia (pain during intercourse), particularly if endometriosis is present in the Pouch of Douglas.

  • Distant site symptoms: Local symptoms such as rectal bleeding.

• Diagnostic Findings:

  • Physical/Vaginal Examination: Findings include thickening of the uterosacral ligaments, tenderness in the Pouch of Douglas, a fixed retroverted uterus, and the presence of an adnexal mass.

  • Investigations:

    • Transvaginal Ultrasound.

    • MRI: Used to detect lesions larger than $5\,\text{mm}$.

    • Laparoscopy: Includes concurrent surgical diathermy and/or excision of lesions and staging.

Management of Endometriosis

• Medical Management:

  • NSAIDs such as ibuprofen: by blocking prostaglandins and reducing inflammation. Utilized to reduce pain and dysmenorrhea.

  • Combined Oral Contraceptives (COC): by preventing ovulation, thinning endometrial tissue, decrease menstrual flow and decrease pain. Used for $6\text{ months}$ and then indefinitely until pregnancy is intended.

  • Progestogens: Indicated for patients at risk with COC. Options include Medroxyprogesterone acetate (MPA) and the Levonorgestrel IU system. Causes enometrial atrophy, supresses growth of impants and reduces bleeding

  • GnRH (Gonadotrophin Releasing Hormone) such as leuprolide: Used to suppress the severity and symptoms of the condition. Supresses pituitary, decrease estrogen, causes temporary menopause, shrinks endometrial lesions.

• Surgical Management:

  • Conservative: Laparoscopic procedures including diathermy, laser vaporization, or excision. Removal of lesions and adhesions.

  • Definitive Surgery: Reserved for when childbearing is complete or if symptoms are severe and progressive. Includes Hysterectomy and bilateral salpingo-oophorectomy.

  • Considered when there is severe pain, infertility, large cysts, affecting organs.

Benign Tumours of the Uterus: Fibroids (Leiomyoma)

• Overview: These are common benign tumours derived from uterine smooth muscle. They affect $20\% - 40\%$ of women over $30\text{ years}$ of age.

• Growth Characteristics:

  • Rarely present before puberty.

  • Growth stops after menopause; no new fibroids develop during this time.

  • Dependency: They are dependent on Estrogen and Gonadotrophin-releasing hormone (GnRH).

  • A hypoestrogenic environment leads to a reduction in size, though this is reversible if treatment is ceased.

  • Fibroids vary in diameter and can be single or multiple.

• Pathology:

  • Pseudo-encapsulated: Solid tumours well demarcated from surrounding tissue.

  • Appearance: Smooth, solid, and pinkish-white. The surface is trabeculated, fleshy, and has a whorl-like appearance.

  • A single uterine cell undergoes mutation, the cell starts to multiply rapidly. Dependent on estrogen and progesterone, formation of well defined tumor, smooth muscle cells accumulate and fibrous connective tissue also develops, forms firm round mass inside uterus, increased blood supply, get their own vascular supply which leads to heavy menstrual bleeding. Pressure affects surrounding organs.

• Classifications by Location:

  • Submucous: Located in the endometrial cavity.

  • Intramural: Located within the myometrium (the most common type).

  • Subserous: Located at the outer border of the myometrium.

  • Pedunculated: Growth on a narrow pedicle.

  • Cervical: Located in the cervix.

Clinical Manifestations and Degeneration of Fibroids

• Symptoms:

  • Asymptomatic in many cases.

  • Symptomatic in $10\% - 40\%$ of cases.

  • Menstrual Disturbances: Menorrhagia (heavy bleeding), specifically from submucous fibroids distorting the cavity.

  • Pressure Symptoms: Urinary frequency, retention, unilateral ureteral obstruction, constipation, difficult defecation.

  • Vascular Compression: Deep Vein Thrombosis (DVT) and varicosities.

  • Pain: Is unusual unless there is torsion of a pedunculated fibroid or carneous (red) degeneration.

• Reproductive and Pregnancy Complications:

  • Ectopic pregnancy (if intramural at the cornual region).

  • Poor implantation (submucosal types).

  • Subfertility due to occlusion of the fallopian tubes.

  • Red degeneration (mostly during late pregnancy).

  • Preterm labour, malpresentation, mechanical obstruction, and uterine dystocia.

  • Postpartum haemorrhage (PPH) due to insufficient uterine contraction.

• Degenerative Changes:

  • Hyaline Degeneration: Most common; overgrowth of fibrous tissue leading to hyalinization and subsequent calcification.

  • Cystic Degeneration: Occasional necrosis leads to the formation of cystic cavities.

  • Necrosis: caused by impairment of blood supply or infection. Includes red/carneous degeneration (common in pregnancy).

  • Mucoid Degeneration: Occurs when arterial input is disrupted; hyalinization areas change to mucoid and then possibly cystic degeneration.

  • Infection: Most common with pedunculated submucosal fibroids that become necrotic.

  • Calcification: Common in post-menopausal women.

  • Sarcomatous Degeneration: Malignant change occurring in < 1\% of cases.

Diagnostic and Treatment Options for Fibroids

• Diagnosis:

  • Physical Exam: Abdominal (firm, irregular, nodular), Pelvic (uterine enlargement), Cervical examination.

  • Lab Tests: Hemoglobin (Hb) and Hematocrit (low due to bleeding), coagulation/bleeding profile.

  • Imaging/Biopsy: Endometrial biopsy, Ultrasonography, Hysteroscopy, Hysterosalpingography, and MRI.

• Medical Treatment:

  • Bimanual observation every $3 - 6\text{ months}$.

  • Reduction of blood loss using NSAIDs (prostaglandin inhibition) or low-dose oral contraceptives.

  • GnRH (leuprolide) : Suppresses estrogen; limited to $6\text{ months}$ duration to prevent osteoporosis.

• Surgical Criteria: Excessive bleeding, chronic pelvic pressure/pain, protrusion through the cervix, rapid growth (to explore for leiomyosarcoma), repetitive pregnancy loss, infertility, or impaired renal function/hydronephrosis.

• Surgical Types:

  • Myomectomy: Removal of single or multiple leiomyomas via abdominal, hysteroscopic, or laparoscopic routes. Removal of tumor from the uterine wall.

  • Hysterectomy: Indicated when childbearing is complete and uterine conservation is not desired. Removal of the uterus.

  • Uterine Artery Embolization: A catheter inserts gel foam microspheres or polyvinyl alcohol particles into the femoral artery to occlude blood supply; only the fibroids necrotize, not the uterus.

  • Newer Treatments: MRI-guided focused ultrasound (heat-induced cell death), laparoscopic myolysis, and cryomyolysis (using laser, coagulation current, or a probe at $-180\,\text{C}$).

Malignant Tumours of the Reproductive System

Vaginal Cancer:

• Frequently missed in diagnosis.

• Signs: Discharge, ulcers, pruritus, abnormal vaginal bleeding, postmenopausal bleeding, pelvic pain, dyspareunia

• Staging:

  • Stage 1: Cancer cells in the vaginal wall.

  • Stage 2: Spread to tissue next to the vagina.

  • Stage 3: Spread to nearby lymph nodes or elsewhere in the pelvis.

  • Stage 4: Spread beyond the pelvis to other body parts.

• Treatment: External radiotherapy to shrink, then local radiation; excision, radical hysterectomy, or upper vaginectomy.

Cervical Cancer:

• Risk Factors: Early first intercourse, marriage/conception at a young age, multiple partners, smoking, high-risk partners, immunosuppression, HPV infections (HSV-2 increases HPV risk).

• Signs: Postcoital bleeding and discharge, unusual bleeding between periods, post menopause, heavy/ long periods, foul smelling discharge.

• Staging:

  • Stage I: Small tumour limited to the cervix.

  • Stage II: Grown beyond cervix; potentially to lymph nodes.

  • Stage III: Spread to lower vagina or pelvis.

  • Stage IV: Spread beyond pelvis to other organs.

• Treatment: Pre-cancerous (Conization, LEEP, cryotherapy, cauterization, laser). Later stages (Hysterectomy, adjuvant radiotherapy, chemotherapy, biological therapy like Interferon).

Endometrial Cancer:

• Malignancy of the uterus

• Risk Factors: Obesity, nulliparity, DM, late menopause, unopposed estrogen therapy, HRT, family history of colorectal or ovarian cancer.

• Signs: Irregular vaginal bleeding or postmenopausal bleeding.

• Treatment: TABHBSO.

• FIGO Staging:

  • Stage IA: Invasion $\le 50\%$ of myometrium.

  • Stage IB: Invasion > 50\% of myometrium.

  • Stage II: Invasion of cervical stroma.

  • Stage IIIA: Invasion of adnexa and/or uterine serosa.

  • Stage IIIB: Invasion of parametrium and/or vagina.

  • Stage IIIC: Invasion of pelvic (IIIC1) or para-aortic (IIIC2) lymph nodes.

  • Stage IVA: Invades mucosa of rectum or bladder.

  • Stage IVB: Distant organs or inguinal spread.

Uterine Cancer:

• Risk Factors: Few children, estrogen use, anovulatory cycles, obesity, diabetes, hypertension.

• Diagnosed early; usually affects menstruation.

• S&S: Inter-menstrual bleeding.

• Staging:

  • Stage 1: Only in the uterus.

  • Stage 2: Spread to the cervix.

  • Stage 3: Outside uterus to nodes, ovaries, tubes, or vagina; not to bladder/rectum.

  • Stage 4: Spread to bladder, rectum, or outside pelvis (lungs/abdomen).

• Treatment: TABHBSO and pelvic node dissection if cervical involvement is present.

Ovarian Cancer:

• Risk Factors: Low parity, nulliparity, IUD use, endometriosis, smoking, obesity, heredity.

• Characteristics: Diagnosed late (except hormone-secreting types); poor survival rate; 2nd most common.

• S&S: None in early phase; abdominal pain, distension; menstrual disturbances only if hormone-secreting.

• Staging:

  • Stage 1: Found in one or both ovaries.

  • Stage 2: Spread to pelvis (tubes or uterus).

  • Stage 3: Spread to lymph nodes, diaphragm, intestines, or liver.

  • Stage 4: Beyond abdomen (lungs or spleen).

• Treatment: Staging followed by surgery (TAHBSO, Omentectomy) and adjuvant chemotherapy.

Diagnostic Assessment and Biochemical Markers

• Baseline Investigations:

  • Ultrasound.

  • Cervix: Pap smear, Punch Biopsy, Colposcopy.

  • Uterine: Pipelle biopsy, Hysteroscope.

  • Ovarian: Tumour markers, CT Scan, Laparotomy.

• Tumour Markers (Note: markers alone are indexed as inadequate for definitive diagnosis):

  • Human chorionic gonadotropin (hCG): Associated with gestational trophoblastic disease (GTD).

  • Alpha fetoprotein (AFP): Associated with ovarian or testicular cancer.

  • Carcinoembryonic antigen (CEA): Associated with breast, cervical, and ovarian cancer.

  • CA 125: Especially indicative of ovarian cancer; also increased in uterine, cervical, and breast cancer.

  • CA 15-3: Increased in advanced breast cancer; may increase in ovarian cancer.

Nursing Management

• Pre-operative Care Goals:

  1. Active participation in treatment decisions.

  2. Achieving satisfactory pain and symptom management.

  3. Recognizing and reporting problems promptly.

  4. Maintaining preferred lifestyle as long as possible.

  5. Continuing practice of cancer detection strategies.

• Post-operative Problems:

  • Acute pain.

  • Ineffective breathing pattern.

  • Nausea.

  • Risk for imbalanced fluid volume.

  • Risk for infection.

  • Haemorrhage.

  • Urinary retention.