6- Gynaecological oncology Flashcards

Question

ovarian cancer can originate from a number of cell lines

Answer 1

Epithelial - serous - mucinous - endometriod - clear - cell Germ cell - teratoma - yolk sac - choriocarcinoma - dysgerminoma Stroma/sex cord - granulosa cell - sertoli-leydig cell Miscellaenous and metastatic - primary lymphoma - metastases - krukenberg tumour

Answer 2

Epithelial o Serous o Mucinous- Germ cells o Teratoma (dermoid)

Answer 3

Krugenberg tumour- metastasis in ovary usually from GI cancer- signet ring cells

Answer 4

* Surgery + chemotherapy * Staging laparotomy, TAH PLUS BSO and debulking * Platinum (Cisplatin, carboplatin) and Taxane (paclitaxel) * In women of reproductive age, where the tumour is confined to one ovary, oophorectomy only may be considered

Answer 5

often occur in young women and can be extremely chemo-sensitive (e.g. germ cell). Often treated with combination of ‘conservative’ surgery and chemo

Answer 6

palliative chemo

Answer 7

CA125 is a tumour marker for epithelial cell ovarian cancer. It is not very specific, and there are many non-malignant causes of a raised CA125: * Endometriosis * Fibroids * Adenomyosis * Pelvic infection * Liver disease * Pregnancy

Answer 8

- 3rd most common gynae in England - More common in developing - Bimodal age distribution - Low socioecomic groups

Answer 9

- 2/3 squamous cell carcinoma -15% adenocarcinoma

Answer 10

- HPV - Young age at first intercourse - Multiple partners - Exposure - Smoking - COCP - Immunosuppression/ HIV - Non compliance with cervical screening

Answer 11

- HPV vaccine - Cervical screening compliance

Answer 12

- Post coital bleeding - PMH - IMB - Dyspareunia - Blood stained vaginal discharge - In advanced o Fistulae o Renal failure o Nervous foot pain o Lower limb oedema

Answer 13

- Most women will be infected at some time - HPV infection is common in late teens and early twenties - Infection lasts on average 8 months - Prevalence 5% by age 50 o Immunological clearance of virus o Reduced opportunities for re-infection - HPV is an accepted necessary (but not sufficient) cause of cervical cancer - Cervical cancer could be viewed as a rare complication of a common infection - A vaccine can reasonably be expected to prevent most cases of cervical carcinoma - Biggest implication is in developing nations

Answer 14

HPV (esp subtypes 16 & 18): produce proteins (E6&7) which suppress the products of ‘p53’ tumour suppressor gene in keratinocytes

Answer 15

* Asymptomatic * Can be cleared or persist or cause CIN

Answer 16

cervical intraepithelial neoplasia

Answer 17

is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at **colposcopy** (not with cervical screening). The grades are: * CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment * CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated * CIN III: severe dysplasia, very likely to progress to cancer if untreated

Answer 18

CIN III is sometimes called cervical carcinoma in situ. * Asymptomatic and pre-malignany * Can regress, persist or progress to cancer * Best Estimates * 60% CIN1 regress spontaneously * 30% of CIN3 progress to invasion over 5-10 years

Answer 19

- see and treat concept - excisional: LLETZ or cold knife cone - destructive: cryocautery, diaethermy

Answer 20

large loop excision of the transformation zone (LLETZ). LLETZ is often done at the same time as colposcopy.

Answer 21

screening is very importnant due to less advanced cancers have a much better prognosis

Answer 22

1. Microinvasive carcinoma: can be more conservative. If fertility is an issue, then *cone biopsy* can be used. Once family is complete, hysterectomy is appropriate. 2. Clinical Lesions (1b - 2a): **Wertheim’s radical hysterectomy** or chemoradiotherapy (survival same) 3. Clinical lesions beyond stage 2a: Chemoradiotherapy 4. Postoperative radiotherapy: with lymph node involvement 5. Recurrent disease: Radiotherapy, chemotherapy, monoclonal antibody (bevacizumab) exenteration (removal of most pelvic organs), palliative care

Answer 23

- Starts at 25 years old - Every 3 years from 25-50 - 5 years from 50-65 - After 65 selected patients only

Answer 24

* Speculum examination * Cells collected from cervix (transformation zone) and exfoliated morphology examined * Samples initially tested for high risk HPB and then Liquid based cytology- UK

Answer 25

* Normal * Inadequate * Borderline- HPV test * Mild Dyskaryosis- HPV test * Moderate Dyskaryosis- coloscopy * Severe Dyskaryosis- coloscopy * Possible Invasion

Answer 26

* Inadequate sample – repeat the smear after at least three months * HPV negative – continue routine screening * HPV positive with normal cytology – repeat the HPV test after 12 months * HPV positive with abnormal cytology – refer for colposcopy

Answer 27

It involves inserting a speculum and using equipment (a colposcope) to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail. During colposcopy, stains such as **acetic acid and iodine solution** can be used to differentiate abnormal areas.

Answer 28

- Causes abnormal cells to appear white. This appearance is described as acetowhite. This occurs in cells with an increased nuclear to cytoplasmic ratio (more nuclear material), such as cervical intraepithelial neoplasia and cervical cancer cells.

Answer 29

- Involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain.

Answer 30

**Large loop excision of transformational zoen (LLETZ)** - Under local anaesthetic during colposcopy - Loop of wire with electrical current (diathermy) used tor emove abnormal tissue - Risk of infection and preterm labour **Punch biopsy** **Cone biopsy for CIN** - For high risk CIN or for low grade cervical cancer - under general - Surgeon removes a cone-shaped piece of the cervix using a scalpel (pain, bleeding, infection, stenosis of cervix)

Answer 31

Vaccination * Gardasil: 6,11,16,18 * Cervarix:16 & 18 * NHS Programme * 3 injections over 6 months * Ideally prior to SI * 5 years protection * Still need smears (HPV 31, 45 & others)

Answer 32

* Gardasil: 6,11,16,18 * Cervarix:16 & 18 * NHS Programme * 3 injections over 6 months * Ideally prior to SI * 5 years protection * Still need smears (HPV 31, 45 & others)

Answer 33

- Very rare - Elderly patients - Usually SCC - Caused by HPV and chronic skin disease - premalignant condition - VIN

Answer 34

* Involves squamous epithelium * Can resolve spontaneously * Can progress to vulval cancer

Answer 35

* Can be asymptomatic * Can present with itching/burning/pain

Answer 36

* Conservative: Antihistamine * Medical: Imiquimod * Surgical: Excision

Answer 37

- HPV - Herpes simples virus type 2 - Smoking - Immunosuppression - Chronic vulvar irritation - Conditions such as Lichen sclerosis

Answer 38

* Vulval lump * Ulceration * Bleeding * Pain * Itching * Lymphadenopathy in the groin Vulval cancer most frequently affects the labia majora, giving an appearance of: * Irregular mass * Fungating lesion * Ulceration * Bleeding

Answer 39

* Biopsy of the lesion * Sentinel node biopsy to demonstrate lymph node spread * Further imaging for staging (e.g. CT abdomen and pelvis)

Answer 40

Lichen sclerosus is a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis.

Answer 41

Lichen sclerosus is thought to be an autoimmune condition. It is associated with other autoimmune diseases, such as type 1 diabetes, alopecia, hypothyroid and vitiligo.

Answer 42

Lichen sclerosus is thought to be an autoimmune condition. It is associated with other autoimmune diseases, such as type 1 diabetes, alopecia, hypothyroid and vitiligo.

Answer 43

usually made clinically, based on the history and examination findings. Where there is doubt, a vulval biopsy can confirm the diagnosis.

Answer 44

The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms: * Itching * Soreness and pain possibly worse at night * Skin tightness * Painful sex (superficial dyspareunia) * Erosions * Fissures The **Koebner phenomenon **refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.

Answer 45

“Porcelain-white” in colour Shiny Tight Thin Slightly raised There may be papules or plaques

Answer 46

cannot be cured but can be symptom controlled - potent topical steroids e.g. clobetasol propionate 0.05% (dermovate) - emollients

Answer 47

normal physiological condition due to increased expsorue to oestrogen

Answer 48

The cervix is the lower portion of the uterus. It is composed of two regions; the ectocervix and the endocervical canal. 1) Endocervical canal (endocervix) – the more proximal, and ‘inner’ part of the cervix. It is lined by a mucus-secreting simple columnar epithelium. 2) Ectocervix– the part of cervix that projects into the vagina. It is normally lined by stratified squamous non-keratinised epithelium. A cervical ectropion is the presence of everted endocervical columnar epithelium on the ectocervix. This change is thought to be induced by high levels of oestrogen, and does not represent metaplasia.

Answer 49

The columnar epithelium contains mucus-secreting glands, and thus some individuals with cervical ectropion experience increased vaginal discharge. It may also give rise to post-coital bleeding, as the fine blood vessels present within the epithelium are easily broken during intercourse.

Answer 50

* Use of the combined oral contraceptive pill * Pregnancy * Adolescence * Menstruating age (it is uncommon in post-menopausal women)

Answer 51

- post-coital bleeding - discharge - IMB On speculum examination, the everted columnar epithelium has a reddish appearance – usually arranged in a ring around the external os.

Answer 52

normal variant and does not require treatment unless ysmptomatic First line- stop oestrogen containing medication e.g. COCP Second line; ablation by electrocautery