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Obstetrics and Gynaecology > Cancer - done > Flashcards

Cancer - done Flashcards

1
Q

Who does cervical cancer typically affect?

A

Younger women, peaking in reproductive years

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2
Q

What are the common types of cervical cancer?

A

Squamous cell carcinoma (80%)

Adenocarcinoma

Small cell cancer

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3
Q

What virus is cervical cancer typically associated with?

A

Human papillomavirus

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4
Q

When are children typically vaccinated against HPV?

A

Aged 12-13

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5
Q

What is the purpose of smear tests?

A

To screen for precancerous and cancerous changes to the cells of the cervix

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6
Q

What type of cancer is HPV associated with?

A

Cervical

Anal

Vulval

Vaginal

Penis

Mouth

Throat

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7
Q

What strains of HPV are responsible for cervical cancers?

A

Types 16 and 18

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8
Q

What is the treatment for HPV infection?

A

No treatment (most infections resolve within 2 years)

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9
Q

How does HPV cause cancer?

A

HPV produces two proteins E6 and E7 which inhibit tumour supressor genes p53 and pRb respectively

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10
Q

What are the types of risks for cervical cancer?

A
  • Increased risk of catching HPV
  • Later detection of precancerous or cancerous changes (non-engagement with screening)
  • Other risk factors
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11
Q

What are the risks of catching HPV?

A
  • Early sexual activity
  • Increased number of sexual partners
  • Sexual partners who have had more partners
  • Not using condoms
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12
Q

What are the other risk factors for cerival cancer?

A
  • Smoking
  • HIV (patients with HIV are offered yearly smear tests)
  • COCP use for more than 5 years
  • Increased number of full-term pregnancies
  • Family history
  • Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)
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13
Q

What are the presenting symptoms of cervical cancer?

A
  • Abnormal vaginal discharge (intermenstrual, postcoital or post-menopausal bleeding)
  • Vaginal discharge
  • Pelvic pain
  • Dyspareunia (pain or discomfort with sex)
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14
Q

After taking a history suspicious of cervical cancer, what is the next step?

A

Examine the cervix with a speculum (during examination swabs can be taken to exclude infection)

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15
Q

What appearance on speculum is suggestive of cervical cancer?

A
  • Ulceration
  • Inflammation
  • Bleeding
  • Visible tumour

Urgent cancer referral for colposcopy should be made to assess further

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16
Q

If a smear test returns normally can that rule out cervical cancer?

A

No

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17
Q

What is cervical interaepithelial neoplasia?

A

A grading system for the level of dysplasia (premalignant change) in the cells of the cervix, its diagnosed at colposcopy (not with cervical screening)

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18
Q

What are the different grades of cervical intraepithelial neoplasia?

A

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

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19
Q

What is CIN III also known as?

A

Cervical carcinoma in situ

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20
Q

What is the difference between dysplasia found during colposcopy and dyskaryosis on smear results?

A
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21
Q

Who performs a smear test?

A

A practise nurse

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22
Q

What are precancerous cells also known as?

A

Dyskaryosis

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23
Q

What is the mode of transporting smear cells also known as?

A

Liquid-based cytology

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24
Q

What are the smear samples initially tested for?

A

High-risk HPV before the cells are examined, if the HPV test is negative then the person does not have HPV and the cells are not examined and the smear is considered negative

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25
Q

How often is the smear test done?

A

Every 3 years for those ages 25-49

Every 5 years for those aged 50-64

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26
Q

What are the exceptions to the smear screening schedule?

A
  • Women with HIV are screened annually
  • Women over 65 may request a smear if they have not had one since aged 50
  • Women with previous CIN may require additional tests (e.g. test of cure after treatment)
  • Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
  • Pregnant women undergoing a routing smear should wait until 12 weeks post-partum
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27
Q

What are the possible cytology results to the smear test?

A

Inadequate

Normal

Borderline changes

Low-grade dyskaryosis

High-grade dyskaryosis (moderate)

High-grade dyskaryosis (severe)

Possible invasive squamous cell carcinoma

Possible glandular neoplasia

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28
Q

What other infections may be reported on the smear result?

A
  • Bacterial vaginosis
  • Candidiasis
  • Trichomoniasis
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29
Q

When are actinomyces-like organisms found on a smear? Do they need treating?

A

Women with intrauterine devices (coil)

Do not require treatment unless they are symptomatic (e.g. pelciv pain or abnormal bleeding) - removal of the device may be considered

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30
Q

What are the possible management options of the smear test?

A

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

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31
Q

What does a colposcopy involve?

A

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 this stains such as acetic acid and iodine solution can be used to differentiate abnormal areas

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32
Q

What types of cells does acetic acid target and what is the colour change?

A

Cells with an increased nuclear to cytoplasmic ratio (more nuclear material) e.g. cervical intraepithelial neoplasia and cervical cancer cells

Abnormal cells appear white (acetowhite)

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33
Q

What does Schiller’s iodine test involve?

A

Using an iodine solution to stain the cells of the cervix - iodine will stain healthy cells a brown colour, abnormal cells will not stain

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34
Q

How can a tissue sample be obtained from a smear test?

A

Punch biopsy or large loop excision of the transformational zone can be performed during the colposcopy procedure

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35
Q

What is a large loop excision of the transformation zone (LLETZ) also known as?

A

Loop biopsy

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36
Q

How is a LLETZ performed?

A

Under local anaesthetic during a colposcopy with a loop diathermy to remove abnormal epithelial tissue on the cervix cauterising the tissue and stopping it from bleeding

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37
Q

What is the after care advice after a LLETZ?

A

Bleeding and abnormal dischage can occur for several weeks following a LLETZ procedure

Intercourse and tampons should be avoided to reduce the risk of infection

Increased risk of preterm labour

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38
Q

When is a cone biopsy done?

A

As a treatment for CIN and very early-stage cervical cancer under general anaesthetic

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39
Q

How is a cone biopsy done?

A

Surgeon removes a cone-shaped piece of the cervix using a scalpel - sent to histology to assess for malignancy

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40
Q

What are the main risks of a cone biopsy?

A
  • Pain
  • Bleeding
  • Infection
  • Scar formation with stenonsis of the cervix
  • Increased risk of miscarriage and premature labour
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41
Q

What is the international federation of Gynaecology and Obstetrics (FIGO) staging system for cervical cancer?

A

Stage 1: Confined to the cervix

Stage 2: Invades the uterus or upper 2/3 of the vagina

Stage 3: Invades the pelvic wall or lower 1/3 of the vagina

Stage 4: Invades the bladder, rectum or beyond the pelvis

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42
Q

What is the usual treatment for cervical intraepithelial neoplasia and early-stage 1A cervical cancer?

A

LLETZ or cone biopsy

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43
Q

What is the treatment for:

Stage 1B – 2A

Stage 2B – 4A

Stage 4B cervical cancer?

A

Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy

Stage 2B – 4A: Chemotherapy and radiotherapy

Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care

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44
Q

What is the range of 5 year survival depending on stage of cervical cancer?

A

98% with stage 1A

15% with stage 4

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45
Q

When is pelvic exenteration used?

A

Advanced cervical cancer

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46
Q

What is pelvic extenteration?

A

Operation to remove most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum (vast operation and has significant implcations on the quality of life)

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47
Q

What chemotherapy agent is used in the treatment of metastatic or recurrent cervical cancer?

A

Bevacizumab (avastin) a monoclonal antibody

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48
Q

What is the MOA of bevacizumab?

A

Targets vascular endothelial growth factor A (VEGF-A) which is responsible for the development of new blood vessels

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49
Q

What else is Bevacizumab used for?

A

Wet age-related macular degeneration - where it is injected directly into the patients eye to stop new blood vessels forming on the retina

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50
Q

What is the current NHS vaccine against HPV?

A

Gardasil (protects against stains 6, 11, 16 and 18)

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51
Q

Which strains of HPV cause genital warts?

A

6 and 11

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52
Q

Which strains of HPV cause cervical cancer?

A

16, 18 and 33

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53
Q

What helps when counselling parents for HPV vaccination?

A

It needs to be given before their child is sexually active and it protects them from cervical cancer and genital warts.

HPV is very common and infection is the number one risk factor for cervical cancer.

54
Q

What is endometrial cancer?

A

Cancer of the endometrium, the lining of the uterus

55
Q

What type of cancer are most endometiral cancers?

A

Adenocarcinoma

56
Q

What stimulates the growth of endometrial cancer?

A

Oestrogen

57
Q

What is the most likely diagnosis of a woman with postmenopausal bleeding?

A

Endometrial cancer

58
Q

What is endometrial hyperplasia?

A

Precancerous condition involving thickening of the endometrium

59
Q

What % of endometrial hyperplasias go on to become endometrial cancer?

A

5%

60
Q

What are the two types of endometrial hyperplasias?

A
  • Hyperplasia without atypia
  • Atypical hyperplasia
61
Q

How is endometrial hyperplasia treated?

A

By a specialist using progestogens with:

  • Intrauterine system (e.g. Mirena coil)
  • Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
62
Q

What is unopposed oestrogen?

A

Oestrogen without progesterone

63
Q

What exposure puts a patient at risk of endometrial cancer?

A

Exposure to unopposed oestrogen

64
Q

What are some causes of increased unopposed oestrogen?

A
  • Increased age
  • Earlier onset of mensturation
  • Late menopause
  • Oestrogen only HRT
  • No or fewer pregnancies
  • Obesity
  • Polycystic ovarian syndrome
  • Tamoxifen
65
Q

How does polycystic ovarian syndrome lead to increased exposure to oestrogen?

A

Lack of ovulation

66
Q

How does PCOS cause the endometrium to have more exposure to unopposed oestrogen?

A
67
Q

What can be given to women with PCOS for endometrial protection

A

Combined contraceptive pill

Intrauterine system

Cyclical progesterones

68
Q

Why is obesity a risk factor for endometrial cancer?

A

Adipose tissue is a source of oestrogen

69
Q

What is the primary source of oestrogen in post menopausal women?

A

Adipose tissue

70
Q

How does adipose tissue cause increases in oestrogen?

A

Contains aromatase which is an enzyme which converts androgens such as testosterone into oestrogen

71
Q

Where are androgens mainly produced?

A
72
Q

How does tamoxifen increase the amount of unopposed oestrogen?

A

Anti-oestrogenic effect on breast tissue but an oestrogenic effect on the endometrium

73
Q

What are some risk factors for endometrial cancer which are not related to unopposed oestrogen?

A

Type 2 diabetes

Hereditary nonpolyposis colorectal cancer or lynch syndrome

74
Q

How may type 2 diabetes increase the risk of endometrial cacner?

A

Increased production of insulin which stimulates the endometrial cells, causing hyperplasia and possibly cancer

75
Q

What is the relationship between PCOS and insulin?

A

PCOS is associated with insulin resistance and increased insulin production

76
Q

What are some protective factors for endometrial cancer?

A

COCP

Mirena coil

Increased pregnancies

Cigarette smoking

77
Q

How is smoking protective against endometrial cancer?

A

Anti-oestrogenic

78
Q

What oestrogen dependent cancer is smoking not protective against?

A

Breast cancer

79
Q

How does smoking have an antioestrogenic effect?

A
  • Oestrogen may be metabolised differently in smokers
  • Smokers tend to be leaner and so have less adipose tissue and aromatase enzyme
  • Smoking destroys oocytes (eggs) resulting in an earlier menopause
80
Q

What is the main presenting symptom for endometrial cancer?

A

Post-menopausal bleeding

81
Q

How else may endometrial cancer present?

A

Postcoital bleeding

Intermenstrual bleeding

Unusually heavy menstrual bleeding

Abnormal vaginal discharge

Haematuria

Anaemia

Raised platelet count

82
Q

When is a 2WW referral needed for suspected endometrial cancer?

A

Postmenopausal bleeding (more than 12 months since last menstrual period)

83
Q

When is a transvaginal ultrasound required for women over 55 years old?

A

Unexplained vaginal discharge

Visible haematuria (plus raised platelets, anaemia or elevated glucose levels)

84
Q

What are the three investigations for diagnosing and excluding endometrial cancer?

A
85
Q

What is a pipelle biopsy?

A

Speculum examination with a thin tube inserted into the uterus through the cervix - tube fills with a sample of endometrial tissue that can be examined for endometrial hyperplasia or cancer

86
Q

Why is a pipelle biopsy better than a hysteroscopy for excluding cancer in lower-risk women?

A

It’s a quicker and less invasive alternative to hysteroscopy

87
Q

What investigations are sufficient to rule out endometrial cancer and dischage a patient?

A
  • Normal transvaginal ultrasound (endometrial thickness < 4mm)
  • Normal pipelle biopsy
88
Q

What is the FIGO staging for endometrial cancer?

A

Stage 1: Confined to the uterus

Stage 2: Invades the cervix

Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes

Stage 4: Invades bladder, rectum or beyond the pelvis

89
Q

What is the usual treatment for stage 1 and 2 endometrial cancer?

A

Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH and BSO - removal of cervix, uterus and adnexa)

90
Q

What are the other treatments for endometrial cancer?

A

Radical hysterectomy (also removing the pelvic lymph nodes, surrounding tussue and top of the vagina)

Radiotherapy

Chemotherapy

Progesterone for hormonal treatment to slow the progression of the cancer

91
Q

Why does ovarian cancer often present late?

A

Non-specific symptoms resulting in a worse prognosis (more than 70% of patients with ovarian cancer present after it has spread beyond the pelvis)

92
Q

What are some different types of ovarian cancers?

A
93
Q

What is the most common type of ovarian cancer? And some subsets?

A

Epithelial cell tumours

  • Serous tumours (the most common)
  • Endometrioid carcinoma
  • Clear cell tumour
  • Mucinous tumour
  • Undifferentiated tumour
94
Q

Are dermoid cysts / germ cell tumours benign or malignant?

A

Benign

95
Q

What kind of tumours are dermoid cysts and germ cell tumours?

A

Teratomas (they come from germ cells)

96
Q

What do teratomas contain?

A

Various tissue types such as skin, teeth, hair and bone

97
Q

What are germ cell tumours associated with?

A

Ovarian torsion

98
Q

What tumour markers may be raised in germ cell tumours?

A

Alpha-fetoprotein

Human chorionic gonadotrophin

99
Q

Are sex cord-stromal tumours cancerous?

A

Can be benign or malignant

100
Q

What are some types of sex cord-stromal tumours?

A

Sertoli-leydig cell tumours

Granulosa cell tumours

101
Q

What is a krukenberg tumour?

A

Metastasis in the ovary, usually from a gastrointestinal tract cancer particularily the stomach

102
Q

How do Krukenberg tumours appear on histology?

A

“Signet ring” cells on histology

103
Q

What are some risk factors for ovarian cancer?

A

Age (peaks at 60)

BRCA1 and BRCA2 genes (consider the family history)

Increased number of ovulations

Obesity

Smoking

Recurrent use of clomifene

104
Q

What are the factors which increase the number of ovulations (and thus the risk of ovarian cancer)?

A
  • Early onset of periods
  • Late menopause
  • No pregnancies
105
Q

What are some factors which are protective against ovarian cancer?

A
  • Combined contraceptive pill
  • Breastfeeding
  • Pregnancy
106
Q

How can ovarian cancer present?

A

Abdominal bloating

Early satiety (feeling full after eating)

Loss of appetite

Pelvic pain

Urinary symptoms (frequency / urgency)

Weight loss

Abdominal or pelvic mass

Ascites

(have a low threshold for referring older women)

107
Q

Why does hip/groin pain occur in ovarian cancer?

A

Due to compression on the obturator nerve (as it passes along the inside of the pelvis, lateral to the ovaries)

108
Q

When should a 2WW referral be made for suspected ovarian cancer?

A
  • Ascites
  • Pelvic mass (unless clearly due to fibroids)
  • Abdo mass
109
Q

What symptoms should prompt further investigations for ovarian cancer (starting with CA125)?

A

Women older than 50 presenting with:

New symptoms of IBS / change in bowel habit

Abdominal bloating

Early satiety

Pelvic pain

Urinary frequency or urgency

Weight loss

110
Q

What are the inital investigations for ovarian cancer in primary or secondary care?

A

CA125 blood test (>35 is significant)

Pelvic ultrasound

111
Q

What is the risk of malignancy index (RMI) calculating?

A

Risk of an ovarian mass being malignant

112
Q

What is the RMI based on?

A

Menopausal status

Ultrasound findings

CA125 level

113
Q

What are some other further investigations in secondary care to include?

A

CT scan to establish the diagnosis and stage cancer

HIstology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy

Paracentesis (ascitic tap) - assesses ascitic fluid for cancer cells

114
Q

What tumour markers are required for a woman under 40 with a complex ovarian mass?

A

α-FP

hCG

115
Q

What cancer is CA125 a marker for?

A

Epithelial cell ovarian cancer

116
Q

What are the non-malignant causes of a raised CA125?

A
  • Endometriosis
  • Fibroids
  • Adenomyosis
  • Pelvic infection
  • Liver disease
  • Pregnancy
117
Q

What are the stages of the FIGO system used for ovarian cancer?

A

Stage 1: Confined to the ovary

Stage 2: Spread past the ovary but inside the pelvis

Stage 3: Spread past the pelvis but inside the abdomen

Stage 4: Spread outside the abdomen (distant metastasis)

118
Q

How is ovarian cancer managed?

A

Specialist gynarcology oncology MDT usually involving a combination of surgery and chemotherapy

119
Q

Is vulval cancer common?

A

Rare (compared with other gynarcological cancers)

120
Q

What is the most common type of vulval cancers?

A

90% are squamous cell carcinoma (less commonly malignant melanoma)

121
Q

What are some risk factors for vulval cancers?

A
  • Advanced age (over 75)
  • Immunosuppression
  • HPV (human papillomavirus) infection
  • Lichen sclerosus
122
Q

What percent of women with lichen sclerosus get vulval cancer?

A

5%

123
Q

What is vulval intraepithelial neoplasia?

A

Premalignant condition affecting the squamous epithelium of the skin preceding vulval cancer

124
Q

What is a high grade squamous intraepithelial lesion?

A

Type of VIN associated with HPV infection that typically occurs in younger women aged 35-50 years

125
Q

What is differentiated VIN?

A

Alternative type of VIN associated with lichen sclerosus, typically occuring in older women (aged 50-60 years old)

126
Q

How is VIN diagnosed?

A

A biopsy

127
Q

What are the treatment options for VIN?

A

Watch and wait with close follow up

Wide local excision (surgery) to remove the lesions

Imiquimod cream

Laser ablation

128
Q

How may vulval cancer present?

A

Symptoms of:

Vulval lump

Ulceration

Bleeding

Pain

Itching

Lymphadenopathy in the groin

129
Q

Where does vulval cancer commonly affect?

A

Labia majora

130
Q

How to establish diagnosis of vulval cancer and stage?

A

Biopsy of the lesion

Sentinel node biopsy to demonstate lymph node spread

Further imaging for staging (CT abdo and pelvis)

131
Q

What staging system is used for vulval cancer?

A

FIGO

132
Q

What is the management of vulval cancer?

A

Wide local excision to remove the cancer

Groin lymph node dissection

Chemotherapy

Radiotherapy

Obstetrics and Gynaecology (10 decks)

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