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Year 4k: Obs and Gynae > Cancers > Flashcards

Cancers Flashcards

1
Q

What are the types of Cervical Cancer?

A
  • Squamous cell cancer (80%)
  • Adenocarcinoma (20%)
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2
Q

What is the natural history of HPV mediated Cervical Cancer?

A
  • HPV: asymptomatic and can be cleared or persist or cause CIN
  • CIN is an asymptomatic premalignant condition which can regress, persist or progress to cancer.
  • 60% CIN1 regress spontaneously and 30% of CIN3 progress to invasion over 5-10 years.
  • It occurs in the transformation zone.
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3
Q

What are clinical signs and symptoms of Cervical Cancer?

A
  • Abnormal vaginal bleeding: post coital, intermenstrual or postmenopausal bleeding
  • Vaginal discharge
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4
Q

What are the significant risk factors in the pathogenesis of Cervical Cancer?

A
  • Human Papillomavirus (HPV) is the most important factor particularly the serotypes 16,18 & 33.
  • Smoking
  • Human immunodeficiency virus
  • Early first intercourse, many sexual partners
  • High parity
  • Lower socioeconomic status
  • Combined oral contraceptive pill
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5
Q

How does HPV causes Cervical Cancer?

A
  • HPV 16 and 18 produces oncogenes E6 and E7 respectively.
  • E6 inhibits p53 tumour suppressor gene and E7 inhibits the RB suppressor gene
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6
Q

What are the qualification criteria for Cervical Screening?

A
  • Smear test offer to all women aged between 25 and 64 years
    • 25-49 years: 3-yearly screening
    • 50-64 years: 5 yearly screening
  • Past 64, it cannot be offered
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7
Q

What are the aims of cervical cancer screening?

A
  • Preventative for 1000-4000 deaths per year.
  • Main aim is to detect pre-malignant changes rather than cancer.
  • Cervical adenocarcinomas are frequently undetected by screening
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8
Q

What are special circumstances encountered in cervical cancer screening?

A
  • In pregnancy cervical screening is delayed until 3 months post-partum unless missed screening or previous abnormal smears
  • Women who have never been sexually active have very low risk of developing cervical cancer so may wish to opt out of screening
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9
Q

What are the methods of Cervical Cancer Screening?

A
  • Papanicolaou (Pap) smears – smearing sample unto slide
  • Liquid-based cytology – sample is either rinsed into preservative fluid or the brush head is simply removed into the sample bottle containing preservative fluid
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10
Q

What are advantages of Liquid-Based cytology?

A
  • Reduced rate of inadequate smears
  • Increased sensitivity and specificity
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11
Q

How is Testing conducted in the NHS?

A
  • The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
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12
Q

What is done in the presence of a negative Negative hrHPV?

A

Return to normal recall

  • 25-49 years: 3-yearly screening
  • 50-64 years: 5 yearly screening
    • Past 64, it cannot be offered
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13
Q

What are the exceptions to returning to normal recall following a normal hrHPV?

A
  • Test of cure pathway: Individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
  • Untreated CIN1 pathway
  • Follow-up for incompletely excised cervicial glandular intraepithelial neoplasia (CGIN)/stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
  • Follow-up for borderline changes in endocervical cells
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14
Q

What occurs if there is a postive hrHPV and the cytology is abnormal?

A

Refer for Colposcopy to determine if there is:

  • Borderline changes in squamous or endocervical cells.
  • Low-grade dyskaryosis.
  • High-grade dyskaryosis (moderate).
  • High-grade dyskaryosis (severe).
  • Invasive squamous cell carcinoma.
  • Glandular neoplasia
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15
Q

What occurs if there is a postive hrHPV and the cytology is normal?

A

The test is repeated after 12 months

  • If the repeat test is now hrHPV -ve → return to normal recall
  • If the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later
  • If hrHPV -ve at 24 months → return to normal recall
  • If hrHPV +ve at 24 months → colposcopy
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16
Q

What happens with an inadequate sample?

A
  • Repeat the sample within 3 months
  • If two consecutive inadequate samples then → colposcopy
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17
Q

How are patients with previous CIN followed up?

A
  • The follow-up of patients who’ve previously had CIN is complicated but as a first step, individuals who’ve been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community.
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18
Q

How is Cervical cancer staged?

A

Figo Staging

  • Stage 1A: Confined to cervix, only visible by microscopy and less than 7 mm wide (A1 is <3mm deep and A2 is 3-5mm deep)
  • Stage 1B: Confined to cervix, clinically visible or larger than 7 mm wide. (B1 = < 4 cm diameter, B2 = > 4 cm diameter)
  • Stage 2: Extension of tumour beyond cervix but not to the pelvic wall (A = upper two thirds of vagina, B = parametrial involvement)
  • Stage 3: Extension of tumour beyond the cervix and to the pelvic wall (A = lower third of vagina, B = pelvic side wall). IT is stage if it causes hydronephrosis or non-functioning kidney
  • Stage 4: Extension of tumour beyond the pelvis or involvement of bladder or rectum (A = involvement of bladder or rectum, B = involvement of distant sites outside the pelvis)
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19
Q

How are cancer stage 1B and above treated?

A

Radiotherapy and concurrent chemotherapy

  • Radiotherapy may either be bachytherapy or external beam radiotherapy
  • Cisplatin is the commonly used chemotherapeutic agent
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20
Q

How are cancers at CIN1 treated?

A
  • Gold standard of treatment is hysterectomy +/- lymph node clearance. Nodal evaluation and clearance for A2 tumours
  • For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed.
    • Excisional options are LLETZ and Cold Knife Cone
    • Destructive options are Cryocautery, Diathermy, Laser Vaporisation
    • Close follow-up of these patients is advised
  • Radical trachelectomy is also an option for A2
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21
Q

What is a Cervical Ectropion?

A
  • On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal.
  • Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
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22
Q

What are clinical signs of Cervical Ectropion?

A
  • Vaginal discharge
  • Post-coital bleeding
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23
Q

What is the management for Cervical Ectropion?

A
  • Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
24
Q

What are the 4 main types of ovarian tumours?

A
  • Surface derived tumours
  • Germ cell tumours
  • Sex cord-stromal tumours
  • Metastasis
25
Q

What are some malignant ovarian tumours?

A
  • ​Serous Cystadenocarcinoma: Often bilateral. Psammoma bodies seen (collection of calcium)
  • Mucinous Cystadenocarcinoma: May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is more common causes)
  • Immature teratoma
  • Dysgerminoma: Most common malignant germ cell tumour. Histological appearance similar to testicular seminoma. It is associated with Turner’s syndrome and typically secrete hCG and LDH
  • Yolk Sac Tumour: Typically, secretes AFP. Schiller-Duval bodies on histology are pathognomonic
  • Choriocarcinoma: Rare tumour that is part of spectrum gestational trophoblastic disease. Early haematogenous spread to the lung. There are typically, have increase hCG levels
  • Granulosa Cell Tumour: Produces oestrogen leading to precocious puberty if in children or endometrial hyperplasia in adults. Contain Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)
  • Krukenberg Tumour: Metastases from gastrointestinal tumour resulting in mucin-secreting signet-ring cell adenocarcinoma
26
Q

What are features of benign ovarian tumours?

A
  • Divided into:
    • Physiological cysts
    • Benign germ cell tumours
    • Benign epithelial tumours
    • Benign sex cord stromal tumours.
  • Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.
27
Q

What are some physiological (functional) cysts?

A
  1. Follicular cysts (commonest type)
    * Due to rupture of dominant follicle or failure of atresia in non-dominant follicle. Commonly regress after several menstrual cycles​​​
  2. Corpus Luteum Cysts
  • If the corpus luteum doesn’t break down and disappear during the menstrual cycle, the corpus luteum may fill with blood or fluid forming a corpus luteal cyst
  • More likely to present with intraperitoneal bleeding
28
Q

What are some bening germ cell tumours?

A

Dermoid Cyst (mature cystic teratomas)

  • Linked with epithelial tissue and may contain skin appendages, hair and teeth. Usually asymptomatic but torsion is more likely than with other ovarian tumours
  • Most common benign ovarian tumour in women under 30 years of age, median age is 30y and bilateral in 10-20%
  • Histopathological analysis reveals Rokitansky’s protuberance
29
Q

What are some benign epithelial tumours?

A
  1. Serous Cystadenoma
    • Most common type bearing resemblance to serous carcinoma
    • Bilateral in around 20%. Cysts line by ciliated cells
  2. Mucinous Cystadenoma
    • 2nd most common benign epithelial tumour.
    • Typically, large and if it ruptures, it may cause pseudomyxoma peritonei. Cysts lined by mucous-secreting epithelium
  3. Brenner Tumour
    • Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have ‘coffee bean’ nuclei.
30
Q

What are some benign sex cord stromal tumours?

A
  1. Sertoli-Leydig cell tumour
    • Produces androgens which leads to masculinizing effects
    • Associated with Peutz-Jegher syndrome
  2. Fibroma
    • Associated with Meigs’ Syndrome
      • Ascites, Pleural Effusion
    • Solid tumour consisting of bundles of spindle-shaped fibroblasts
    • Typically occur around the menopause classically causing pulling sensation in the pelvis
31
Q

What are some characteristics of ovarian tumours?

A
  • 90% are epithelial with 70-80% of cases being due to serous carcinomas
  • Distal end of fallopian tube is often site of origin of many ovarian cancers
32
Q

What are risk factors for Ovarian Tumours?

A
  • Family history: mutations of BRCA1 (50%) or BRCA2 gene. HNPCC
  • Many ovulations: early menarche, late menopause, nulliparity
  • Endometriosis
33
Q

What are some factors that reduce risk of ovarian tumours?

A
  • COCP
  • Breastfeeding
  • Multiparity reduces risk
34
Q

What are some signs and symptoms of Ovarian Tumours?

A
  • Abdominal distension and bloating (may lead to pressure effects on bladder)
  • Abdominal and pelvic pain
    • Torsion or rupture of cysts lead to severe abdominal pain
  • Urinary symptoms e.g. Urgency
  • Early satiety
  • Diarrhoea
  • Anorexia
  • Nausea and vomiting
35
Q

How are Ovarian Tumours investigated?

A
  • Pelvis examination
  • FBC, U&E, LFT
  • CA125
  • Ultrasound is Initial imaging. Report will show:
    • Simple: unilocular, more likely to be physiological or benign
    • Complex: multilocular, more likely to be malignant
  • Laparotomy: may be involved diagnostically as diagnosis is difficult
  • Histopathology
  • CT to assess peritoneal, omental and retroperitoneal disease
  • Cytology of ascitic tap
36
Q

How is CA125 beneficial in the investigation of Ovarian Tumours?

A
  • Testing done initially but endometriosis, menstruation, benign ovarian cysts and other conditions may also raise CA125 level
  • If CA125 is raised then an urgent ultrasound scan of abdomen and pelvis should be ordered
  • CA125 should not be used for screening for ovarian cancer in asymptomatic woman
37
Q

How is Ovarian cancer staged?

A
  • Stage 1: Limited to ovary/ovaries (90%)
  • Stage 2: Spread to pelvic organs (60%)
  • Stage 3: Spread to rest of peritoneal cavity, omentum and/or positive lymph nodes (30%)
  • Stage 4: distant metastases, liver parenchymal or lung involvement (5%)

(survivial rate)*

38
Q

How are Ovarian tumours referred for investigation?

A
  • Premenopausal women: Conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
  • Postmenopausal women: Physiological cysts are unlikely. Any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
39
Q

How is Epithelial Ovarian cancer managed?

A
  • Surgery and chemotherapy (platinum based). Staging laparotomy with total abdominal hysterectomy plus bilateral salpingoophrectomy and debulking.
  • In women of reproductive age where the tumour is confined to one ovary, oophorectomy only may be considered
40
Q

What is endometrial hyperplasia?

A
  • Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle.
  • A minority of patients with endometrial hyperplasia may develop endometrial cancer (pre-malignant)
41
Q

What are risk factors for Endometrial Hyperplasia?

A
  • Obesity
  • Unopposed oestrogen use
  • Tamoxifen use
  • Polycystic ovary syndrome
  • Diabetes
42
Q

What are types of endometrial hyperplasia?

A
  • Simple
  • Complex
  • Simple atypical
  • Complex atypical
43
Q

What are clinical features of endometrial hyplerplasia?

A
  • Abnormal vaginal bleeding e.g. intermenstrual, postmenopausal
44
Q

How is endometrial hyperplasia managed?

A
  • Simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The Levonorgestrel IUS may be used
    • Dilatation and curettage are performed to remove the excess endometrial tissue
  • Atypia: hysterectomy is usually advised.
45
Q

Which patient group does endometrial cancer often occur in?

A
  • Classically seen in post-menopausal women but around 25% occur before menopause. Usually carries good prognosis due to early detection
  • Makes up 2% of uterine cancer and the peak age is 64-74 and rare before 35. Declines in risk after 80yrs
  • COCP and smoking are protective
46
Q

What are the types of Endometrial Cancer?

A

TYPE 1: endometrial adenocarcinoma

TYPE 2: papillary serous, clear cell, carcinosarcoma

Sarcoma: extremely rare

47
Q

How is Endometrial cancer staged?

A

Figo Staging

  • Stage 1: limited to myometrium
  • Stage 2: cervical spread
  • Stage 3: uterine serosa, ovaries/tubes, vagina, pelvic/para-aortic lymph nodes
  • Stage 4: Bladder/Bowel involvement or Distant metastases
48
Q

What are risk factors for Endometrial cancer?

A
  • Obesity
  • Nulliparity
  • Early menarche
  • Late menopause
  • Unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
  • Diabetes mellitus
  • Tamoxifen
  • Polycystic ovarian syndrome (PCOS)
  • Hereditary non-polyposis colorectal carcinoma
  • Parkinsons
  • Previous breast cancer
49
Q

What leads to reduction in risk of Endometrial Cancer?

A
  • Continuous combined HRT
  • Combined oral contraceptive pill
  • Smoking
  • Physical activity
50
Q

What are signs and symptoms of Endometrial Cancer?

A
  • Postmenopausal bleeding is the classic symptom
  • Premenopausal women may have a change intermenstrual bleeding
  • Blood stained watery or purulent vaginal discharge (Less common)
  • Pain (less common)
51
Q

What are investigations for Endometrial Cancer?

A

Women ≥ 55 years with post-menopausal bleeding referred using suspected cancer pathway:

  • 1st line investigation is Trans-vaginal ultrasound – normal endometrial thickness (<4mm) has high negative predictive value.
  • Hysteroscopy with endometrial biopsy sampling by Pipelle or dilation and curettage (less commonly)
    • Pipelle is where a thin flexible tube is inserted into the uterus via a speculum to remove cells for testing

If metastases at presentation: intraperitoneal, lung, bone, brain

  • FBC, U&Es, LFTs
  • CT chest/abdo/pelvis
  • MRI pelvis
52
Q

What is the management of Endometrial Cancer?

A
  • Localised disease
    • Abdominal hysterectomy with bilateral salpingo-oophrectomy.
    • High risk patients have post-operative radiotherapy
    • Progestogen therapy sometimes used in frail elderly women not suitable for surgery
  • Advanced disease, inoperable disease or unfit for surgery
    • Chemotherapy
    • Radiotherapy
    • Hormone and palliative care
53
Q

What are the typical features of those presenting with Vulval Carcinoma?

A
  • Around 80% of vulval cancers are squamous cell carcinomas.
  • Most cases occur in women over the age of 65 years.
  • Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.
54
Q

What are risk factors of Vulval Carcinoma?

A
  • Age
  • Human papilloma virus (HPV) infection
  • Vulval intraepithelial neoplasia (VIN)
  • Immunosuppression
  • Lichen sclerosis
55
Q

What are signs/symptoms of Vulval Carcinoma?

A
  • Lump or ulcer on the labia majora
  • Associated with itching, irritation
56
Q

How is Vulval Carcinoma managed?

A
  • Surgery
  • Radiotherapy

Year 4k: Obs and Gynae (19 decks)

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