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Reproductive Health Block > Cancers In Gynaecology > Flashcards

Cancers In Gynaecology Flashcards

1
Q

How common is cervical cancer in the UK?

A

Roughly 2800 cases each year in the UK, although incidence is decreasing since the introduction of the HPV vaccine

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2
Q

What is the most common early symptom of cervical cancer?

A

Post-coital bleeding, although many women are asymptomatic

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3
Q

What kind of cancers are the majority (70-80%) of cervical cancers?

A

Squamous cell carcinoma

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4
Q

Other than cervical scc, what is the other type of cervical cancer?

A

Adenocarcinoma - 20-25%, although incidence increasing especially in younger women.

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5
Q

What kinds of epithelium are present in the cervix?

A

Squamous epithelium externally, and columnar epithelium internally. They meet at the squamocolumnar junction.

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6
Q

Where is the squamocolumnar junction?

A

Its location on the cervix is variable

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7
Q

Why is the squamocolumnar junction/transitional zone important in gynaecological cancers?

A

The increased rate of cell turnover in this area increases the risk of mutation and formation of dyskaryotic/precancerous cells, which in turn may transform into cancerous cells

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8
Q

How can precancerous change in the cervix be detected?

A

Cervical smear -> Pap staining for abnormal nuclei

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9
Q

Do all people with an HPV infection know about it?

A

No - it is usually symptomless and disappears within a few month.

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10
Q

What are the risk factors for cervical cancer?

A

Sexual activity (no. Partners + no. of partners partners)
Cigarette smoking
Immunosuppression
Vitamin deficiencies
Hormonal factors e.g. use of COCP for 8+ years

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11
Q

How frequently is cervical screening done in the UK?

A

Starts at age 25, repeat every 3 years until age 50.

After 50, repeat every 5 years until age 64.

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12
Q

When should women recommence smears after pregnancy?

A

3 months post-partum, unless they have previously missed a smear, or had abnormal results.

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13
Q

How many smears are abnormal?

A

About 5%

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14
Q

If a smear report comes back as borderline/showing mild dyskaryosis, how should this patient be managed?

A

Original sample should be tested for HPV.
If negative, go back to routine screening.
If positive, refer for colposcopy.

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15
Q

If a smear report comes back showing moderate dyskaryosis, how should this patient be managed?

A

Refer for urgent (2ww) colposcopy as consistent with CIN II.

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16
Q

If a smear report comes back showing severe dyskariosis, how should this patient be managed?

A

Refer for urgent (2ww) colposcopy as consistent with CIN III.

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17
Q

If a smear report comes back as suspected invasive cancer, how should this patient be managed?

A

Refer urgently (2ww) for colposcopy.

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18
Q

If a smear report comes back as inadequate, how should this patient be managed?

A

Repeat smear ~4 weeks later.

If 3 unsatisfactory in a row, refer for investigation by colposcopy.

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19
Q

What does CIN stand for?

A

Cervical intraepithelial neoplasia

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20
Q

Can CIN regress?

A

Yes:

  • 40-60% ofmild dysplasia/CIN I will regress back to normal.
  • CIN II and III can also regress, but at a rate of only 15-20%
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21
Q

What does CIN progress to?

A

Cervical cancer

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22
Q

How quickly does CIN progress to cervical cancer?

A

Usually over 10-20 years

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23
Q

Where does cervical cancer metastasise to?

A

Lung
Liver
Bowel
Bone

These are the most common sites.

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24
Q

How does cervical cancer present?

A

Abnormal vaginal bleeding

E.g. post-coital, intermenstrual, post-menopausal

Vaginal discharge
Dyspareunia
Pelvic pain
Weight loss

May be asymptomatic

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25
Q

How might advanced cervical cancer present?

A

With symptoms related to mets or local invasion:

  • Oedema
  • Loin pain
  • Rectal bleeding
  • Radiculopathy
  • Haematuria
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26
Q

A woman presents with post-menopausal bleeding and pelvic pain.
What are your differentials?

If she was pre-menopausal, what else would you add?

A 
STI
Cervical ectropion
Polyps
Fibroids
Endometrial cancer

Pregnancy related bleeding
Chlamydia

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27
Q

How should suspected cervical cancer be investigated?

A

It depends on pt age:

  • Pre-menopausal - test for chlamydia, treat if positive. If negative, colposcopy and biopsy.
  • Post-menopausal - urgent colposcopy and biopsy.
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28
Q

A young woman is referred for colposcopy, but doesn’t know what it means.

What do you tell her?

A

Method of visualising the cervix.

Colposcope (microscope on a tube) is inserted via vagina.

Use acetic acid to stain areas of suspicious/pre-cancerous change, and take a biopsy.

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29
Q

A young woman with post-coital bleeding has a colposcopy which confirms cervical cancer.

What further investigations should be performed?

A 
Bloods - FBC, LFTs, U&Es
CT CAP (look for mets)

Further staging scan e.g. MRI or PET

Further biopsies may be taken under GA.

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30
Q

How is cervical cancer staged?

A

FIGO staging system:

  • Stage 0 = Carcinoma in situ
  • Stage 1 = Confined to cervix
  • Stage 2 = Beyond cervix, but not pelvic sidewall or lowest 1/3 of vagina
  • Stage 3 = Extends to pelivc sidewall/lower 1/3 of vagina/unexplained hydronephrosis
  • Stage 4 = extends to bladder/rectum/metastases
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31
Q

How should cervical cancer be managed?

A

That depends on the pt, the stage, co-morbidities, and fertility issues.

Should be decided by MDT.

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32
Q

What are the options for management of cervical cancer?

A

Surgery, chemo, radiotherapy.

Radiotherpy is an alternative to surgery in early stages, and gold standard with chemotherapy for Stage 1b-3.

Surgery may involve pelvic lymphadenectomy, hysterectomy, or pelvic adnexae depending on disease extent.

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33
Q

What kind of followup should pts with cervical cancer receive?

A

Review every 4 months after treatment is completed for 2 years, then 6-12 months for the next 3 years.

All follow-up should involve examination of vagina and cervix.

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34
Q

You examine a woman who presented with post-coital vaginal bleeding. Based on the signs, you suspect cervical cancer.

What signs might you have illicited?

A

Depends on severoty of disease:

Abnormal appearance of cervix - white or red patches.

Bimanual - pelvic mass/bulkiness.

Leg oedema

Hepatomegaly

PR - bleeding or mass due to invasion and erosion.

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35
Q

What is the prognosis associated with cervical cancer/CIN?

A

Good up tp Stage IIa/b - 5 year survival rate can be up to ~90%.
Stage III - 5 year survival is less than 50%.

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36
Q

Tell me about HPV.

A
  • Double stranded DNA virus
  • Around 100 subtypes, 40 of which infect genital tract
  • Classified into high risk and low risk categories
  • HPV 16 and 18 are responsible for most cervical cancers worldwide
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37
Q

What are the 2 UK HPV vaccines, and which is used and why?

A

Cervarix and Gardasil.

Gardasil is used because it protects against 4 strains rather than 2.

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38
Q

For roughly how long does the HPV vaccine provide protection?

A

Around 10 years

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39
Q

How many Gardasil doses are given?

A

3

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40
Q

Who is currently routinely vaccinated against HPV?

A

All girl aged 11-18, usually before age 14.

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41
Q

What kind of cancer is vaginal cancer?

A

Squamous cell carcinoma for 85%

Adenocarcinoma 10%

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42
Q

Which part of the vagina is most commonly affected by cancer?

A

Posterior wall of upper third of vagina

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43
Q

How common is vaginal cancer in the UK?

A

Rare - it only accounts for 1% of all gynae cancers

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44
Q

Which group of women is vaginal cancer more common in?

A

HIV-positive women

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45
Q

An HIV-positive woman is seen for a routine checkup. She reports recent onset of PV bleeding even when she isn’t on her period.

Which gynae cancer should you consider?

A

Any of them, but vaginal is more common in these women than background population.

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46
Q

How does vaginal cancer present?

A
  • Local - PV bleed or bloody discharge

- Surrounding structures -Rectum or bladder involvement

47
Q

How should suspected vaginal cancer be investigated?

A
  • Colposcopy
  • Biopsy
  • Cervical cytology
  • Endometrial biopsy
  • CT
  • CXR for mets
  • Cystoscopy if bladder symptoms
48
Q

Why do the cervix and endometrium need to be investigated in a case of vaginal cancer?

A

Vaginal cancer is associated with other genital neoplasia.

49
Q

How is vaginal cancer staged?

A 
Using FIGO staging system:
1 - limited to vaginal wall mucosa
2 - subvaginal tissue involved
3 - pelvic wall involved
4 - extends to a) adjacent organs or b) distant organs
50
Q

How is vaginal cancer managed?

A

Depends on the stage:

  • Early - surgery and radiotherapy
  • Advanced - Radiotherapy

There are no standard chemo regimens for vaginal cancer.

51
Q

What are some poor prognostic factors for vaginal cancer?

A
  • Age over 60
  • Symptomatic at diagnosis
  • Middle/lower vaginal lesions
  • Adenocarcinoma
  • Poor differentiation
52
Q

What kind of cancers are endometrial cancers generally?

A

Adenocarcinoma

53
Q

What is cancers can occur in the body of the uterus?

A

Myometrial sarcoma

54
Q

What are the 2 types of endometrial cancer?

A

Oestrogen-dependant

Oestrogen-independant

55
Q

What are the risk factors for endometrial cancer?

A 
Prolonged oestrogen exposure:
-Age over 50
-Nulliparous
-Menopause after 52
-Obesity
-PCOS
-Tamoxifen
Other:
-Endometrial hyperplasia
-HNPCC
-Diabetes
56
Q

What is considered a protective factor against endometrial cancer?

A

Use of combined oral contraceptive in later life

57
Q

How does endometrial cancer typically present?

A

Post-menpausal bleeding

Can also be abnormal uterine bleeding or irregular menstrual cycle.

58
Q

What would you find on examination of a woman with suspected endometrial cancer?

A

Nothing really, unless there is very advanced disease.

59
Q

How should suspetced endometrial cancer be investiagted?

A

2ww referral for:

  • TVUS
  • Hysteroscopy with endometrial biopsy

CXR and bloods (FBC and LFTs) also often done.

60
Q

What technique is used for both primary treatment and for staging of endometrial cancer?

A

Total abdominal hysterectomy and bilateral salpingo-oophrectomy.

61
Q

How is endometrial cancer staged?

A

FIGO:
1a/b - myometrium invaded (less than half/more than half)
2 - cervical stroma involved but not outside uterus
3 - local/regional spread beyond uterus
4 - bladder/bowel involved or distant mets

62
Q

How is endometrial cancer managed?

A

Depends on the stage

63
Q

How is stage 1 endometrial cancer managed?

A

Total abdominal hysterectomy with bilateral salpingo-oophorectomy.

If fertility wants to be rpeserved, progestogen can be used in stage 1a.

64
Q

How is stage 2 endometrial cancer managed?

A

Radical hysterectomy with lymh node clearance

65
Q

How are stage 3 and 4 endometrial cancers managed?

A

Maximal debulking - basically it aint good and only women with good performance status can undergo surgery.

Many places just try chemo + radiotherapy + surgery for best results.

66
Q

What is the prognosis associated with endometrial cancer?

A

20 year survival overall is 80%.

Individually depends on stage and type of tumour.

Early diagnosis and lower BMI associated with better outcomes.

67
Q

What are the 4 types of ovarian cancers?

A
  • Epithelial
  • Germ cell
  • Sex cord-stromal
  • Metastatic
68
Q

Which type of ovarian cancer accounts for 90% of all ovarian cancers?

A

Epithelial

69
Q

Who do epithelial ovarian cancers occur?

A

Women over 50 most commonly

70
Q

What are the subtypes of endometrial ovarian cancer?

A
  • Serous (most common)
  • Endometrioid
  • Clear cell
  • Mucinous
  • Brenner
  • Undifferentiated
71
Q

What are germ cell tumours derived from?

A

Primitive germ cells of eembryonic gonad

72
Q

Who are germ cell ovarian cancers most common in?

A

Women under 35

73
Q

How do germ cell tumours usually present?

A

Woman under 35 with rapidly enlarging abdominal mass causing considerable pain

74
Q

What do sex cord-stromal tumours arise from?

A

Connective tissue cells

75
Q

What are the different types of sex cord-stromal tumours?

A
  • Fibroma
  • Fibrosarcoma
  • Sertoli-Leydig tumours
  • Granulosa cell tumours
76
Q

Which cancers metastasise to the ovaries?

A 
Breast
GI
Haemopoietic
Uterine
Cervical
77
Q

Why is ovarian cancer a bad diagnosis to have?

A

Most are diagnosed at a late stage and ovarian cancer has a high mortality rate.

78
Q

What are the risk factors for ovarian cancer?

A
  • Increasing age
  • Lifestyle - smoking, obesity, lack of exercise, asbestos exposure
  • Oestrogen exposure (infertility, use of fertility drugs, nulliparous, early menarche, late menopause, HRT)
  • Genetics - FHx, BRCA1 and 2
  • PMHx of CaO/Br/Bowel, or endometriosis
79
Q

What are some protective factors against ovarian cancer?

A
  • Child bearing
  • Breast feeding
  • Early menopause
  • OCP
80
Q

Do we screen for ovarian cancer in the UK?

A

No - no programme has been shown to affect mortality significantly.

81
Q

A 65 year old woman comes to the GP with a long history of abdominal discomfort and bloating, along with some weight loss. Recently she has noticed a mass is palpable in her lower abdomen.

What are we most concerned about here?

A

Ovarian cancer

82
Q

What are the 2ww guidelines for ovarian cancer?

A

Urgent referral for pt with ascites, or pelvic/abdominal mass who ovarian cancer is suspected in

83
Q

How does ovarian cancer generally present?

A

Insidious onset of:

  • Abdo discomfort/bloating/distension
  • Urinary frequency
  • Dyspepsia
  • Systemic symptoms of fatigue, weight loss, anorexia, depression
  • Pelvic/abdo mass with pain
  • Ascites
  • Change in bowel habit
  • Abnormal uterine bleeding
84
Q

Where do ovarian cancers metastasise?

A

Pelvic and peri-aortic lymph nodes

Pelvic and abdominal peritoneum

85
Q

A woman comes to the GP with a long history of abdominal discomfort and bloating, along with some weight loss. Recently she has noticed a mass is palpable in her lower abdomen.

Form a list of differentials, with the most worrying at the top.

A 
Ovarian cancer
Benign ovarian tumour/cyst
Fibroids
Other pelvic malignancy
Endometriosis
IBS
Constipation
IBD
Diverticular disease
PID
Coeliac disease
86
Q

What investigations should be done by primary care when referring a suspected ovarian cancer?

A

CA125
General bloods (LFTs for other causes of ascites)
STI screen
Pregnancy test (as appropriate)

87
Q

How can ovarian cancer symptoms be investigated if not sure about 2ww referrral?

A
  • CA 125

- Pelvic + abdominal USS

88
Q

How is ?ovarian cancer investigated in secondary care?

A

CA 125
Pelvic + abdo USS
CT of pelivs and abdo

CT/MRI used for pre-op staging

89
Q

With which other diseases is ovarian cancer associated?

A

Breast (BRCA1/2)

Nonpolyposis colon cancer

90
Q

How is ovarian cancer staged?

A 
FIGO:
1 - limited to ovaries (a=1, b=2, c=1/2 with some extension)
2 - pelvic extension or implants
3 - peritoneal implants outside pelvis
4 - distant mets
91
Q

How is ovarian cancer managed?

A

Depends on the stage and grade of the cancer, but often management is geared towards palliative care.

92
Q

What is the standard treatment for ovarian cancer?

A

Surgery followed by chemotherapy - this can be treatment or palliation.

93
Q

If early stage ovarian cancer is found, how can we improve outcomes?

A

Assess peritoneum, and perform hysterectomy, remove ovaries and fallopian tubes. Basically remove anything extra that it might metastasise to.

94
Q

In advanced ovarian cancer, what is the main surgical option?

A

Debulking for palliative care and symptom management.

95
Q

What chemo can we use for early stage ovarian cancer?

A

Platinum-based chemo

96
Q

How can we monitor efficacy of Rx and disease recurrence in ovarian cancer?

A

CA 125

97
Q

What local complications can occur due to ovarian cancer?

A
  • Ovarian torsion
  • Rupture
  • Infection
98
Q

What systemic complications can occur due to ovarian cancer?

A
  • Malnutrition
  • Electrolye disturbance
  • Bowel obstruction
  • Infection
  • Ascites
  • Pleural effusion
99
Q

What is the overall 5 year survival rate for ovarian cancer?

A

46%

This changes with age at diagnosis and stage.

100
Q

What is gestational trophoblastic disease?

A

Group of rare disorders in which abnormal trophoblast cells grow inside the uterus after conception.

101
Q

What is the pre-malignant form of gestational trophoblastic disease known as?

A

Hydatiform mole aka molar pregnancy

102
Q

What is a complete molar pregnancy?

A

A pregnancy where all the genetic material comes from the father after a single sperm duplicates in an empty ovum

103
Q

What is a partial molar pregnancy?

A

Trophoblast cells are triploidy i.e. 3 sets of chromosomes

104
Q

What is an invasive mole?

A

A complete mole that invades the myometrium

105
Q

What is choriocarcinoma?

A

A fast growing cancer that grows from chorion/tissues that become the placenta. This can occur following any type of pregnancy, but most commonly follows a molar pregnancy.

106
Q

How common is gestational trophoblastic disease?

A

Rare

107
Q

What are the rsik factors for GTD?

A
  • Age over 45 or under 16
  • Multiple pregnancy
  • PMHx of molar pregnancy
  • Asian descent
108
Q

How does GTD present?

A
  • PV bleeding in the first trimester
  • Hyperemesis
  • Abnormally larger uterus for gestational age
  • Picked up on early USS
109
Q

If a woman has a non-molar pregnancy but then gets persistent abnormal vaginal bleeding, what investigation should be done?

A

Pregnancy test to exclude persistent GTN.

110
Q

How should GTD be investiagted?

A

Urine an blood beta hCG - abnormally high.
Histology of products of conception.
USS (not diagnostic)

111
Q

How should a molar pregnancy be managed?

A

Surgical evacuation of PoC with Anti-D prophylaxis

112
Q

In what situation can a molar pregnancy be allowed to proceed?

A

Where there is a twin pregnancy with a viable foetus and a molar pregnancy and the mother has been counselled appropriately.

113
Q

How are hydatidiform moles followed up?

A

2 weekly serum and urine hCG until back to normal levels. Usually takes around a month.

Reproductive Health Block (10 decks)

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