Cancers In Gynaecology Flashcards
How common is cervical cancer in the UK?
Roughly 2800 cases each year in the UK, although incidence is decreasing since the introduction of the HPV vaccine
What is the most common early symptom of cervical cancer?
Post-coital bleeding, although many women are asymptomatic
What kind of cancers are the majority (70-80%) of cervical cancers?
Squamous cell carcinoma
Other than cervical scc, what is the other type of cervical cancer?
Adenocarcinoma - 20-25%, although incidence increasing especially in younger women.
What kinds of epithelium are present in the cervix?
Squamous epithelium externally, and columnar epithelium internally. They meet at the squamocolumnar junction.
Where is the squamocolumnar junction?
Its location on the cervix is variable
Why is the squamocolumnar junction/transitional zone important in gynaecological cancers?
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
How can precancerous change in the cervix be detected?
Cervical smear -> Pap staining for abnormal nuclei
Do all people with an HPV infection know about it?
No - it is usually symptomless and disappears within a few month.
What are the risk factors for cervical cancer?
Sexual activity (no. Partners + no. of partners partners)
Cigarette smoking
Immunosuppression
Vitamin deficiencies
Hormonal factors e.g. use of COCP for 8+ years
How frequently is cervical screening done in the UK?
Starts at age 25, repeat every 3 years until age 50.
After 50, repeat every 5 years until age 64.
When should women recommence smears after pregnancy?
3 months post-partum, unless they have previously missed a smear, or had abnormal results.
How many smears are abnormal?
About 5%
If a smear report comes back as borderline/showing mild dyskaryosis, how should this patient be managed?
Original sample should be tested for HPV.
If negative, go back to routine screening.
If positive, refer for colposcopy.
If a smear report comes back showing moderate dyskaryosis, how should this patient be managed?
Refer for urgent (2ww) colposcopy as consistent with CIN II.
If a smear report comes back showing severe dyskariosis, how should this patient be managed?
Refer for urgent (2ww) colposcopy as consistent with CIN III.
If a smear report comes back as suspected invasive cancer, how should this patient be managed?
Refer urgently (2ww) for colposcopy.
If a smear report comes back as inadequate, how should this patient be managed?
Repeat smear ~4 weeks later.
If 3 unsatisfactory in a row, refer for investigation by colposcopy.
What does CIN stand for?
Cervical intraepithelial neoplasia
Can CIN regress?
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%
What does CIN progress to?
Cervical cancer
How quickly does CIN progress to cervical cancer?
Usually over 10-20 years
Where does cervical cancer metastasise to?
Lung
Liver
Bowel
Bone
These are the most common sites.
How does cervical cancer present?
Abnormal vaginal bleeding
E.g. post-coital, intermenstrual, post-menopausal
Vaginal discharge
Dyspareunia
Pelvic pain
Weight loss
May be asymptomatic
How might advanced cervical cancer present?
With symptoms related to mets or local invasion:
- Oedema
- Loin pain
- Rectal bleeding
- Radiculopathy
- Haematuria
A woman presents with post-menopausal bleeding and pelvic pain.
What are your differentials?
If she was pre-menopausal, what else would you add?
STI Cervical ectropion Polyps Fibroids Endometrial cancer
Pregnancy related bleeding
Chlamydia
How should suspected cervical cancer be investigated?
It depends on pt age:
- Pre-menopausal - test for chlamydia, treat if positive. If negative, colposcopy and biopsy.
- Post-menopausal - urgent colposcopy and biopsy.
A young woman is referred for colposcopy, but doesn’t know what it means.
What do you tell her?
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.
A young woman with post-coital bleeding has a colposcopy which confirms cervical cancer.
What further investigations should be performed?
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.
How is cervical cancer staged?
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
How should cervical cancer be managed?
That depends on the pt, the stage, co-morbidities, and fertility issues.
Should be decided by MDT.
What are the options for management of cervical cancer?
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.
What kind of followup should pts with cervical cancer receive?
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.
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?
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.
What is the prognosis associated with cervical cancer/CIN?
Good up tp Stage IIa/b - 5 year survival rate can be up to ~90%.
Stage III - 5 year survival is less than 50%.
Tell me about HPV.
- 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
What are the 2 UK HPV vaccines, and which is used and why?
Cervarix and Gardasil.
Gardasil is used because it protects against 4 strains rather than 2.
For roughly how long does the HPV vaccine provide protection?
Around 10 years
How many Gardasil doses are given?
3
Who is currently routinely vaccinated against HPV?
All girl aged 11-18, usually before age 14.
What kind of cancer is vaginal cancer?
Squamous cell carcinoma for 85%
Adenocarcinoma 10%
Which part of the vagina is most commonly affected by cancer?
Posterior wall of upper third of vagina
How common is vaginal cancer in the UK?
Rare - it only accounts for 1% of all gynae cancers
Which group of women is vaginal cancer more common in?
HIV-positive women
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?
Any of them, but vaginal is more common in these women than background population.
How does vaginal cancer present?
- Local - PV bleed or bloody discharge
- Surrounding structures -Rectum or bladder involvement
How should suspected vaginal cancer be investigated?
- Colposcopy
- Biopsy
- Cervical cytology
- Endometrial biopsy
- CT
- CXR for mets
- Cystoscopy if bladder symptoms
Why do the cervix and endometrium need to be investigated in a case of vaginal cancer?
Vaginal cancer is associated with other genital neoplasia.
How is vaginal cancer staged?
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
How is vaginal cancer managed?
Depends on the stage:
- Early - surgery and radiotherapy
- Advanced - Radiotherapy
There are no standard chemo regimens for vaginal cancer.
What are some poor prognostic factors for vaginal cancer?
- Age over 60
- Symptomatic at diagnosis
- Middle/lower vaginal lesions
- Adenocarcinoma
- Poor differentiation
What kind of cancers are endometrial cancers generally?
Adenocarcinoma
What is cancers can occur in the body of the uterus?
Myometrial sarcoma
What are the 2 types of endometrial cancer?
Oestrogen-dependant
Oestrogen-independant
What are the risk factors for endometrial cancer?
Prolonged oestrogen exposure: -Age over 50 -Nulliparous -Menopause after 52 -Obesity -PCOS -Tamoxifen Other: -Endometrial hyperplasia -HNPCC -Diabetes
What is considered a protective factor against endometrial cancer?
Use of combined oral contraceptive in later life
How does endometrial cancer typically present?
Post-menpausal bleeding
Can also be abnormal uterine bleeding or irregular menstrual cycle.
What would you find on examination of a woman with suspected endometrial cancer?
Nothing really, unless there is very advanced disease.
How should suspetced endometrial cancer be investiagted?
2ww referral for:
- TVUS
- Hysteroscopy with endometrial biopsy
CXR and bloods (FBC and LFTs) also often done.
What technique is used for both primary treatment and for staging of endometrial cancer?
Total abdominal hysterectomy and bilateral salpingo-oophrectomy.
How is endometrial cancer staged?
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
How is endometrial cancer managed?
Depends on the stage
How is stage 1 endometrial cancer managed?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy.
If fertility wants to be rpeserved, progestogen can be used in stage 1a.
How is stage 2 endometrial cancer managed?
Radical hysterectomy with lymh node clearance
How are stage 3 and 4 endometrial cancers managed?
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.
What is the prognosis associated with endometrial cancer?
20 year survival overall is 80%.
Individually depends on stage and type of tumour.
Early diagnosis and lower BMI associated with better outcomes.
What are the 4 types of ovarian cancers?
- Epithelial
- Germ cell
- Sex cord-stromal
- Metastatic
Which type of ovarian cancer accounts for 90% of all ovarian cancers?
Epithelial
Who do epithelial ovarian cancers occur?
Women over 50 most commonly
What are the subtypes of endometrial ovarian cancer?
- Serous (most common)
- Endometrioid
- Clear cell
- Mucinous
- Brenner
- Undifferentiated
What are germ cell tumours derived from?
Primitive germ cells of eembryonic gonad
Who are germ cell ovarian cancers most common in?
Women under 35
How do germ cell tumours usually present?
Woman under 35 with rapidly enlarging abdominal mass causing considerable pain
What do sex cord-stromal tumours arise from?
Connective tissue cells
What are the different types of sex cord-stromal tumours?
- Fibroma
- Fibrosarcoma
- Sertoli-Leydig tumours
- Granulosa cell tumours
Which cancers metastasise to the ovaries?
Breast GI Haemopoietic Uterine Cervical
Why is ovarian cancer a bad diagnosis to have?
Most are diagnosed at a late stage and ovarian cancer has a high mortality rate.
What are the risk factors for ovarian cancer?
- 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
What are some protective factors against ovarian cancer?
- Child bearing
- Breast feeding
- Early menopause
- OCP
Do we screen for ovarian cancer in the UK?
No - no programme has been shown to affect mortality significantly.
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?
Ovarian cancer
What are the 2ww guidelines for ovarian cancer?
Urgent referral for pt with ascites, or pelvic/abdominal mass who ovarian cancer is suspected in
How does ovarian cancer generally present?
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
Where do ovarian cancers metastasise?
Pelvic and peri-aortic lymph nodes
Pelvic and abdominal peritoneum
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.
Ovarian cancer Benign ovarian tumour/cyst Fibroids Other pelvic malignancy Endometriosis IBS Constipation IBD Diverticular disease PID Coeliac disease
What investigations should be done by primary care when referring a suspected ovarian cancer?
CA125
General bloods (LFTs for other causes of ascites)
STI screen
Pregnancy test (as appropriate)
How can ovarian cancer symptoms be investigated if not sure about 2ww referrral?
- CA 125
- Pelvic + abdominal USS
How is ?ovarian cancer investigated in secondary care?
CA 125
Pelvic + abdo USS
CT of pelivs and abdo
CT/MRI used for pre-op staging
With which other diseases is ovarian cancer associated?
Breast (BRCA1/2)
Nonpolyposis colon cancer
How is ovarian cancer staged?
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
How is ovarian cancer managed?
Depends on the stage and grade of the cancer, but often management is geared towards palliative care.
What is the standard treatment for ovarian cancer?
Surgery followed by chemotherapy - this can be treatment or palliation.
If early stage ovarian cancer is found, how can we improve outcomes?
Assess peritoneum, and perform hysterectomy, remove ovaries and fallopian tubes. Basically remove anything extra that it might metastasise to.
In advanced ovarian cancer, what is the main surgical option?
Debulking for palliative care and symptom management.
What chemo can we use for early stage ovarian cancer?
Platinum-based chemo
How can we monitor efficacy of Rx and disease recurrence in ovarian cancer?
CA 125
What local complications can occur due to ovarian cancer?
- Ovarian torsion
- Rupture
- Infection
What systemic complications can occur due to ovarian cancer?
- Malnutrition
- Electrolye disturbance
- Bowel obstruction
- Infection
- Ascites
- Pleural effusion
What is the overall 5 year survival rate for ovarian cancer?
46%
This changes with age at diagnosis and stage.
What is gestational trophoblastic disease?
Group of rare disorders in which abnormal trophoblast cells grow inside the uterus after conception.
What is the pre-malignant form of gestational trophoblastic disease known as?
Hydatiform mole aka molar pregnancy
What is a complete molar pregnancy?
A pregnancy where all the genetic material comes from the father after a single sperm duplicates in an empty ovum
What is a partial molar pregnancy?
Trophoblast cells are triploidy i.e. 3 sets of chromosomes
What is an invasive mole?
A complete mole that invades the myometrium
What is choriocarcinoma?
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.
How common is gestational trophoblastic disease?
Rare
What are the rsik factors for GTD?
- Age over 45 or under 16
- Multiple pregnancy
- PMHx of molar pregnancy
- Asian descent
How does GTD present?
- PV bleeding in the first trimester
- Hyperemesis
- Abnormally larger uterus for gestational age
- Picked up on early USS
If a woman has a non-molar pregnancy but then gets persistent abnormal vaginal bleeding, what investigation should be done?
Pregnancy test to exclude persistent GTN.
How should GTD be investiagted?
Urine an blood beta hCG - abnormally high.
Histology of products of conception.
USS (not diagnostic)
How should a molar pregnancy be managed?
Surgical evacuation of PoC with Anti-D prophylaxis
In what situation can a molar pregnancy be allowed to proceed?
Where there is a twin pregnancy with a viable foetus and a molar pregnancy and the mother has been counselled appropriately.
How are hydatidiform moles followed up?
2 weekly serum and urine hCG until back to normal levels. Usually takes around a month.
