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Obs & Gynae > Endometrial and Ovarian Cancer > Flashcards

Endometrial and Ovarian Cancer Flashcards

1
Q

What is type 1 endometrial cancer

A

Endometriod adenocarcinoma

Most common

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2
Q

What is the precursor for type 1

A

Endometrial hyperplasia with atypia

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3
Q

What is type 2 endometrial cancer

A

Uterine serous = most common
Uterine clear cell
More aggressive and higher grade

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4
Q

What is a precursor for type 2

A

Serous intraepithelial carcinoma

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5
Q

What causes endometrial cancer

A

Stimulation of endometrium by oestrogen without protective effects of progesterone

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6
Q

Where is progesterone produced

A

CL in pregnancy

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7
Q

What are the RF for endometrial cancer

A 
Age - post menopause
HNPCC
DM 
FH / PMH 
Hypertension
Tamoxifen 
Atypical hyperplasia 
Anovulation as no progesterone 
PCOS - anovulation 
High circulating oestrogen
Obesity
Early menarche
Late menopause
Nulliparity 
HRT - unopposed oestrgen
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8
Q

WHat is protective of endometrial cancer

A

OCP
Pregnancy
Mirena coil
Smoking

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9
Q

What cancer does HNPCC cause

A 
Breast
Ovarian 
Cervical
Bowel 
Endometrial
Prostate 
Ask in FH if anyone had these
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10
Q

How does endometrial cancer present

A

PMB
IMB if pre-menopause
Pain / discharge is unusual

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11
Q

What is PMB

A

Bleeding 12 months since last period

1 in 10 = cancer

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12
Q

What is endometrial cancer until proven otherwise

A

PMB

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13
Q

What makes you worry more and what should you do

A

Older patient with PMB or failed Rx

Refer urgent cancer pathway

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14
Q

What is important to ask in history

A 
Time, consistency, quantity of blood
Obestric and gynae
RF for Ca
Full menarche - menopause Hx
Contraception 
Menopause Sx to know if gone through if on coil
Drug Hx inc HRT
Tamoxifen - how long and any bleeding 
Last smear
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15
Q

What investigations can be done in primary care

A 
Urine dip - infection cause haematuria
VE + speculum
FBC - anaemia / bleed
CA-125 for ovarian 
Rx menorrhagia - refer if failed pre-menopause
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16
Q

What is done at clinic

A

Transvaginal USS

Biopsy = diagnostic

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17
Q

What does USS assess

A

Endometrial thickness and contour

Should be thin in post-menopausal

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18
Q

When do you biopsy

A

If >4mm in post-menopause
If >10mm in pre-menopause
Do pipette with speculum or hysteroscopy
Dx by histology

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19
Q

What do you do if cervix too inflamed for biopsy

A

EUA

Hysteroscopy

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20
Q

How do you stage

A

Surgical / pathological

MRI

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21
Q

What do all patients on tamixoen with bleeding get

A

Transvaginal USS

HYsteroscopy

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22
Q

How do you treat hyperplasia with no atypia

A

Progesterone e.g. Mirena IUS

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23
Q

What else does USS pick up

A 
Endometrial thickness
Look at ovaries - shrink in post
Follicles sugest residual activity
Polyp
Fibroid
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24
Q

Where would a polyp be discovered and how do you treat

A

Treat at hysteroscopy with myosure

Remove and send to lab

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25
Q

How is endometrial cancer staged

A 
FIGO 
1 = in uterine body / myometrium
2 = cervix
3 = belong uterus but confined to pelvis and PA noe
4 = involves bladder / bowel / inguinal
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26
Q

How do you treat endometrial cancer

A

Surgical trans abdominal hysterectomy + BSO
Washings
RT if LN +Ve

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27
Q

What do you give if high risk histology

A

Chemotherapy

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28
Q

What do you do if advanced

A

RT

Progesterone for palliation

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29
Q

What is advised if atypia

A

Hysterectomy

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30
Q

What are other causes of PMB

A 
Atrophic vaginitis
Resiual ovarian activity (peri-menopause) 
HRT 
Polyps 
Fibroids 
Endometrial hyperplasia 
Other cancers - cervix / vulval / bladder 
Vagina = rare
Endometritis 
Cervicitis - C+G
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31
Q

Why don’t fibroids present with PMB

A

Usually calcify after menopause

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32
Q

What does prognosis depend on

A

Histological type and grade
Stage
Lymph vascular invasion

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33
Q

What causes endometrial hyperplasia

A 
Age 
Smoking 
Unopposed oestrogen  - nulli, early menarche 
Tamoxifen
Obesity
PCOS 
DM
Thyroid
Ovarian tumour that secrete hormones - sertoli. / granulosa
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34
Q

How does it present

A

Abnormal bleeding

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35
Q

If no atypia

A

Progesterone

Dilation and curettage for excess tissue

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36
Q

What do you do if atypia

A

TAH + BSO

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37
Q

What does tamoxifen do

A

Anti-oestrogen in breast

Pro-oestrogen in endometrium

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38
Q

What is most common type of ovarian cancer

A

Serous - germ cell

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39
Q

What are other type

A

Clear cell
Endometriod
Mucinous

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40
Q

How is ovarian cancer staged

A 
FIGO 
1 = limited to ovaries
2 = local spread to pelvis
3 = peritoneal spread
4 =distant mets, para-aortic, liver
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41
Q

What gene is associated with ovarian cancer

A

BRCA - AD
- Tumour suppressor gene involved in DNA repair
Also HNPCC

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42
Q

When would you be referred to genetic clinic

A

2+ relatives ovarian
1+ ovarian and 1+ breast
Known mutation
FH colon cancer

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43
Q

Who is considered high risk

A

Gene mutation

2+ relatives

44
Q

What do high risk people get

A

Prophylactic oophorectomy and salpingectomy after family complete

45
Q

How does ovarian cancer present

A 
Vague
Poor appetite
Indigestion
Altered bowel habit
Bloating
Weight gain
Early satiety
Abdo pain 
Pressure symptoms- urgency / diarrhoea
46
Q

When should you suspect

A 
Older women
Non specific abdominal pain
Blaoting 
Early satiety / poor appeitite
Increased urinary frequency
47
Q

What is DDX of bloating

A

IBS
Coeliac
IBD
GI cancer

48
Q

How do you exclude Ddx

A

IBS rare in >50
Colonoscopy
Abdo USS

49
Q

What are RF for ovarian cancer

A 
Age - rare <30
HNPCC
BRCA1+2 
Incessant ovulation - nulli, early menarche, last menopause
HRT 
Obesity
Smoking 
Endometrisosi
FH
50
Q

What is protective

A

OCP
Pregnancy
Breast feeding

51
Q

What do you do in GP is suspect ovarian cancer

A

Abdo and pelvic exam
Ca125
Refer USS urgent

Refer directly to gynaecologist URGENT if mass / ascites found O/E

52
Q

What is Ca125 and what is abnormal

A

Protein antigen tumour marker
80% raised in ovarian
>35 = abnormal

53
Q

What else can raised Ca125

A 
Cyst
Endometriosis
Fibroids 
Menstruation
PID
COlon / pancreas / breast ca
Liver effusion / cirrhosis 
Irritation of peritoneum
54
Q

If Ca125 raised what do you do

A

Refer for USS

If suggest malignancy = refer

55
Q

What are other investigation

A

CT for staging if USS cancer
Biopsy
Ascitic fluid tap if ascites

56
Q

What is best way to Dx

A

Laparotomy + removal of ovary

57
Q

What on USS suggest malignancy

A 
Multi-locular
Solid
Bilateral
Ascites
Intra-abdominal
58
Q

What score is used to calculate likelihood of cancer

A

RMI

USS x menopause xCa125

59
Q

If symptoms of IBD in>50

A

OVARIAN CANCER

60
Q

When do you do a Ca125

A 
>50
Abdominal discomfort
Early satiety
Loss of appetite
Pelvic / abdo pain
Increased urinary
61
Q

How do you treat ovarian cancer

A

Laparotomy + clearance = 1st line

Chemo in later stages

62
Q

How do you monitor

A

Ca-125 every 5 years

63
Q

What do you do if recurrent

A

Chemo
Palliate
Surgery 2nd line

64
Q

What do you do if not fit for surgery or chemo

A

Tamoxifen (selective oestrogen receptor antagonist)

65
Q

What is an adnexal mass

A

Mass of ovary / Fallopian tube or connective tissue

Most ovarianly

66
Q

What helps determine cause

A

Location
Age
Reproductive status

67
Q

If pre-menopausal

A 
Likely benign
Associated with menstrual cycle 
Endometrioma
Follicular cyst
CL cyst 
Dermoid 
Pregnancy
68
Q

If post menopausal

A

Must exclude cancer

Ca-125 useful

69
Q

If solid ovarian mass post menopausal

A

Ovarian cancer

Adnexal torsion

70
Q

Fallopian mass + pain + bleed

A

Exclude ectopic

71
Q

Ovarian mass

A 
Cancer
Metastatic 
Cyst
CL cyst 
Endometrioma
72
Q

Mass in fallopian

A

Ectopic
Hydrosalpinx
Malignancy

73
Q

Mass in connective tissue

A

Paraovarain cyst
Abscess
Broad ligament fibroid

74
Q

What are urgent symptoms

A

Severe pain
Fever
1st trimester bleed

75
Q

How does a tubal-ovarian abscess present

A

Lower abdominal pain
Fever
Discharge
Mass

76
Q

What are other Sx of adnexal mass

A 
Asymptomatic and found on routine USS 
Pelvic pain
Pressure Sx
Bloating 
Bleeding
Discharge
Fever
Infertility 
Ascites
Mass if extremely large
77
Q

What is associated with infertility

A

Endometrioma

Hydrosalpinx

78
Q

How do you investigate

A 
Pregnancy test
FBC
Abdo + pelvic exam
USS = 1st line 
Ca125
CT / MRI
Surgical exploration
79
Q

What suggest inflammation

A

Tender / pain

Fever

80
Q

What needs urgent intervention

A

Ectopic
Torsion
Malignancy

81
Q

What are types of ovarian cyst

A 
Follicular
CL cyst 
Dermoid 
Endometrioma - benign tumour 
Cystadenoma - serous or muconious
82
Q

What is endometrioma also known as

A

Chocolate cyst

83
Q

What causes follicular cyst

A

Non rupture of follicle
Will regress after a few cycles
Very common

84
Q

What causes CL cyst

A

If CL doesn’t break down i.e. due to pregnancy
Resolves by 2nd trimester
May notice in 1st
Fills with blood / fluid so can cause bleed

85
Q

What is dermoid cyst

A

From germ cell - teratoma
Con contain skin / hair / teeth
Usually asymptomatic but high risk of rupture
Main complications = torsion

86
Q

What is most common benign tumour in young

A

Dermoid

87
Q

How does ovarian cyst present

A 
Pain - dull ache
May be worse during sex
Bleeding
ABdo distension
Urinary Sx
Pressure - constipaiton / freq
88
Q

What happens if ruptures

A

Peritonitis
May happen after strenuous activity / intercourse
Present like torsion

89
Q

When is CL cyst likely to rupture

A

Menstruation

90
Q

When is CL unlikely

A

Post menopause as no eggs

91
Q

How do you investigate

A

USS - unilocular and smooth

If rupture = free fluid

92
Q

What needs biopsy

A 
Malignant suspected USS 
Complex cyst 
Multillocular
Septum
Papilla
93
Q

If <35 + smooth

A

Unlikely malignancy

Repeat USS

94
Q

When do you refer

A

Post menopause as follicular / CL unlikely

95
Q

What else do you do for complex as well as biopsy

A

AFP
BHCG
Ca-125
Cystectomy

96
Q

What is Meig syndrome

A

Benign ovarian mass - fibroma
Pleural effusion
Ascites

97
Q

How does ovarian torsion present

A

Sudden onset pain - unilateral iliac fossa

98
Q

What causes

A

Ovary twists and blood supply disrupted
Can lead to necrosis
Usually due to cyst or tumour

99
Q

If pain doesn’t resolve what happens

A 
Colicky
Severe
N+V
Restless
Fever
Leucocytosis
100
Q

How do you Dx

A

Tender palpable mass on examination
USS shows free fluid / whirldwind
Transvaginal > abdominal
Laparoscopy = Dx

101
Q

How do you Rx

A

Laparoscopy to untwist

Remove in infarction as won’t resolve

102
Q

Complication of cyst

A

Haemorrhage
Torsion
Rupture

103
Q

Complication of torsion

A

Pain
Infection
Rupture = peritonitis / adhesion
Loss of function of ovary due to ischaemia

104
Q

Most common cyst <20

A

Dermoid - high rupture risk

- Cytic teratoma

105
Q

Most common cyst overall

A

Follicualr

Obs & Gynae (23 decks)

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