Endometrial and Ovarian Cancer Flashcards
What is type 1 endometrial cancer
Endometriod adenocarcinoma
Most common
What is the precursor for type 1
Endometrial hyperplasia with atypia
What is type 2 endometrial cancer
Uterine serous = most common
Uterine clear cell
More aggressive and higher grade
What is a precursor for type 2
Serous intraepithelial carcinoma
What causes endometrial cancer
Stimulation of endometrium by oestrogen without protective effects of progesterone
Where is progesterone produced
CL in pregnancy
What are the RF for endometrial cancer
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
WHat is protective of endometrial cancer
OCP
Pregnancy
Mirena coil
Smoking
What cancer does HNPCC cause
Breast Ovarian Cervical Bowel Endometrial Prostate Ask in FH if anyone had these
How does endometrial cancer present
PMB
IMB if pre-menopause
Pain / discharge is unusual
What is PMB
Bleeding 12 months since last period
1 in 10 = cancer
What is endometrial cancer until proven otherwise
PMB
What makes you worry more and what should you do
Older patient with PMB or failed Rx
Refer urgent cancer pathway
What is important to ask in history
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
What investigations can be done in primary care
Urine dip - infection cause haematuria VE + speculum FBC - anaemia / bleed CA-125 for ovarian Rx menorrhagia - refer if failed pre-menopause
What is done at clinic
Transvaginal USS
Biopsy = diagnostic
What does USS assess
Endometrial thickness and contour
Should be thin in post-menopausal
When do you biopsy
If >4mm in post-menopause
If >10mm in pre-menopause
Do pipette with speculum or hysteroscopy
Dx by histology
What do you do if cervix too inflamed for biopsy
EUA
Hysteroscopy
How do you stage
Surgical / pathological
MRI
What do all patients on tamixoen with bleeding get
Transvaginal USS
HYsteroscopy
How do you treat hyperplasia with no atypia
Progesterone e.g. Mirena IUS
What else does USS pick up
Endometrial thickness Look at ovaries - shrink in post Follicles sugest residual activity Polyp Fibroid
Where would a polyp be discovered and how do you treat
Treat at hysteroscopy with myosure
Remove and send to lab
How is endometrial cancer staged
FIGO 1 = in uterine body / myometrium 2 = cervix 3 = belong uterus but confined to pelvis and PA noe 4 = involves bladder / bowel / inguinal
How do you treat endometrial cancer
Surgical trans abdominal hysterectomy + BSO
Washings
RT if LN +Ve
What do you give if high risk histology
Chemotherapy
What do you do if advanced
RT
Progesterone for palliation
What is advised if atypia
Hysterectomy
What are other causes of PMB
Atrophic vaginitis Resiual ovarian activity (peri-menopause) HRT Polyps Fibroids Endometrial hyperplasia Other cancers - cervix / vulval / bladder Vagina = rare Endometritis Cervicitis - C+G
Why don’t fibroids present with PMB
Usually calcify after menopause
What does prognosis depend on
Histological type and grade
Stage
Lymph vascular invasion
What causes endometrial hyperplasia
Age Smoking Unopposed oestrogen - nulli, early menarche Tamoxifen Obesity PCOS DM Thyroid Ovarian tumour that secrete hormones - sertoli. / granulosa
How does it present
Abnormal bleeding
If no atypia
Progesterone
Dilation and curettage for excess tissue
What do you do if atypia
TAH + BSO
What does tamoxifen do
Anti-oestrogen in breast
Pro-oestrogen in endometrium
What is most common type of ovarian cancer
Serous - germ cell
What are other type
Clear cell
Endometriod
Mucinous
How is ovarian cancer staged
FIGO 1 = limited to ovaries 2 = local spread to pelvis 3 = peritoneal spread 4 =distant mets, para-aortic, liver
What gene is associated with ovarian cancer
BRCA - AD
- Tumour suppressor gene involved in DNA repair
Also HNPCC
When would you be referred to genetic clinic
2+ relatives ovarian
1+ ovarian and 1+ breast
Known mutation
FH colon cancer
Who is considered high risk
Gene mutation
2+ relatives
What do high risk people get
Prophylactic oophorectomy and salpingectomy after family complete
How does ovarian cancer present
Vague Poor appetite Indigestion Altered bowel habit Bloating Weight gain Early satiety Abdo pain Pressure symptoms- urgency / diarrhoea
When should you suspect
Older women Non specific abdominal pain Blaoting Early satiety / poor appeitite Increased urinary frequency
What is DDX of bloating
IBS
Coeliac
IBD
GI cancer
How do you exclude Ddx
IBS rare in >50
Colonoscopy
Abdo USS
What are RF for ovarian cancer
Age - rare <30 HNPCC BRCA1+2 Incessant ovulation - nulli, early menarche, last menopause HRT Obesity Smoking Endometrisosi FH
What is protective
OCP
Pregnancy
Breast feeding
What do you do in GP is suspect ovarian cancer
Abdo and pelvic exam
Ca125
Refer USS urgent
Refer directly to gynaecologist URGENT if mass / ascites found O/E
What is Ca125 and what is abnormal
Protein antigen tumour marker
80% raised in ovarian
>35 = abnormal
What else can raised Ca125
Cyst Endometriosis Fibroids Menstruation PID COlon / pancreas / breast ca Liver effusion / cirrhosis Irritation of peritoneum
If Ca125 raised what do you do
Refer for USS
If suggest malignancy = refer
What are other investigation
CT for staging if USS cancer
Biopsy
Ascitic fluid tap if ascites
What is best way to Dx
Laparotomy + removal of ovary
What on USS suggest malignancy
Multi-locular Solid Bilateral Ascites Intra-abdominal
What score is used to calculate likelihood of cancer
RMI
USS x menopause xCa125
If symptoms of IBD in>50
OVARIAN CANCER
When do you do a Ca125
>50 Abdominal discomfort Early satiety Loss of appetite Pelvic / abdo pain Increased urinary
How do you treat ovarian cancer
Laparotomy + clearance = 1st line
Chemo in later stages
How do you monitor
Ca-125 every 5 years
What do you do if recurrent
Chemo
Palliate
Surgery 2nd line
What do you do if not fit for surgery or chemo
Tamoxifen (selective oestrogen receptor antagonist)
What is an adnexal mass
Mass of ovary / Fallopian tube or connective tissue
Most ovarianly
What helps determine cause
Location
Age
Reproductive status
If pre-menopausal
Likely benign Associated with menstrual cycle Endometrioma Follicular cyst CL cyst Dermoid Pregnancy
If post menopausal
Must exclude cancer
Ca-125 useful
If solid ovarian mass post menopausal
Ovarian cancer
Adnexal torsion
Fallopian mass + pain + bleed
Exclude ectopic
Ovarian mass
Cancer Metastatic Cyst CL cyst Endometrioma
Mass in fallopian
Ectopic
Hydrosalpinx
Malignancy
Mass in connective tissue
Paraovarain cyst
Abscess
Broad ligament fibroid
What are urgent symptoms
Severe pain
Fever
1st trimester bleed
How does a tubal-ovarian abscess present
Lower abdominal pain
Fever
Discharge
Mass
What are other Sx of adnexal mass
Asymptomatic and found on routine USS Pelvic pain Pressure Sx Bloating Bleeding Discharge Fever Infertility Ascites Mass if extremely large
What is associated with infertility
Endometrioma
Hydrosalpinx
How do you investigate
Pregnancy test FBC Abdo + pelvic exam USS = 1st line Ca125 CT / MRI Surgical exploration
What suggest inflammation
Tender / pain
Fever
What needs urgent intervention
Ectopic
Torsion
Malignancy
What are types of ovarian cyst
Follicular CL cyst Dermoid Endometrioma - benign tumour Cystadenoma - serous or muconious
What is endometrioma also known as
Chocolate cyst
What causes follicular cyst
Non rupture of follicle
Will regress after a few cycles
Very common
What causes CL cyst
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
What is dermoid cyst
From germ cell - teratoma
Con contain skin / hair / teeth
Usually asymptomatic but high risk of rupture
Main complications = torsion
What is most common benign tumour in young
Dermoid
How does ovarian cyst present
Pain - dull ache May be worse during sex Bleeding ABdo distension Urinary Sx Pressure - constipaiton / freq
What happens if ruptures
Peritonitis
May happen after strenuous activity / intercourse
Present like torsion
When is CL cyst likely to rupture
Menstruation
When is CL unlikely
Post menopause as no eggs
How do you investigate
USS - unilocular and smooth
If rupture = free fluid
What needs biopsy
Malignant suspected USS Complex cyst Multillocular Septum Papilla
If <35 + smooth
Unlikely malignancy
Repeat USS
When do you refer
Post menopause as follicular / CL unlikely
What else do you do for complex as well as biopsy
AFP
BHCG
Ca-125
Cystectomy
What is Meig syndrome
Benign ovarian mass - fibroma
Pleural effusion
Ascites
How does ovarian torsion present
Sudden onset pain - unilateral iliac fossa
What causes
Ovary twists and blood supply disrupted
Can lead to necrosis
Usually due to cyst or tumour
If pain doesn’t resolve what happens
Colicky Severe N+V Restless Fever Leucocytosis
How do you Dx
Tender palpable mass on examination
USS shows free fluid / whirldwind
Transvaginal > abdominal
Laparoscopy = Dx
How do you Rx
Laparoscopy to untwist
Remove in infarction as won’t resolve
Complication of cyst
Haemorrhage
Torsion
Rupture
Complication of torsion
Pain
Infection
Rupture = peritonitis / adhesion
Loss of function of ovary due to ischaemia
Most common cyst <20
Dermoid - high rupture risk
- Cytic teratoma
Most common cyst overall
Follicualr
