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OnG Active > Gargi & Emma's Notes - Gynae > Flashcards

Gargi & Emma's Notes - Gynae Flashcards

1
Q

What is vulval cancer?

A

Cancer of the vulva (external genitalia)

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2
Q

What is the aetiology of vulval cancer?

A

90% are squamous cell carcinomas; remainder are malignant melanoma, basal cell carcinoma and adenocarcinoma of the Bartholin gland

Squamous cell carcinoma has 2 aetiologies:

  • HPV-associated: arise on a background of high-grade vulval intraepithelial neoplasia (VIN3); affects younger women
    → VIN: multifocal leukoplakic, erythematous or pigmented lesions caused by high-risk HPV; 10% risk of malignancy
  • Non-HPV associated: associated with lichen sclerosus; affects older women
  • Spread is local, then lymphatic spread via inguinofemoral and pelvic lymph nodes
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3
Q

How is vulval cancer staged?

A

Staging (FIGO):

  • Stage 1: tumour confined to vulva/perineum, negative nodes
    • 1A: ≤2cm in size, stromal invasion ≤1mm
    • 1B: >2cm in size or stromal invasion >1mm
  • Stage 2: tumour of any size extending to lower 1/3 of urethra or vagina, or anus, negative nodes
  • Stage 3: as for stage 2, but positive inguinofemoral lymph nodes
    • 3A1: 1 lymph node metastasis ³5mm
    • 3A2: 1-2 lymph node metastases <5mm
    • 3B1: ³2 lymph node metastases ³5mm
    • 3B2: ³3 lymph node metastases <5mm
    • 3C: extracapsular spread
  • Stage 4: regional or distant spread
    • 4A1: upper urethra/vaginal mucosa, bladder or rectal mucosa, fixed to pelvic bone
    • 4A2: fixed or ulcerated inguinofemoral lymph nodes
    • 4B: distant metastases, including pelvic lymph nodes
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4
Q

What are the symptoms of vulval cancer?

A
  • Vulval lump/swelling/ulcer
  • May be itchy or painful
  • Bleeding or discharge
  • May have inguinal lymphadenopathy (hard, craggy, fixed subcutaneous swellings)
  • May have associated pre-malignant disease
    • VIN may be asymptomatic, or itchy/irritated
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5
Q

What are the Ix for ?vulval cancer?

A
  • Examination of external genitalia
  • Biopsy
    • To confirm diagnosis
  • Cervical smear
    • If VIN-associated; to exclude CIN
  • Bloods: FBC, U&Es
  • Staging: cystoscopy, proctoscopy, CT CAP, MRI (LN involvement), CXR
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6
Q

What is the Mx of vulval cancer?

A

Specialist gynae oncology MDT approach (gynae onc surgeons, radiologists, histopathologists, specialist nurses)

Surgery:

  • Early-stage disease: wide radical local excision +/- inguinofemoral lymphadenectomy
    • Clear margin of >10mm is ideal (difficult if close proximity to urethra/anus)
    • Sentinel LN biopsy may be done to determine whether full lymphadenectomy is needed
  • Large/multifocal lesions: radical vulvectomy +/- inguinofemoral lymphadenectomy
    • May need vulval reconstruction

Radiotherapy:

  • External-beam radiation
  • Adjuvant treatment after surgery if excision margins are small; neoadjuvant for large tumours that are close to anus/urethra (to shrink before surgery); advanced disease or when surgery is not possible
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7
Q

What are the complications of vulval cancer?

A

Complications:

  • Psychosexual implications
  • Surgical complications: wound breakdown, infection, chronic lymphoedema (if lymphadenectomy
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8
Q

What is the prognosis of vulval cancer?

A

May present late due to embarrassment

  • 5-year survival: stage 1: 90%; stage 2: 50%; stage 3: 30%; stage 4: 15%

N.B. VIN may resolve spontaneously, or takes 10yrs to progress to cancer

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9
Q

What is the aetiology of cervical cancer?

A

70% are squamous cell carcinomas; 15% adenocarcinoma; 15% mixed

Develops as a progression from CIN, which takes 10-20 years

  • Not all CIN progresses to cancer
  • Invasive cervical cancer occurs when the basement membrane of the epithelium has been breached
  • Spread is direct to parametria (lateral to cervix), bladder, vagina and rectum; metastases via lymphatics (pelvic and para-aortic LNs to liver and lungs)
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10
Q

What are the risk factors for cervical cancer?

A
  • HPV infection,
  • smoking,
  • other STIs,
  • immunodeficiency
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11
Q

How is cervical cancer staged?

A

Staging (FIGO):

  • Stage 1: tumour confined to cervix
    • 1A: microscopic disease
      • 1A1: maximum horizontal dimension 7mm and depth 3mm
      • 1A2: maximum horizontal dimension 7mm and depth 3-5mm
    • 1B: clinical lesions confined to cervix or preclinical lesions greater than 1A
      • 1B1: clinical lesions <4cm in size
      • 1B2: clinical lesions >4cm in size
  • Stage 2: tumour extends beyond the cervix and involves vagina (not lower 1/3) and/or parametrium (not reaching pelvic side wall)
    • 2A: tumour involves vagina
    • 2B: tumour involves parametrium
  • Stage 3: tumour involves lower 1/3 of vagina and/or extends to pelvic side wall
    • 3A: tumour involves lower 1/3 of vagina
    • 3B: tumour extends to pelvic wall and/or causes hydronephrosis/non-functioning kidney
  • Stage 4: further spread
    • 4A: tumour involves bladder or rectum and/or extends beyond true pelvis
    • 4B: spread to distant organs
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12
Q

What are the symptoms of cervical cancer?

A
  • May be asymptomatic → incidental finding on LLETZ for CIN
  • Abnormal vaginal bleeding → PCB, IMB, PMB
  • Dyspareunia, pelvic pain
  • Vaginal discharge (mucoid/purulent)/blood stained)
  • Late symptoms (from mets): black pain (spread to spinal cord), anaemia (chronic vaginal bleeding), renal failure (ureteric blockage), incontinence (vesicovaginal fistulae), haematuria, pressure symptoms
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13
Q

What may be seen O/E in cervical cancer?

A
  • On examination:
    • Speculum: macroscopic tumour/discolouration/ulceration/erosion on cervix; may bleed on contact
    • Vaginal/abdo: mass (if pelvic spread)
    • Chest: possible pulmonary mets
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14
Q

What are the Ix for ?cervical cancer?

A
  • Speculum, bimanual, abdo, chest examinations
  • Colposcopy and biopsy (<2wks)
    • Confirms diagnosis, identifies subtype

If the diagnosis of cervical cancer is confirmed:

  • Basic bloods: FBC (anaemia), LFTs (liver/bone involvement), U&Es (renal involvement)
  • Staging: CXR, cystoscopy, barium enema/proctoscopy, CT CAP, MRI, PET etc

N.B. cervical smears detect CIN, not cancer

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15
Q

What is the Mx of cervical cancer?

A

MDT approach

Depends on stage of disease and requirement for future fertility

Surgery:

  • Stage 1A1 (micro-invasive): cone biopsy excision; remove co-existing CIN
    • Allows fertility to be preserved
  • Stage 1A2-2A (early stage): radical hysterectomy + lymphadenectomy
    • Usually laparotomy (laparoscopic has lower survival rates)
    • Radical trachelectomy considered if fertility is desired (removal of cervix and upper part of vagina) + lymphadenectomy

Chemoradiotherapy:

  • External beam radiation/brachytherapy + cisplatin-based chemotherapy
  • Indications:
    • Stage 1A1-1B1 if positive margins/positive nodes (postoperatively)
    • Instead of surgery if tumours >4cm (1B2, 2A2)
    • Locally advanced or metastatic disease (2B and above)
      • Surgery is not attempted because unlikely to remove all of the tumour

Recurrent tumours:

  • Chemo-radiotherapy if not already given
  • Pelvic extenteration (removal of vagina, uterus, cervix, bladder and rectum)

Palliative therapy if it is not possible to offer curative treatment

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16
Q

What are the complications of cervical cancer?

A

Complications:

  • Metastases → renal failure, oedema etc, death
  • Complications of treatment:
    • Surgery: infertility, bladder/bowel dysfunction, sexual dysfunction, lymphoedema
    • Radiotherapy: bladder/bowel dysfunction, rash, bowel perforation, menopause

Obstetric complications:

  • Cervical abnormalities are harder to treat in pregnancy → ethics about whether pregnancy should be terminated to facilitate treatment
17
Q

What is the prognosis of cervical cancer?

A

Overall 5yr survival 65%;

  • stage 1: 83%;
  • stage 2: 65%;
  • stage 3: 36%;
  • stage 4: 10%
18
Q

What is a polyp?

A

An abnormal, benign, growth of issue which projects from a mucous membrane

19
Q

What are the different types of polyp?

A
20
Q

What is the aetiology of polyps?

A

Endometrial:

  • Benign tumours that grow into the uterine cavity; usually endometrial but may be from submucosal glands

Cervical:

  • Arise from endocervical columnar epithelium
  • Aetiology is unknown
  • Associated with high oestrogen, chronic inflammation and atherosclerotic blood vessels
  • Do not respond to normal hormonal changes (like normal endometrium)  unscheduled vaginal bleeding
21
Q

What is the epidemiology of polyps?

A

Common in women aged 40-50yo

22
Q

What are the symptoms of polyps?

A
  • Often asymptomatic
  • Endometrial:
    • Intermenstrual bleeding (usually spotting)
    • Irregular menstrual bleeding, HMB
    • Vaginal discharge (white/yellow mucus)
  • Cervical:
    • Contact bleeding  post-coital bleeding, bleeding after vaginal examination
23
Q

What are the symptoms of polyps?

A
  • Often asymptomatic
  • Endometrial:
    • Intermenstrual bleeding (usually spotting)
    • Irregular menstrual bleeding, HMB
    • Vaginal discharge (white/yellow mucus)
  • Cervical:
    • Contact bleeding  post-coital bleeding, bleeding after vaginal examination
24
Q

What might be seen O/E in polyps?

A
  • On examination:
    • Cervical can be seen on speculum examination (may be identified on routine smear)
      • Endometrial may prolapse through the cervix → may look like cervical polyp
25
Q

What are the Ix for ?polyps?

A
  • Speculum examination
  • TVUSS
    • Endometrial: endometrial thickening, hypoechoic protrusion from the endometrium
      • May use hysterosonography (saline injected into uterus) → clearer view during USS
    • Cervical: shows polyp
  • Hysteroscopy
    • Visualisation of polyp
  • Histological examination of polyp after removal
26
Q

What is the Mx of polyps?

A

Symptomatic women:

  • Polypectomy
    • Cervical: avulsion with polyp forceps; outpatient procedure; anaesthetic not usually needed
    • Endometrial: polypectomy via hysteroscope; outpatient procedure +/- local anaesthesia
    • Histological examination to exclude malignany
  • Medical management:
    • Can control bleeding with tranexamic acid, NSAIDs, COCP etc.

Asymptomatic premenopausal women:

  • Management is based on risk of endometrial cancer
    • If high risk or subfertile → polypectomy

Asymptomatic postmenopausal women:

  • Polypectomy (as higher risk of endometrial cancer than premenopausal
27
Q

What are the complications of polyps?

A

Complications:

  • Subfertility (may block cervical canal, prevent implantation if multiple)
  • Recurrence (10%)
  • 1% risk malignant transformation (endometrial/cervical cancer)
  • Complications of polypectomy: bleeding, infection, uterine perforation (rare)
    • Do not attempt to remove polyps that are not easily visible without Ix (i.e. from cervical canal)
28
Q

What is the prognosis of polyps?

A

Excellent prognosis after removal

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