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YEAR 4 REPRO > Gynae Cancer > Flashcards

Gynae Cancer Flashcards

1
Q

What health-screening programmes are available for women at the moment?

A

Cervical screening offered from 25-64
Breast screening offered from 50-74

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2
Q

What is screening and why do we do it?

A

What? A way of identifying apparently healthy peole who may have an increased risk of a particular condition

Why? Can find out conditions early to allow for further diagnostic tests. Can then be offered treatment (sooner = more effective), advice and support.

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3
Q

Define lead-time bias

A

Early diagnosis of a disease falsely makes it look like people are surviving longer.

Another definition:
health outcome is the same in someone whose disease is detected by screening compared with someone whose disease is detected from symptoms, but survival time from the time of diagnosis is longer in the screened patient.

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4
Q

What is length time bias?

A

Length time bias occurs when patients with less severe diseases are more likely to have them detected during screening. Length time bias leads us to think that it was the screening was responsible for higher survival rates (but the conditions picked up are just slower growing )

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5
Q

What does cervical screening look for?

A

Looks for HPV
Also sees if there are any changes in cells (dyskaryosis) in the transitional zone (aka the squamocolumnar junction) which can then lead to cancer/malignant changes.

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6
Q

What type of cells/epithelium make up the cervix?

A

Stratified squamous epithelium

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7
Q

Age distribution of cervical cancer?

A

Bimodal age distribution - 30s and 80s

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8
Q

What cells make up cervical cancer?

A

Squamous cell carcinoma = 2/3rd (66%)
15% are adenocarcinoma

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9
Q

What increases the risk of cervical cancer?

there are a lot!

A
  • HPV
  • Young age of first intercourse
  • multiple sexual partners
  • exposure (no barrier contraception)
  • smoking
  • long use of COCP
  • immunosuppression/HIV
  • non compliance with cervical screening
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9
Q

What lowers risk of cervcial cancer?

A

HPV vaccine
Cervical screening compliance

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10
Q

What are high risk types of HPV which can lead to cervical cancer?

A

16, 18
some others: 31, 33, 34, 35, 39

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11
Q

Which types of HPV are low risk for causing cervical cancer?

A

6, 11, 42, 43, 44

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12
Q

How does HPV infection lead to cervical cancer?

A

HPV (especially subtypes 16 and 18) produce proteins E6 and E7
These proteins suppress tumour suppressor genes such as p53 and Rb in keratinocytes
So cells of cervix proliferate excessively, and develop changes in additional genes - which can lead to cancer

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13
Q

Symptoms of HPV?

A

Asymptomatic

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14
Q

What are the possible outcomes of a HPV infection?

A
  • regress
  • persist
  • cause CIN - cervical intraepithelial neoplasia
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15
Q

Describe the criteria for cervical screening

from oxford specialities book

A
  • sexually active women 25-64
  • every 3 years if 25-50
  • every 5 years from 50-64
  • yearly for HIV positive women
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16
Q

Cervical smear screening results:
High-risk HPV detected. (hr-hpv)
Cytology normal

How would you manage this?

oxford handbook

A

Repeat the smear in 12m; if HR-HPV is negative = continue as normal recall (every 3-5 years as required based on age).
If positive = colposcopy

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17
Q

Cervical smear screening results:
HR-HPV detected
Cytology borderline, mild, moderate or severe

How would you manage this?

A

Colposcopy referral
Management depends on CIN
* If colposcopy is negative, continue as a routine recall (every 3-5 years as needed based on age)
* CIN I = repeat smear in 12m
* CIN II and III = LLETZ - large loop exision of the transformation zone

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18
Q

Cervical smear screening results:
HR-HPV deteted and shows moderate dyskaryosis
Cytology shows treated CIN

How would you manage this?

FROM OXFORD HANDBOOK

A

Repeat smear at 6m

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19
Q

Cervical smear screening results:
HR-HPV detected
Cytology shows suspected invasion / abnormal cytology

What would management be for this?

A

50% invasion = need 2ww referral to colposcopy

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20
Q

Describe changes in CIN I - CIN III based on histology?

A
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21
Q

Symptoms/Presentation of cervical cancer?

A

Persistant unexplained abnormal bleeding (which is not secondary to infection)
* PCB
* PMB and not taking HRT
* IMB
* PMB if there is an increase in heaviness, duration of bleeding or irregular bleeding if taking sequential HRT, bledding beyond 6m, or after spell of amenorrhea if taking continuous HRT

Blood stained vaginal discharge
Pelvic pain
Abnormal appearance of cervix

Could also present with complication of advanced disease:
fistulae, renal failure, nerve root pain, lower limb odema

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22
Q

Describe stages 1-4 of cervical cancer

A

Stage 1 = confined to cervix
Stage 2 = beyond cervix but not pelvic side wall or lower 1/3 of vagina
Stage 3 = pelvic spread, reaches side wall or lower 1/3 of vagina. 3a is lower 1/3 of vagina, hydronephrosis. 3b extends into pelvic side wall, hydronephrosis
Stage 4 = distant spread. 4a = invades adjacent organs (bladder/bowel). 4b =distant sites.

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23
Q

Risk factors for CIN (cervical intraepithelial neoplasia)?

A
  • persistent high risk HPV (HR-HPV) infection
  • multiple sexual partners - as have increased exposure to HPV
  • smoking
  • immunocompromised (HIV, transplant patients, immunosuppressants)
  • oral contraceptive pill is associated with CIN, probably due to reduced use of barrier contraception.
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24
What may be seen on examination in a pt with cervical cancer? a) on colposcopy? b) on bimanual exam? c) on speculum examination?
*a) on colposcopy:* irregular cervical surface, abnormal vessels and dense uptake of acetic acid *b) on bimanual exam: * cervix feels roughened and hard *c) on speculum examination:* irregular mass that will bleed with contact
25
Treatment of cervical cancer: If microinvasive carcinoma is found?
Treatment can be more conservative. If fertility is an issue, cone biopsy can be used. Once family is complete, hysterectomy is appropriate.
26
Treatment of cervical cancer: If clinical lesions (stage 1b-2a) are found?
Wertheim's radical hysterectomy or chemoradiotherapy (survival same for these)
27
Treatment of cervical cancer: If clinical lesions beyond stage 2a are found?
Chemoradiotherapy
28
Treatment of cervical cancer: if there is lymph node involvment?
Postoperative radiotherapy
29
Treatment of cervical cancer: If there is recurrent disease?
Radiotherapy, chemotherpay, exenteration (complete removal of organs from that area/cavity of the body), palliative care
30
Complications of **surgically** treating cervical cancer?
* Infection * VTE * haemorrhage * vesicovaginal fistula * bladder dysfunction * lymphocyst formation * short vagina
31
Complications of treating cervical cancer with **radiotherapy**?
* vaginal dryness * vaginal stenosis * radiation cystitis * radiation proctitis * loss of ovarian function
32
What is colposcopy?
Low-power binocular microscopy of cervix Looks for features suggestive of CIN or invasion * abnormal vascular pattern * abnormal staining of the tissue (aceto-white, bown iodine)
33
Treatment options for CIN?
* see and treat concept * excisional treatment - LLETZ, cold knife cone * destructive treatment - cryocautery, diathermy, laser vaporisation (not used much in UK) * after colposcpy, follow up (depending on what was found)
34
What does this show?
Normal cervix
35
What does this show?
Acetowhite cervix - seen in colposcopy on abnormal cervix
36
What does this show?
Iodine negtive cervix on colposcopy - abnormal
37
What does this show?
Invasive Cervical carcinoma
38
Differentials for vulval lumps?
Vulal carcinoma Local varicose veins Boils Sebacous cysts Bartholin's cyst or abscess Uterine prolapse or polyp Inguinal hernia Varicoele Viral warts Painless genital ulcer from syphilis Molluscum contagiosum
39
What is vulval intraepithelial neoplasia (VIN)?
Pre-malignant condition Can resolve spontaneously Can progress to vulval cancer
40
How can VIN present? | vulval epitherlial neoplasia
Asymptomatic Can present with itching, burning, pain
41
How is VIN treated? conservative, medical, surgical
Conservative - antihistamine given for symptom control Medical - imiquimod Surgical - excision
42
Risk factors for VIN?
* HPV (having vaccine reduces incidence) * HSV Type 2 * smoking * immunosuppression * Chronic vulvar irritation * Lichen sclerosus
43
Epidemiology of vulval cancer?
v rare elderly patients 70-80 yrs
44
Cell type/ make up of vulval cancer?
SCC = 90% Other 10% = melanoma, BCC or carcinoma of Bartholin's glands
45
Presentation of vulval carcinoma?
Elderly lady 70s-80s Lump Indurated (hardened) ulcer Not noticed unless causes pain and bleeds - so often presents late
46
Treatment for vulval cancer?
Surgery - excision +/- LN excision if involved and removal of inguinal glands Radiotherapy/Chemoradiotheapy (can also be used pre-op to shrink tumours)
47
Complications of LLETZ for CIN?
* haemorrhage * infection * vaso-vagal symptoms * anxiety * cervical stenosis * small risk of cervical incompetence and premature delivery
48
Aetiology of vaginal cancer?
Most common - metastatic spread from cervical, uterine and vulval cancer
49
Primary vaginal cancer: 1. age it affects? 2. type of cell? 3. assocations/risk factors? 4. where in the vagina does it present?
1. older women 2. squamous cell vaginal carcinoma 3. previous CIN, pelvic radiotherapy, long term vaginal inflammation (from pessaries or complete uterine prolapse), HPV 4. upper third of the vagina (most common)
50
Primary vaginal cancer: 1. presenting complaint? 2. where does it spread to, and how/via...? 3.treatment? 4.prognosis?
1. PV bleeding 2. local spread, via lymphatics 3. radiotherapy usually 4. poor
51
Presenting complaint for endometrial cancer?
Post menopausal vaginal bleeding
52
Endometrial cancer - what is the cell type?
Adenocarcinoma
53
Association to having endometrial cancer (which may be in the stem of a qu)?
Pt had excesive exposure to unopposed oestrogen (ie preparation without oestrogen)
54
RFs for endometrial cancer?
* Obesity, T2DM, HTN = all increase peripheral oestrogens * Nulliparity (pregnancy is associated to high progesterone levels, so not being pregant = more unopposed oestrogen than if you were) * Anovulatory cycles (eg PCOS - have absence of corpus luetum so less progesterone) * Early/late menopause - get shift in hormone balance * Genetic predisposition - HNPCC (Lynch II syndrome). * Breast cancer (use of tamoxifen) * Oestrogen only HRT
55
HNPCC is a gene that is a high risk RF for endometrial cancer. What other cancers is it associated to?
Colorectal Ovarian
56
Protective factors against endometrial cancer?
COCP parity
57
How does endometrial cancer present?
* Most common - PMB * If premenopausal, bleed is heavy or irregular * PV discharge * (Pyometra - uterine infection)
58
Endometrial cancer: What is seen on... 1. examination of woman when she attends Dr with PMB? 2. on transvaginal scan?
1. normal 2. endometrial thickness >4mm
59
**Diagnostic** investigations for endometrial cancer?
Biopsy - either in outpatients or with hysteroscopy
60
Once diagnosis of endometrial cancer is made, what investigations are done, and why?
CT or MRI Why? to help with preoepratively stage the cancer
61
For endometrial cancer, what is used to indicate prognosis?
Grade of differentiation FIGO staging
62
Descirbe FIGO staging I, II, III, IV
I - the tumour is in the body of the uterus only. II - the tumour is in the body of the uterus and the cervix only III - the tumour is advnacing beyond the uterus, but not beyond the pelvis IV - the tumour is extending outside the pelvis (e.g. into bowel and bladder)
63
Treatment for endometrial cancer?
Depends on FIGO stage and functional status of pt Ideal - total hysterectomy with bilateral salpingo-oophrectomy (laparoscopically if possible) Low grade disease with deep myometrial invasion = total hysterectomy w/ bilat sal-ooph AND adjuvant radiotherapy V advanced disease = high dose progesterone helps w/ palliation of symptoms. External beam radiotherapy can help to control bleeding
64
Mechanism of action of tamoxifen?
selective estrogen receptor modulator BNF: An anti-oestrogen which induces gonadotrophin release by occupying oestrogen receptors in the hypothalamus, thereby interfering with feedback mechanisms
65
Tamoxifen is a selective oestroegn receptor modulator used in the treatment of breast cancer. Why is it a RF for endometrial cancer?
Z2F: Tamoxifen has an anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium. So... endometrial cells that have pre-existing mutations have a growth advantage via oestrogenic alterations. This increase the risk of endometrial cancer
65
Tamoxifen is a selective oestroegn receptor modulator used in the treatment of breast cancer. Why is it a RF for endometrial cancer?
Z2F: Tamoxifen has an anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium. So... endometrial cells that have pre-existing mutations have a growth advantage via oestrogenic alterations. This increase the risk of endometrial cancer
66
Age for ovarian cancer?
75-84
67
Why does ovarian cancer have a lower prognosis than endometrial or cervical cancer?
* it presents late * has vague symptoms * insidious onset
68
RF for ovarian cancer?
* Nulliparity * Early menarche and late menopause * Gene mutations in BRCA * HNPCC gene
69
Protective factors for ovarian cancer?
COCP Pregnancy Breastfeeding Tubal ligation (female sterilisation)
70
How does ovarian cancer present?
* vague symptoms misinterpreted as IBS or diverticular disease * Bloating * Loss of appetite, early satiety, unexplained weight loss * Fatigue * Urinary symptoms * Change in bowel habit * Abdo or pelvic pain * Vaginal bleeding * Pelvic mass palpable
71
What may be seen on examination of lady with ovarian cancer?
* Abdo/pelvic mass * ascites * omental mass * pleural effusion * supraclavicular LN enlargement
72
Inv for ovarian cancer?
* FBC, U+Es, LFTs * Tumour markers: Ca125, CEA (raised in colorectal but normal in ovarian), ca19-9 (raised in mucinous tumours) * If lady is younger than 40, do AFP, LDH and hCG * TVS * CXR - look for pleural effusion and lung mets * MRI - help distinguish beningn from malignant disease
73
Treatment options for ovarian cancer?
**Surgery**: full staging laparotomy. This involves: * midline laparotomy * hysterectomy + bilateral salpingo-oophrectomy * omentectomy - remove omentum * para-aortic and pelvic LN sampling * peritoneal washings and biopsies **Chemotherapy** : recommended for everyone after surgery unless low grade or stage 1a or 1b.
74
Describe FIGO staging for ovarian cancer: I, II, III, IV
I: limited to one or both ovaries. (1a = one ovary. 1b = both. 1c = if capsule is breached and tumour is present on ovarian surface or present in pertioneal washings) II: limited to the pelvis III: limited to the abdomen, including regional LN mets IV: Distant mets outsidef abdominal cavity
75
Borderline ovarian tumours: 1. benign or malignant? 2. age group? 3. characteristics 4. treatment?
1. malignant 2. younger women, premenopausal 3. confined to one ovary, premenopausal, metastatic implants, hard to diagnose histologically 4. conservative surgery - unilateral oophrectomy and staging biopsies
76
What type of disease is lichen sclerosis?
Autoimmune - 40% of pts with this develop other AI disorders such as T1DM, alopecia, hypothyroidism and vitiligo
77
Presentation of lichen sclerosis?
From Z2F: Woman aged **45 – 60** years complaining of **vulval itching** and **skin changes** in the vulva. The condition may be **asymptomatic**, OR present with **several symptoms**: * Itching * Soreness and pain possibly worse at night * Skin tightness * Painful sex (superficial dyspareunia) * Erosions * Fissures
78
What is Koebner phenomenon with regard to lichen sclerosis?
Koebner phenomenon = signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching
79
What is seen on examination of skin in woman with lichen sclerosis?
Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin. The affected skin appears: * “Porcelain-white” in colour * Shiny * Tight * Thin * Slightly raised * There may be papules or plaques * There may be hourglass shape around vulva and anus
80
Treatment for lichen sclerosis?
Clobetasol propinate cream (dermovate daily for 28days, then alternate days for 4 weeks, then twice weekly for 8 weeks) If steriod unresponsive = use topical tacrolimus (specialist needs to do this)
81
Complications of lichen sclerosis?
* 5% become squamous cell carcinoma of the vulva * Pain and discomfort * Sexual dysfunction * Bleeding * Narrowing of the vaginal or urethral openings

YEAR 4 REPRO (26 decks)

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