Gynae Cancers Flashcards
What are the RFs for endometrial cancer?
Anovulation
- Early menarche and/or late menopause
- Low parity
- Polycystic ovarian syndrome
- HRT with oestrogen alone.
- Tamoxifen
Age: 65 and 75
Obesity
Hereditary Factors: HNPCC Lynch. 2
How does endometrial cancer present?
- postmenopausal bleeding (PMB)
- IMB
- Uncommon: clear or white vaginal discharge, or with abnormal cervical smears.
- Rare in premenopausal women: irregular bleeding or IMB
- Advanced: abdominal pain or weight loss.
Give some differential dx for PMB
- Vulval – vulval atrophy, vulval pre-malignant or malignant conditions.
- Cervical – cervical polyps, cervical cancer
- Endometrial – hyperplasia without malignancy, benign endometrial polyps, endometrial atrophy.
How is endometrial cancer ixd?
- TVS: measure endometrial thickness
- >4mm in PMB - hysteroscopy + endometrial biopsy
- Staging (if cancer): MRI / CT
- baseline bloods: FBC, U&Es, LFTs, G+S
What staging is used for endometrial cancer?
Stage I – Carcinoma confined to within uterine body.
Stage II – Carcinoma may extend to cervix but is not beyond the uterus.
Stage III – Carcinoma extends beyond uterus but is confined to the pelvis.
Stage IV – Carcinoma involves bladder or bowel, or has metastasised to distant sites.
How is endometrial cancer mxd?
Stage I – lap. TAH+ BSO, Peritoneal washings
Stage II – Radical hysterectomy + removal of pelvic lymph nodes (lymphadenectomy) (stage Ic or II) - +/- adjuvant radiotherapy.
Stage III – Maximal de-bulking surgery + chemo (prior to radiotherapy)
Stage IV – Maximal de-bulking surgery. Palliative: low dose radiotherapy, or high dose oral progestogens.
What are the RFs for ovarian cancer?
Nulliparity
Early menarche
Late menopause
Hormone replacement therapy containing oestrogen only
Smoking
Obesity
FH: BRAC1/2 + HNPCC
Protective: COCP, breastfeeding, multiparity
How does ovarian cancer present?
- Bloating
- Change in bowel habit
- Change in urinary frequency
- Weight loss
- Irritable bowel syndrome
- Bleeding per vagina
- Incidental and asymptomatic
- Chronic pain – may develop secondary to pressure on the bladder or bowel also causing frequency or constipation.
HOW is ovarian cancer ixd?
bloods: FBC, U&E, LFT and albumin. CA125
Abdominal + pelvic US pelvic masses - calculate RMI
Confirmed cancer: CXR + CT abdomen/pelvis - staging
How is ovarian cancer mxd?
- Staging laparotomy
- TAH+BSO: Total abdomino hysterectomy, bilateral salpingo-oophorectomy, omentectomy
- Para aortic pelvic lymph node sampling
- Peritoneal washing + biopsy
- Adjuvant Chemotherapy: Platinum (Cisplatin, carboplatin) and Taxane (paclitaxel)
- Follow up – involves clinical examination and monitoring of CA125 level for 5 years
How is ovarian cancer staged?
What are some RFs for cervical cancer?
- Smoking
- STIs: HPV
- Other sexually transmitted infections
- Long-term (> 8 years) COCP use
- Immunodeficiency (e.g. HIV)
- HPV
How can HPV causes cancer?
HPV (esp 16 & 18) -> produce proteins (E6&7) -> suppress the products of ‘p53’ tumour suppressor gene in keratinocytes
How does cervical cancer presnent?
- Abnormal vaginal bleeding (PCB, IMB, PMB)
- Vaginal discharge (blood-stained, foul-smelling)
- Dyspareunia
- Pelvic pain
- weight loss.
- Asymptomatic
What are some late fx of cevical cancer?
oedema, loin pain, rectal bleeding, radiculopathy and haematuria
What are some differentials for cervical cancer?
STIs, cervical ectropion, polyp, fibroids, and pregnancy related bleeding.
How is suspected cervical cancer ixd?
- Pre-menopausal – STI (chlamydia trachomatis) -> +ve -> mx -> sx persist -> refer for colposcopy and biopsy.
- Post-menopausal – urgent colposcopy (acetic acid) + biopsy.
- If diagnosed:
- Basic blood tests –FBC, LFT, UE
- Staging: CT Chest-Abdomen-Pelvis, MRI pelvis, PET.
- +/- EUA
What are the stages of cervical cancer?
Stage 0 – Carcinoma in-situ
Stage 1 – Confined to cervix
Stage 2 – Beyond cervix but not pelvic sidewall/ involves vagina but not lower 1/3
Stage 3 – Extends to pelvic sidewall/ involves lower 1/3 vagina/ hydropnephrosis not explained by another cause.
Stage 4 – Extends to bladder or rectum, or metastases
How is cervical cancer mxd?
- Stage 1a: Radical trachelectomy/ cone biopsy (rare) - fertility preserving. Family complete - lap. hysterectomy + pelvic lymphadenectomy
- Stage 1b/2a: Radical (Wertheim’s) hysterectomy :removal of the uterus, vagina and parametrial tissues up to the pelvic sidewall, + lymphadenectomy.
- Stage 4a or Recurrent disease: Anterior/posterior/total pelvic extenteration. Removal of all pelvic adnexae plus bladder (anterior)/rectum (posterior or both (total).
- Chemoradiation: can be offered stage 1b - 3 as alternative to surgery Radiotherapy can be delivered in the form of intracavity brachytherapy.
- Chemotherapy: cisplatin-based (neo/adjuvant). Palliative.
- Follow-Up: reviewed by a gynaecologist every 4 months after treatment has been completed for the first 2 years, and every 6-12 months for the subsequent 3 years.
*
How is CIN mxd?
1: Watch + wait, most regress spont.
II/III: LLETZ, cold knife cone. 6 monthly smears (HPV testing) for test of cure. If +ve -> repeat assessment via colposcopy. -ve -> return to routine 3y (or 5) yearly smears
What are cervical extropions how are they mxd
TZ: stratified squamous meets columnar.
Raised oestrogen: pregnancy, COCP, ovulation -> larger area of columnar epithelium on ectocervix
Sx: PCB, vaginal discharge
Mx: ablative tx, cold coagulation if troublesome
How is `VIN mxd
Conservative: Antihistamine
Medical: Imiquimod
Surgical: Excision. Surveillance + biopsy. Bad: laser, excision -> high rate of recurrence
What are some RFs for vulval cancer
RFs: HPV, HSV 2, Smoking, Immunosuppression, Chronic vulvar irritation, Lichen Sclerosis
How does vulval cancer present
Sx: lump, ulcer (often unnoticed), late: pain, bleeding
Mainly SCC: 50% by HPV. 50% Chronic skin disease. Others: BCC, melanoma
How is vulval cancer mxd
Mx: Surgery: anatomical considerations, neoadjuvant radiotherapy/ chemoradiotherapy (shrink tumour)
SURGERY: vulvectomy +/- skin grafts
<2cm width <1mm depth: lymph node excision not required
>over: do WLE. + removal of inguinal glands
Chemoradiotherapy: palliative/ unsuitable for surgery/ shrink large tumours pre op
How does lichen sclerosis present?
Fx: itch, skin fissuring/ erosions, white atrophic patches in anogenital region
Examination: clitoral hood fusion, fusion of labia minora to majora, posterior fusion -> loss of vaginal opening
What are some RFs for lichen sclerosis
RFs: FH, autoimmune (thyroid, T1DM, alopecia areata)
How does lichen sclerosis get mx
Mx: immunosuppression. 1st: topical steroids (clobetasol propionate) OD (night) x 4 weeks. FU: risk of SCC
