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Y5 O&G > Gynae Cancers > Flashcards

Gynae Cancers Flashcards

1
Q

Define Cervical intraepithelial neoplasia.

A

Premalignant cellular atypia within squamous epithelium of cervix.

  • FIGO stage 0
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2
Q

What are the risk factors for CIN?

A
  • HPV (type 16 and 18) - >95% cases
  • Smoking
  • Multiple sexual partners
  • Early age of first intercourse
  • HIV
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3
Q

What is the peak incidence of CIN and cervical cancer?

A
  • CIN = 25-29yo
  • Cancer = 45-50yo
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4
Q

What public health measure are in place to reduce CIN and cervical cancer?

A
  • HPV vaccination
    • National vaccination for girls and boys aged 12-13yo
      • If pregnant invite ≥12w post-partum
    • Quadrivalent vaccine (Gardasil ©) against HPV 6, 11, 16, 18
  • Cervical Smear
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5
Q

How often are women invited for a cervical smear?

A
  • 25-50yo = every 3 years
  • 50-65yo = every 5 years
  • 65+ = only if 1 of your last 3 tests was abnormal
  • High-risk (i.e. HIV +ve) = every 1 year
  • Pregnancy = if due when pregnant, delay until ≥3m post-partum
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6
Q

Describe the dysplastic changes seen in CIN.

A
  • ↑ nuclear to cytoplasmic ratio
  • ↑ nuclear size
  • ↓ cytoplasm
  • Abnormal nuclear shape – poikilocytosis
  • ↑ nuclear density – koilocytosis
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7
Q

What are the CIN grades?

A
  • CIN 1 = mild dysplasia confined to lower 1/3 of epithelium
  • CIN 2 = moderate dysplasia affecting 2/3 of epithelial thickness
  • CIN 3 = severe dysplasia extending to upper 1/3 of epithelium → risk of stage Ia1 FIGO
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8
Q

What are the signs and symptoms of CIN?

A
  • Asymptomatic
  • Cervical cancer s/s
    • PV bleeding
    • Dyspareunia
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9
Q

What is the follow-up following a smear screening?

A
  • Borderline/mild dyskaryosis / CIN I → HPV test → +ve = colposcopy; -ve = routine recall
  • Moderate dyskaryosis / CIN II → urgent colposcopy (<2w) → tx
  • Severe dyskaryosis / CIN III → urgent colposcopy (<2w) → tx
  • Suspected invasive cancer → urgent colposcopy (<2w) → tx
  • Inadequate sample → repeat (if x3 repeats, refer to colposcopy)
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10
Q

What is the management of CIN 1?

A

Conservative - follow-up smear in 12 months

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11
Q

What is the management of CIN II and III?

A
  • Large Loop Excision of the Transformational Zone (LLETZ)
    • Involves removal of abnormal cells using a thin wire loop that is heated by electric current under LA
  • Cone biopsy
  • Other: cryotherapy, laser treatment, cold coagulation, hysterectomy
  • Follow-up test of cure (6 months later) = smear and HPV test:
    • -ve = routine recall (3 years irrespective of age)
    • +ve = repeat colposcopy to identify residual/untreated CIN
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12
Q

What are the side effects and risks of loop diathermy?

A
  • SEs:
    • Cervical stenosis
    • Cervical incontinence
    • Pyometra
    • Smear follow-up difficulties
  • Risks → increased risk of miscarriage (bigger lumen to cervix so harder to close fully)
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13
Q

What are the complications of CIN?

A
  • Miscarriage and Preterm Labour
  • CIN can progress to cervical carcinoma → may also regress spontaneously, esp. when young
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14
Q

What are the types of cervical cancer and what do they develop from?

A
  • Squamous (80%) → from CIN
  • Adenocarcinoma (20%) → from CGIN
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15
Q

What staging system is used to assess cervical cancer?

A

Figo

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16
Q

What are the risk factors for cervical cancer?

A
  • HPV
  • Smoking
  • Early first intercourse
  • Many sexual partners
  • Immunosuppression
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17
Q

What are the signs and symptoms of cervical cancer?

A
  • PV discharge (offensive or bloodstained)
  • PCB, IMB, PMB
  • Dyspareunia (deep)
  • Symptoms of late metastasis (i.e. SoB, DIC)
  • FLAWS
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18
Q

What are the appropriate investigations for suspected cervical cancer?

A
  • Cervical screening pathway
  • MRI - could use CT-CAP if no MRI
  • Bloods – FBC (anaemia), U&Es (obstructive picture), LFTs (metastasis), clotting, G&S
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19
Q

Out of MRI and CT-CAP which modality is best for cervical, ovarian and andometrial cancers?

A
  • MRI = cervical cancer
  • CT-CAP = ovarian cancer, endometrial cancer
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20
Q

What is the management of stage Ia1 cervical cancer?

A
  • Conservative
  • LLETZ, cone biopsy (follows smear pathway)
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21
Q

What is the management of stage Ia2 to IIa cervical cancer?

A
  • Fertility-sparing = radical trachelectomy (remove cervix) + bilateral pelvic node dissection
  • Tumours ≤4cm = radical hysterectomy + bilateral pelvic node dissection (Wertheim’s)
  • Tumours ≥4cm = chemoradiation
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22
Q

What is the management of stage IIb to IVa cervical cancer?

A

Chemoradiation

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23
Q

What is the management of stage IVb (metastatic) cervical cancer?

A
  • Combination chemotherapy
  • Single agent therapy and palliative care
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24
Q

What management is offered to all patient with stage Ia2 or worse cervical cancer?

A
  • Radiotherapy ± chemotherapy (cisplatin-based therapy)
    • External beam radiotherapy
      • 10 minutes of delivery, completed over 4 weeks
    • Internal radiotherapy
      • Brachytherapy; rods of radioactive selenium is inserted into the affected area
  • Radiotherapy is used more in earlier stages while chemo is used later
25
Q

What are the surgical risks to the Wertheim’s hysterectomy?

A
  • Bladder dysfunction (atony) - common
    • May require intermittent self-catheterisation
  • Sexual dysfunction - due to vaginal shortening
  • Lymphoedema - due to pelvic lymph node removal
    • Leg elevation, good skin care and massage
26
Q

What are the risk factors of radiotherapy for cervical cancer?

A
  • Lethargy/fatigue
  • Urgency
  • Skin erythema (external beam radiotherapy)
  • Dyspareunia/vaginal stenosis
  • Infertility
  • Diarrhoea/malabsorption
  • Dysuria
  • Incontinence
27
Q

Define Endometrial hyperplasia.

A

Excess endometrial growth which usually occurs after the menopause - can progress to cancer

  • EH without atypia = cells are normal
  • EH with atypia = cells are abnormal
28
Q

What are the risk factors for endometrial hyperplasia?

A
  • Increasing age
  • Oestrogen
    • Early menarche
    • Late menopause (>55yo)
    • Nulliparous
    • Tamoxifen
    • HRT
    • COCP
  • High insulin levels - T2DM, PCOS
  • Obesity
  • Smoking
  • FHx - ovarian, bowel (HNPCC, Lynch Syndrome) or uterine cancer
29
Q

What are the signs and symptoms of endometrial hyperplasia?

A
  • PV bleeding - usually PMB
30
Q

What tissues are tamoxifen oestrogenic and anti-oestrogenic too?

A

Oestrogenic = uterus & bone

Anti-oestrogenic = breast

31
Q

What are the appropriate investigations for suspected endometrial hyperplasia?

A
  • 1st: TVUSS (transvaginal USS)
    • <4mm = endometrial cancer unlikely or >10mm if pre-menopausal
    • >4mm = hysteroscopy ± biopsy
  • 2nd: Hysteroscopy ± pipelle biopsy- Diagnostic Gold-Standard
    • Sonohysterography is replacing hysteroscopy as a method of visualisation
32
Q

What is the management of endometrial hyperplasia without atypia?

A
  • Reverse risk factors (e.g. obesity, HRT)
  • Endometrial surveillance every 6 months - biopsies recommended in high-risk women
  • 1st line: progestogens (or observation):
    • LNG-IUS - for 5 years
    • Oral continuous progestogens - for a minimum of 6 months to induce histological regression
  • 2nd line: hysterectomy
33
Q

What is the management of endometrial hyperplasia with atypia?

A
  • Fertility non-sparing = total hysterectomy (+ BSO if post-menopausal)
  • Fertility-preserving:
    • 1st line: LNG-IUS
    • 2nd line: oral progestogens
    • Routine endometrial surveillance with biopsies (every 3 months)
      • If 2 consecutive negative biopsies - extended to every 6-12 months
34
Q

What are the risk factors for endometrial cancer?

A
  • Increasing age
  • Oestrogen
    • Early menarche
    • Late menopause (>55yo)
    • Nulliparous
    • Tamoxifen
    • HRT
    • COCP
  • High insulin levels - T2DM, PCOS
  • Obesity
  • Smoking
  • FHx - ovarian, bowel (HNPCC, Lynch Syndrome) or uterine cancer
35
Q

What are the types of endometrial hyperplasia?

A
  • Type 1 (85%) – SEM = secretory, endometrioid, mucinous carcinoma
    • Oestrogen-dependent
    • Younger patients
    • Superficially invade- Low-grade
    • ≥4 mutations must accumulate to cause this: PTEN, PI3KCA, K-Ras, CTNNB1, FGFR2, p53
  • Type 2 (15%) – SC = uterine papillary serous carcinoma (UPSC), clear cell carcinoma
    • Less oestrogen-dependent
    • Older patients
    • Deeper invasion - Higher grade
    • Mutations associated:
      • Serous Carcinoma: p53 (90%), PI3KCA, Her-2 amplification
      • Clear Cell Carcinoma: PTEN, CTNNB1, Her-2 amplification
36
Q

What are the signs and symptoms of endometrial cancer?

A
  • Most present in stage 1 disease
    • PV bleeding
    • Bulky uterus
    • Metastasises to para aortic LNs
37
Q

What are the appropriate investigations for suspected endometrial cancer?

A
  • 1st: TVUSS
    • <4mm = endometrial cancer unlikely
    • >4mm = 2nd line investigations: hysteroscopy ± biopsy
  • 2nd: Hysteroscopy ± biopsy
38
Q

Define Complex hyperplasia with atypia.

A

Pre-malignant condition that often co-exists with low-grade endometrioid tumours of the endometrium

  • 25-50% risk of progression to endometrial cancer
39
Q

What is the management of endometrial cancer?

A
  • Stage 1 – requires all of the below:
    • Total abdominal hysterectomy
    • Bilateral salpingoopherectomy
    • Peritoneal washings
  • Stage 2+:
    • Radical hysterectomy - including cervix
    • Radiotherapy adjunct
  • Chemotherapy is of limited use - used if cancer is not amenable to radiotherapy
  • Hormone treatments:
    • High-dose oral or intrauterine progestins
40
Q

What are the indications of hormone treatments in endometrial cancer?

A
  • Complex atypical hyperplasia
  • Low-grade stage 1A endometrial tumours
  • Those not fit for surgery or for fertility reasons - relapse rates are high
41
Q

What is the prognosis of endometrial cancer?

A
  • 5-year survival = 80% (dependent on type, stage and grade)
  • Bad prognostic features:
    • Age
    • Grade 3 tumours
    • T2 histology
    • Distant metastasis
    • Deep invasion
    • Lymphovascular space invasion
    • Nodal involvement
  • Hormone receptor expression (Her2) = better prognosis due to treatment options
42
Q

What are the risk factors for ovarian tumours?

A
  • Increasing age
  • FHx (BRCA1/2, MLH1, MSH2)
  • Endometriosis
  • HRT
  • Obesity
  • Smoking
  • Talcum powder
  • More ovulations - nulliparity, early menarche, late menopause
43
Q

What are the protective factors for ovarian tumours?

A

Pregnancy

COCP

44
Q

What is associated with ovarian tumours?

A
  • Lynch syndrome (Autosomal Dominant HNPCC; MLH-1, MSH-2)
  • Breast cancer (BRCA1/2)
45
Q

What are the types of ovarian tumours? Focus on the most malignant types.

A
  • Epithelial
    • Low-grade serous, Endometroid, Mucinous, Clear cell tumour
    • High-grade serous
  • Germ cell
    • Teratoma
    • Dysgerminoma, Endodermal sinus tumour, Choricocarcinoma
  • Sex-cord stromal
    • Fibroma
    • Thecoma
    • Granulosa cell tumour
    • Sertoli-Leydig cell tumour
46
Q

Describe epithelial tumours.

A
  • Postmenopausal women (56yo)
  • Endometriosis association with clear cell (>20%) > endometrioid (10-20%) ovarian cancer
  • Endometroid ovarian carcinoma often found alongside endometroid endometrial carcinoma
  • Later presentation = Worse prognosis
47
Q

Describe germ-cell tumours.

A
  • Young women (20yo) and old women (70yo)
  • Mature teratomas = benign
  • Immature = malignant
48
Q

What is a endometrioma and what happens if it ruptures?

A

Begins as endometriosis on the ovarian surface and with adhesions to the adjacent peritoneum, blood and menstrual debris accumulate on the ovarian surface

  • Acute pain similar to that of an ectopic
49
Q

What are the signs and symptoms of ovarian tumours?

A
  • Late presentation (75%) = vague symptoms
  • Adnexal mass with no PV bleeding
    • Mass is usually palpable
50
Q

What are the FIGO staging for ovarian cancer?

51
Q

What are the appropriate investigations for ovarian tumours?

A
  • Tumour Markers (CA125)
    • ≥35 IU/mL → 2ww referral to O&G and TVUSS
      • Raised in >80% epithelial ovarian cancers
      • CA125 also raised in pregnancy, endometriosis and alcoholic liver disease
  • TVUSS to characterise:
    • Size
    • Consistency
    • Presence of solid elements
    • Bilateral or not
    • Presence of ascites
    • Extraovarian disease
  • Risk of Malignant Index → calculated from:
    • Score >250 is considered high-risk (<25 is low risk)
  • Staging with CT-CAP > MRI
52
Q

What is the management of ovarian cancer?

A
  • Surgery ± chemotherapy (2nd line is just chemotherapy)
  • Chemotherapy
    • Neoadjuvant
      • Platinum compound with paclitaxel
    • Platinum compounds
      • Most effective in ovarian cancer
    • Paclitaxel → microtubular damage → prevent cell division
    • Bevacizumab - monoclonal antibody against VEGF
      • Available for the treatment of recurrent disease
  • Surgery = Laparotomy (TAH + BSO + omentectomy ± extra debulking)
    • Is the mainstay/only treatment for sex cord stromal tumours
53
Q

What is the prognosis of ovarian cancer?

A
  • 5-year survival = 46%
    • Stage 1 = 90%
    • Stage 3 = 30%
54
Q

What is the most common causes of vulval cancer?

A
  • Majority SSC (95%) >>> melanoma, BCC > adenocarcinoma
55
Q

What are the risk factors for vulval cancer?

A
  • Usual type (warty/basaloid SCC) → VIN (HPV type 16), immunosuppression, smoking
  • Differentiated type (keratinised SCC) → lichen sclerosis
56
Q

What are the signs and symptoms of vulval cancer?

A
  • Inguinal lymphadenopathy
  • Vulval swelling/ulcer
  • Pruritus
  • Pain
  • Bleeding/discharge
  • Nodule or ulcer visible on vulva - commonly labia majora
57
Q

What are the appropriate investigations for suspected vulval cancer?

A
  • Tissue diagnosis – full thickness biopsy, sentinel node biopsy
  • Cervical smear – exclude CIN if VIN-associated
  • Imaging – CT or MRI to assess lymphadenopathy
  • Other – staging by cystoscopy, proctoscopy
58
Q

What is the management of vulval cancer?

A
  • 1a = wide local excision ± neoadjuvant chemotherapy
  • >1a = radical vulvectomy + bilateral inguinal lymphadenectomy
    • Complications = wound healing problems, infection, VTE and chronic lymphoedema
  • Unsuitable for surgery = radiotherapy

Y5 O&G (69 decks)

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