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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
What are the surgical risks to the Wertheim's hysterectomy?
* 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
What are the risk factors of radiotherapy for cervical cancer?
* Lethargy/fatigue * Urgency * Skin erythema (external beam radiotherapy) * Dyspareunia/vaginal stenosis * Infertility * Diarrhoea/malabsorption * Dysuria * Incontinence
27
Define Endometrial hyperplasia.
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
What are the risk factors for endometrial hyperplasia?
* 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
What are the signs and symptoms of endometrial hyperplasia?
* PV bleeding - usually **PMB**
30
What tissues are tamoxifen oestrogenic and anti-oestrogenic too?
Oestrogenic = uterus & bone Anti-oestrogenic = breast
31
What are the appropriate investigations for suspected endometrial hyperplasia?
* 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
What is the management of endometrial hyperplasia without atypia?
* 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
What is the management of endometrial hyperplasia with atypia?
* 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
What are the risk factors for endometrial cancer?
* 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
What are the types of endometrial hyperplasia?
* 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
What are the signs and symptoms of endometrial cancer?
* Most present in stage 1 disease * PV bleeding * Bulky uterus * Metastasises to para aortic LNs
37
What are the appropriate investigations for suspected endometrial cancer?
* 1st: TVUSS * \<4mm = endometrial cancer unlikely * \>4mm = 2nd line investigations: hysteroscopy ± biopsy * 2nd: Hysteroscopy ± biopsy
38
Define Complex hyperplasia with atypia.
Pre-malignant condition that often co-exists with low-grade endometrioid tumours of the endometrium * 25-50% risk of progression to endometrial cancer
39
What is the management of endometrial cancer?
* 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
What are the indications of hormone treatments in endometrial cancer?
* Complex atypical hyperplasia * Low-grade stage 1A endometrial tumours * Those not fit for surgery or for fertility reasons - relapse rates are high
41
What is the prognosis of endometrial cancer?
* 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
What are the risk factors for ovarian tumours?
* Increasing age * FHx (BRCA1/2, MLH1, MSH2) * Endometriosis * HRT * Obesity * Smoking * Talcum powder * More ovulations - nulliparity, early menarche, late menopause
43
What are the protective factors for ovarian tumours?
Pregnancy COCP
44
What is associated with ovarian tumours?
* Lynch syndrome (Autosomal Dominant HNPCC; MLH-1, MSH-2) * Breast cancer (BRCA1/2)
45
What are the types of ovarian tumours? Focus on the most malignant types.
* 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
Describe epithelial tumours.
* 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
Describe germ-cell tumours.
* Young women (20yo) and old women (70yo) * Mature teratomas = benign * Immature = malignant
48
What is a endometrioma and what happens if it ruptures?
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
What are the signs and symptoms of ovarian tumours?
* Late presentation (75%) = vague symptoms * Adnexal mass with no PV bleeding * Mass is usually palpable
50
What are the FIGO staging for ovarian cancer?
51
What are the appropriate investigations for ovarian tumours?
* 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
What is the management of ovarian cancer?
* **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
What is the prognosis of ovarian cancer?
* 5-year survival = 46% * Stage 1 = 90% * Stage 3 = 30%
54
What is the most common causes of vulval cancer?
* Majority SSC (95%) \>\>\> melanoma, BCC \> adenocarcinoma
55
What are the risk factors for vulval cancer?
* Usual type (warty/basaloid SCC) → VIN (HPV type 16), immunosuppression, smoking * Differentiated type (keratinised SCC) → lichen sclerosis
56
What are the signs and symptoms of vulval cancer?
* **Inguinal** lymphadenopathy * Vulval swelling/ulcer * Pruritus * Pain * Bleeding/discharge * Nodule or ulcer visible on vulva - commonly labia majora
57
What are the appropriate investigations for suspected vulval cancer?
* 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
What is the management of vulval cancer?
* 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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