Gynae cancers Flashcards
Cancer strongly related to HPV and most common type
-Cervical
-Squamous cell carcinoma
HPV role in cervical cancer
-> E6 and E7 protein prodcution
-> Inhibit p53 and pRb tumour suppressor genes respectively
-> Type 16 and type 18 HPV strains are the biggest causes of cervical cancer
Risk factors for cervical cancer (7)
-Increased risk of HPV : increased no. of sexual partners, no condom used, early sexual activity
-Non engagement with cervical screening
-Smoking
-HIV
-COCP for >5 yrs
-Increased no. of full term pregnancies
-Fx
If not asymptomatic, how can cervical cancer present?
-> Abnormal vaginal bleeding (intermenstraul, postcoital or post-menopausal)
-Vaginal discharge
-Pelvic pain
-Dyspareunia
-If present : examine cervix with a speculum
-If cervix ulcerated, inflammed, bleeding or there is a visible tumour = urgent cancer referral for colposcopy
At what point are women screened for cervical cancer ?
-> Every 3 years aged 25-49
-> Every 5 years aged 50-64
How are women protected against cervical cancer and genital warts ?
-HPV vaccine before boys and girls become sexually active
If a smear comes back as HPV positive with abnormal cytology what is the outcome ?
-Refer for colposcopy
What can be diagnosed at colposcopy ?
-Cervical intraepithelial neoplasia -> grading system for level of dysplasia of the cells in the cervix
-CIN I -> mild, affects 1/3 and likely to return to normal if untreated.
-CIN II -> moderate, affects 2/3 of epithelial thickness. Likely to progress to cancer if untreated
-CIN III -> severe, likely to progress to cancer if untreated (cervical carcinoma in situ)
What are the 2 methods of tissue biopsy during a colposcopy ?
-Punch biopsy
-Large loop excision of the transformation zone
How is CIN treated at the very early stage of cervical cancer
-Cone biopsy
What are the stages of cervical cancer and how are they treated ?
-CIN/early stage 1A -> LLETZ or cone biopsy
-Stage 1b-2a (confined to cervix) - radical hysterectomy + removal of local lymph nodes + chemo or radio
-Stage 2 : invades uterus or upper 2/3 of vagina
-Stage 3 : invades pelvic wall or lower 1/3 of vagina
-Stage 4 : invades bladder, rectum or beyond the pelvis
-Stage 2b to 4a are treated with chemo and radiotherapy
What monoclonal antibody can be used in cervical cancer?
-Bevacizumab (avastin)
-targets VEGF-A reducing the development of new blood vessels
Endometrial cancer
-Type
-RF
-Presentation
-80% = adenocarcinomas
-Anything that increases expose to ‘unopposed oestrogen’ as it is an oestrogen-dependent cancer, obesity, T2DM and HNPCC/lynch syndrome.
-Postmenopausal bleeding !!!! + postcoital, intramenstrual or unsually heavy bleeding. Abnormal vaginal discharge, haematuria, anaemia and raised plt count.
What can increase a womans exposure to ‘unopposed oestrogen? (8)
-PCOS
-Obesity
-Increased age
-Earlier onset menstruation
-Late menopause
-Oestrogen only HRT
-No or fewer pregnancies
-Tamoxifen
What is endometrial hyperplasia and how is it treated ?
-> Precancerous condition involving thickening of the endometrium
-> 2 kinds : hyperplasia without atypia, atypical hyperplasia
-> mirena coil or continuous oral progestogens
What is the referral criteria in endometrial cancer suspicion
-2 week wait : postemenopausal bleeding
-Transvaginal USS in women over 55 : unexplained vaginal discharge or visible haematuria + raised plts, anaemia or elevated glucose levels
What are the 3 investigations for endometrial cancer
-Transvaginal USS for endometrial thickness (normal - <4mm post-menopause)
-Pipelle biopsy
-Hysteroscopy with biopsy
What are the stages of endometrial cancer
1 : confined to uterus
2 : invades the cervix
3 : Invades ovaries, fallopian tubes, vagina or lymph nodes
4 : invades bladder, rectum or beyond the pelvis
How are stage 1 and 2 endometrial cancers treated
-Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH and BSO)
What is the most common type of ovarian cancer ?
-Epithelial cell tumour
Give 6 RF for ovarian cancer
-Age (peaks at 60)
-BRCA1 and BRCA2
-Increased no. of ovulations : early onset periods, late menopause, no pregnancies
-Obesity
-Smoking
-Recurrent use of clomifene
Why would ovarian cancer cause referred hip or groin pain ?
-> If the mass presses on the obturator nerve
What are the initial investigations for an ovarian cancer
-CA125 blood test (>35 significant)
-Pelvic USS
-Risk of malignancy index
Women under 40 with complex ovarian mass require tumour markers for a possible germ cell tumour, what are they :
-Alpha-fetoprotein
-Human chorionic gonadrotropin (HCG)
Give 6 other causes of raised CA125
-Endometriosis
-Fibroids
-Adenomyosis
-Pelvic infection
-Liver disease
-Pregnancy
If a smear test is hrHPV positive, what is done
-Examined cytologically
-If cyctology abnormal -> coloposcopy
If a smear is hrHPV + but cytologically normal, when is the smear repeated
12 mnths
If hrHPV is negative, return to normal recall
If hrHPV is + repeat at 12 mnths
-If sample is inadequate, repeat smear in 3 mnths
If a smear is hrHPV + but cytologically normal, when is the smear repeated
12 mnths
If hrHPV is negative, return to normal recall
If hrHPV is + repeat at 12 mnths
if hrHPV -ve at 24 mnths return to normal recall
If hrHPV +ve ar 24 mnths -> colposcopy
why does obesity increase unopposed oestrogen exposure ?
-Adipose tissue contains atomatase
-Aromatas converts adrogens to oestrogen.
Why does PCOS increase exposure to unopposed oestrogen?
-Lack of ovulation leads to lack of corpus luteum formation
-Progesterone is therefore not produced
What should women with PCOS be given for endometrial protection ?
-COCP
-Mirena coil
-Cyclical progestogens to induce a withdrawal bleed
what are 4 protective factors against endometrial cancer
COCP
Mirena coil
Increased pregnancies
Cigarette smoking
What is the most common type of ovarian cancer ?
Epithelial cell tumour -> serous
Give 3 protective factors against ovarian cancer
-COCP
-Breastfeeding
-Pregnancy
They all stop or reduce the no. of ovulations
how doers ovarian cancer present
Bloating
Eaely satiety
Loss of appetite
Pelvic pain
Urinary sx
Weight loss
Abdominal or pelvic mass
Ascites
What 3 things are taken into account in the risk of malignancy index
-Estimates risk of avarian mass being malignant
-Menopausal status, USS findings and CA125 level
what are the stages of ovarian cacner
1 : confined to ovary
2 : Spread past ovary but inside the pelvis
3 : spread past pelvis but inside the abdomen
4 : spread outside of abdomen
Explain the referral criteria for ovarian cancer
- 2 week wait : ascites, pelvic mass, abdo mass
What can germ cell tumours cause a rise in
-hCG
-Alpha-fetoprotein
what is a krukenberg tumour
-Metastasis in the ovary, usually from a GI cancer
-‘Signet ring’ cells on histology
Give 4 RF for vulval cancers
-Advances age (>75)
-Immunosuppression
-HPV
-Lichen sclerosis
what is the most common type of vulval cancer
squamous cell
how does vulval cancer present and where does it more frequently affect
-Vulval lump, ulceration, bleeeding, pain, itching, lymphadenopathy
-Labia majora
what is vulval intraepithelial neoplasia
-Premalignant condition affecting squamous epithelium of the skin preceding vulval cancer
-High grade squamous intraepithelial lesion (VIN) -> associated with HPV
-Differentiated VIN -> associated with lichen sclerosis
How can VIN be treated
Watch and wait
Wide local excision
Imiquimod
Laser ablation
How is vulval cancer diagnosed and stage
-Diagnose : biopsy lesion
-Check lymph nodes : sentinel node biopsy
-CT abdo and pelvis for staging
Most common gynae cancer
Endometrial
Vulval carcinoma vs VIN
- Carcinoma : ulcerated, labium majora
- VIN : white or plaque like, don’t ulcerate
