Gynae cancers Flashcards
Cancer strongly related to HPV and most common type
-Cervical
-Squamous cell carcinoma
Risk factors for cervical cancer
- Increased risk of HPV = multiple partners, unprotected sex
- Smoking
- Increased no. full term pregnancies
If not asymptomatic, how can cervical cancer present?
- Abnormal vaginal bleeding (intermenstraul, postcoital or post-menopausal)
- Pain : pelvic pain / dyspareunia
- Vaginal discharge
Examination - cervical ulceration, visible mass, inflammation, bleeding.
At what point are women screened for cervical cancer ?
-> Every 3 years aged 25-49
-> Every 5 years aged 50-64
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)
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.
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
Explain the cervical smear testing process
- Testing for high risk HPV (hrHPV)
- Cytological examination if HPV (+ve)
how are the smear results managed in HPV -VE
Return to normal recall
How are the smear tests results managed in HPV +ve
sample examined cytologically
If cervical smear cytology abnormal ?
colposcopy
If cervical smear cytology normal ?
- Repeat smear @12 mnths
When is repeat test done if cervical smear test is inadequate
3 mnths
RF for endometrial cancer
- Excess oestrogen : nulliparity, early menarche, late menopause, unopposed oestrogen
- Metabolic syndrome : obesity, DM, PCOS
- Long term tamoxifen use
- Hereditary non-polyposis colorectal carcinoma
What is endometrial hyperplasia and how is it treated ?
-> Precancerous condition involving thickening of the endometrium
-> 2 kinds : hyperplasia without atypia, atypical hyperplasia
-> SImple : mirena coil or high dose progestogens with repeat sampling 3-4 nths
-> Atypica = hysterectomy advised
What is the referral criteria in endometrial cancer suspicion
-2 week wait : >= 55 with postemenopausal bleeding for transvzginal USS
-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
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 (70-80% = serous carcinomas)
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
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 five RF for vulval cancers
-Advances age (>75)
-Immunosuppression
-HPV
-Lichen sclerosis
- Vulval intraepithelial hyperplasia
what is the most common type of vulval cancer
squamous cell carcinoma
how does vulval cancer present and where does it more frequently affect
- Vulval lump, ulceration, bleeding, pain, itching
- Inguinal 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
what epithelium normally lines the ectocervix ?
stratified squamous non-keratinized epithelium
when are women screened for cervical cancer?
all women are initially screened for high-risk HPV between the ages of 25-64
Treatment of CIN
Large loop excision of transformation zone
FIGO stage IA of cervical cancer
- IA : confined to cervix, only visible by microscopy and <7mm wide (1A1 = <3mm deep, 1A2 = 3-5mm deep)
FIGO stage 1B of cervical cancer
- Confined to cervix, clinically visible or >7mm wide
- 1B1 = <4cm diameter
- 1B2 = >4cm diameter
FIGO stage 2 cervical cancer
- Extension of tumour beyond cervix but not to the pelvic wall
- A = upper two thirds of vagina
- B = parametrial involvement
FIGO stage 3 cervical cancer
- Extension of tumour beyond the cervix and to the pelvic wall
- A = lower third of vagina
- B = pelvic side wall
Any tumour causing hydronephrosis or a non functioning kidney = considered stage III
FIGO stage 4 cervical cancer
- Extension of tumour beyond the pelvis or involvement of bladder or rectum
- A = involvement of bladder or rectum
- B = involvement of distant sites outside the pelvis
Management of IA cervical cancer
- Gold standard = hysterectomy +/- lymph node clearance
- If maintaining fertility = cone biopsy with negative margins
Management of stage IB cervical tumours
- 1B1 : radiotherapy with concurrent chemotherapy is advised
- 1B2 : radical hysterectomy with pelvic lymph node dissection
Management of stage II and III cervical tumours
Radiation with concurrent chemotherapy
Management of stage IV cervical tumours
- Radiation and/or chemotherapy is the treatment of choice
- Palliative chemotherapy may be best option for stage IVB
Indication for hysteroscopy with endometrial biopsy
persistent intermenstraul bleeding or heavy menstrual bleeding in women >=45 with failure of nomral treatment
what is the most common cause of postmenopausal bleeding
Vaginal atrophy
What type of ovarian tumours are associated with the development of endometrial hyperplasia
Granulosa cell tumours
apart from : infection and bleeding give 3 risks of TAH and BSO for endometrial cancer
- Damage to urethra, uterus and bowel
- Stress incontinence
- VTE
Complications of vaginal hysterectomy with antero-posterior repair
Vaginal vault prolapse
