Gynae Cancers Flashcards
What are features of cervical cancer screening?
Pap smear every 2 years
Begins from 18yrs or 2yrs after first sexually active (whichever is later)
Last one at 70yo provided 2 normal smears in last 5 years
Do not require if never sexually active
Require if in same sex relationship
If radical hysterectomy require normal baseline smear (exclude disease in vaginal vault) and then do not require further smears
If subtotal hysterectomy (cervix remains) require as normal
What are the changes to the Pap smear program?
Changing to HPV testing +/- cytology if HPV positive
If HPV negative then do not require further pap test for 5 years
If HPV positive, lab will perform cytology. If normal/low grade probably same pathway (repeat in 12 months)
If high grade - colposcopy
Program commencing from 25y - 74y
What are the strains of HPV in the gardasil vaccine?
High risk strains 16 and 18 - cancer (70%)
Low risk strains 6 & 11 - warts (90%)
But over 50 subtypes so small chance that will develop cancer despite vaccine and may also be non-HPV related (small number)
What is the assessment/management pathway for LSIL/CIN1 pap smear result?
- Educate/reassure - common changes associated with viral infection, likely transient, takes 1-2 years to clear the infection
- Assess for symptoms - dyspareunia, PBC, weight loss, fevers
- Repeat pap smear in 1 year - if abnormal still colposcopy and if normal return to normal program
What is the assessment/management pathway for HSIL/CIN2&3 pap smear result?
- Educate/reassure - explain screening and not diagnostic, will need more investigation but Rx available to significantly reduce risk of developing cancer
- Changes due to HPV infection + additional cell changes that are concerning/pre-cancerous
- Referral to gynaecologist for colposcopy
- Colposcopy - microscope device to examine cervix
- May take a biopsy or perform LETZ procedure
- For follow-up will require a repeat colposcopy and multiple HPV testing and pap smears over next 2 years
- Reassure LETZ will not affect fertility but may be small increase risk of premature delivery when pregnant
Describe colposcopy & LETZ proceedure to patient
-Colposcopy can be performed in the doctors office, without general anaesthetic
-It is similar to a papsmear, however, you will have your legs up in styrups
-A speculum will be inserted to access the cervix
-Colposcopy device is similar to a large binocular, where the doctor will move the device towards you and look at your cervix from the outside (does not need to be inserted)
-Abnormal cells or areas of the cervix may be visible with this but to help two solutions will be added using a cotton tip
-The doctor may just look at the cervix, they may take a biopsy or they may perform a treatment option called a LETZ
-If they take a biopsy, it may be slightly uncomfortable but local anaesthetic can be used if needed. You may have some light bleeding and mild period cramps after, avoid tampons + sex for 2-3 days after
- a LETZ is where the doctor removes all of the abnormal tissue using a heated loop, this will be sent to the lab for testing but usually is the final treatment for an abnormal pap smear. Avoid sex and tampons for 4-6w. Increased prematurity risk
decide to take a biopsy and decide what treatment
- Explain follow-up - further HPV testing, paps and colposcopy then return to normal screening
What are risk factors for cervical cancer?
Multiparity Increasing age (>40) Multiple partners Viral infections Smoking OCP Aboriginal Early age of intercourse Low SES
What is the basic epidemiology of cervical cancer?
Majority SCC (80%)
Mainly problem in developing world
3rd most common cancer world wide, 7th most common in Australia
2x higher incidence in ATSI
What are the symptoms of cervical cancer?
Asymptomatic in pre-cancerous/early stages
Advanced disease
- PCB, IMB
- Dyspareunia
- Pelvic pain
- Weight loss, constitutional symptoms
- Bladder, bowel or renal obstruction if locally invasive
What is the management of invasive cervical cancer?
- Work-up - CXR, chest/abdo/pelvis CT, surgical work-up (FBE, Fe, U&Es, LFTs, ECG)
- Lymph node assessment - sentinel node biopsy
- Counselling and advice for fertility preservation
- Radical hysterectomy +/- LN dissection most recommended (better survival but significant morbidity - lymphaoedema, bowel/bladder)
- Cone biopsy - microscopic disease + low risk
- Trachelectomy - if small lesion, no LN spread, fertility preserving
- +/- adjuvent RTx or ChemoRTx if higher risk
- Primary radiotherapy - if not good candidate for surgery i.e. comorbidities
What are the risk factors for endometrial cancer?
Increasing age
Obesity**, delayed menopause - increased oestrogen
Unopposed oestrogen - tamoxifene, PCOS, oestrogen secreting tumours
DM
HTN
FHx
What are protective factors for endometrial cancer?
Child bearing
COCP
HRT with progesterone
What is the clinical presentation for endometrial cancer and when/who should be investigated?
Any bleeding in postmenopausal women - always Ix
Premenopausal women >45 yo with IMB or heavy menstrual bleeding in setting of regular cycles should be Ix to exclude
Premenopausal women <45 have a low risk but if persistent AUB in setting of unopposed oestrogen or high-risk factors (such as Lynch syndrome) they should be Ix and excluded
How can possible endometrial cancer be investigated for?
Ultrasound with endometrial thickness as a screening
- Postmenopausal <5mm normal
- Premenopausal less helpful due to variation in thickness with cycle but normal is 2 - 16mm depending on phase of cycle
Endometrial thickness >5mm in post-menopausal women requires biopsy
Biopsy
- Outpatient sampling with pipelle - ~90% sensitivity, if negative and high risk should perform surgical biopsy
- Hysteroscopy and D&C - if very high risk should do this first, if HMB may also do it first as it will be diagnostic/therapeutic for other causes of HMB
What is the management of endometrial cancer?
- Surgery
Hysterectomy + bilateral salpingo-oophrectomy - +/- LN dissection
Pelvic and para-aortic sentinel node sampling +/- dissection if positive - +/- adjuvent brachytherapy RTx
Reduces the risk of recurrence in some women
