Gynae cancers Flashcards
Cervical cancer tends to affect women of which age?
Younger
Peak in reproductive years
80% of cervical cancers affect which type of cell?
Squamous cell carcinomas
The 2nd most common type of cervical cancer after squamous cell carcinomas is what?
Adenocarcinoma
The leading cause of cervical cancer is what?
HPV
Children aged 12-13 years are vaccinated against certain strains of _____ to reduce risk of cervical cancer
HPV
Aside from cervical cancers, HPV can also give rise to which cancers?
Anal Vulval Vaginal Penis Mouth Throat
*HPV is primarily a sexually transmitted infection
The two most important types of HPV are ____ and ____. They are responsible for 70% of cervical cancers and as such are targetted with the HPV vaccine.
Type 16
Type 18
Is there a treatment for HPV infection?
No
*Can be vaccinated against though
HPV produces two proteins E6 and E7. What is the role of these proteins?
Both inhibit tumour suppressor genes
E6 inhibits p53
E7 inhibits pRb
What are risk factors for cervical cancer?
- Increased risk of catching HPV
- early sexual activity
- increased sexual partners
- sexual partners with more partners
- not using condoms - Non-engagement with cervical screening
- Other risk factors
- Smoking
- HIV
- COCP >5 years of use
- Increased number of full-term pregnancies
- Family history
- Exposure to diethylstilbestrol during fetal development
How can cervical cancer be detected in otherwise asymptomatic women?
Cervical smear tests
What are presenting symptoms that must be followed up for possible cervical cancer?
Abnormal vaginal bleeding (IMB, PCB, PMB)
Vaginal discharge
Pelvic pain
Dyspareunia
What investigations must be done for possible cervical cancer?
Cervix examination with speculum
Swabs (exclude infection)
If abnormal appearance of cervix, urgent cancer referral for colposcopy.
Ulceration
Inflammation
Bleeding
Visible tumour
On colposcopy suggests what?
Cervical cancer
Can a negative cervical screening test exclude cervical cancer, even if the smear result was normal?
No, it cannot exclude
Referral for colposcopy if suspicion remains
Cervical intraepithelial neoplasia is what?
Grading system for dysplasia premalignant change) in cells of cervix
- 3 grades - grade 3 is severe dysplasia, very likely to progress to cancer if untreated
- diagnosed at colposcopy (NOT cervical screening)
Cervical intraepithelial neoplasia is graded during which investigation?
Colposcopy
*NOT with cervical screening
What is dyskarosis?
Precancerous changes found on smear results
How often is the cervical smear test performed?
Every 3 years 25-49
Every 5 years 50-64
What are exceptions to the usual routine cervical smear test?
Women with HIV screening every year
Women 65+yo can request smear if not done since age 50
Women with previous CIN may require additiona tests
Immunocompromised women may require additional screening
Pregnant women due a routine smear should wait until 112-weeks post-partum
Inadequate
Normal
Borderline changes
Low-grade dyskaryosis
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
Possible invasive squamous cell carcinoma
Possible glandular neoplasia
These are examples of results for what investigation for which cancer?
Cytology results for cervical cancer
Aside from HPV, what other infections can be identified and reported on the smear test?
Bacterial vaginosis
Candidiasis
Trichomoniasis
Actinomyces-like organisms are found with women with an ___________.
Do not require treatment unless symptomatic - otherwise require removal.
IUD (coil)
HPV negative smear is managed how?
Continue routine screening
Inadequate sample on cervical smear is managed how?
Repeat smear after 3 months
HPV positive with normal cytology on a cervical smear is managed how?
Repeat HPV test after 12 months
HPV positive with abnormal cytology on a cervical smear is managed how?
Referral for colposcopy
*For definitive diagnosis
Which 2 stains are used in colposcopy to differentiate abnormal areas?
Acetic acid - abnormal cells appear white if they have increased nuclear to cytoplasmic ratio
Iodine test - stains healthy cells brown, abnormal areas don’t stain
What procedures can be performed during the colposcopy to get a tissue sample?
Punch biopsy
LLETZ (large loop excision of the transformational zone)
What is cone biopsy used as as a treatment for?
Cervical intraepithelial neoplasia and very early-stage cervical cancer
*Sample take and sent to histology to assess for malignancy
What are the risks of cone biopsy?
Pain Bleeding Infection Scar formation with cervix stenosis Increased risk of miscarriage and preterm labour
Which staging system is used to stage cervical cancer?
FIGO (Federation international of Gynae and Obs)
*
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
CIN and Early-stage 1A cervical cancer is treated how?
LLETZ or cone biopsy
Stage 1B-2A cervical cancer is treated how?
Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B-4A cervical cancer is treated how?
Chemotherapy and radiotherapy
Stage 4B cervical cancer is treated how?
Combination of surgery, radiotherapy, chemotherapy and palliative care
How does 5-year survival with cervical cancer differ from stage 1A to stage 4?
98% survival with 1A
15% survival with 4
Pelvic exenteration is a surgical treatment for advanced cervical cancer.
What does it involve?
Removal of most or all of the pelvic organs:
- Vagina
- Cervix
- Uterus
- Fallopian tubes
- Ovaries
- Bladder
- Rectum
*Big operation and has significant impact on QoL.
Which monoclonal antibody can be used in conjunction with chemotherapy in treatment of recurrent/metastatic cervical cancer?
What growth factor does it target?
Bevacizumab (Avastin)
VEGF-A
What is the current HPV vaccine in the NHS called?
Which strains does it protect against?
Gardasil
Strains 6, 11, 16 and 18
Strains 6 and 11 of HPV cause what?
Genital warts
Strains 16 and 18 of HPV cause what?
Cervical cancer
80% of endometrial cancers are ___________.
Adenocarcinomas
Endometrial cancer is dependent on which hormone?
Oestrogen
Woman presents with PMB.
Also is obese and diabetic.
What is the likely diagnosis?
Endometrial cancer
*PMB, obesity and diabetes are major risk factors
What are the 2 important types of endometrial hyperplasia?
Hyperplasia without atypia
Atypical hyperplasia (more potential for cancer)
Endometrial hyperplasia can be treated using which class of drugs?
Give 2 forms of this class of drugs.
Progesterogens
Two types: IUD (Mirena coil), continous oral progestogens (medroxyprogesterone)
What are risk factors for endometrial cancer?
Any situation with unopposed oestrogen (i.e. oestrogen without progesterone):
- Increased age
- Earlier menarche
- Late menopause
- Oestrogen only HRT
- No or fewer pregnancies
- Obesity
- PCOS
- Tamoxifen
Non-oestrogen-related
T2DM
HNPCC (Lynch syndrome)
How does PCOS lead to more unopposed oestrogen?
Due to lack of ovulation
- Normally ovulation occurs –> corpus luteum forms from ruptured follicle –> CL produces progesterone
- Progesterone provides endometrial protection during luteal phase of menstrual cycle
How are women with PCOS given more endometrial protection?
Need more progesterone
- COCP
- IUD (Mirena coil)
- Cyclical progestogens to induce withdrawal bleed
Why is obesity a risk factor for endometrial hyperplasia/cancer?
Adipose tissue is source of estrogen.
*Adipose tissue contains aromatase which converts testosterone into oestrogen.
More fat = more estrogen
Why is tamoxifen use a risk factor for endometrial hyperplasia/cancer?
Tamoxifen has anti-oestrogenic effect on breast tissue
BUT
has a oestrogenic effect on endometrium -»> increases risk of endometrial cancer
What are non-estrogen-related risk factors for endometrial hyperplasia/cancer?
T2DM
PCOS
HNPCC (Lynch syndrome)
How does T2DM increase risk of endometrial cancer?
Increased insulin production
Insulin can stiulate endometrial cells and increase risk of endometrial hyperplasia and cancer.
*PCOS also associated with insulin resistance and increased insulin production
What are protective factors against endometrial cancer?
- COCP
- Mirena
- Increased pregnancies
- Cigarette smoking
What is the MOST IMPORTANT presenting symptom of endometrial cancer?
Postmenopausal bleeding
*Other possible symptoms:
- PCB
- IMB
- HMB
- Abnormal vaginal discharge
- Haematuria
- Anaemia
- Raised platelets
What are 3 investigations for diagnosing and excluding endometrial cancer?
USS transvaginal (endometrial thickness)
Pipelle biopsy (highly sensitive for endometrial cancer)
Hysteroscopy (with endometrial biopsy)
Difference between pipelle biopsy and hysteroscopy with endometrial biopsy?
Both used for endometrial cancer diagnosis
Pipelle biopsy quicker and less invasive alternative to hysteroscopy for excluding cancer in lower-risk women.
What grading system is used to stage endometrial cancer?
FIGO (Federation International Gynae and Obs)
*Stages
Stage 1: Confined to the uterus Stage 2: Invades the cervix Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes Stage 4: Invades bladder, rectum or beyond the pelvis
How is stage 1/2 endometrial cancer managed?
Total abdominal hysterectomy
with
Bilateral salpingo-oophorectomy
(TAH and BSO)
Other treatment options:
- Radical hysterectomy
- Radiotherapy
- Chemotherapy
- Progesterone (to slow progression of cancer)
What hormone can be used to slow the progression of endometrial cancer?
Progesterone
*Opposes oestrogen levels
Why does ovarian cancer usually present late and lead to a worse prognosis?
Due to non-specific symptoms
*70%+ women with ovarian cancer present after spread beyond pelvis
What are the 4 types of ovarian cancer?
Epithelial cell tumours (most common is serous tumour)
Dermoid cysts/germ cell tumours
Sex cord/Stromal tumours
Metastasis
Which type of ovarian cancer is most associated with ovarian torsion?
Dermoid cysts/germ cell tumour
A Krukenberg tumour is mets from where usually?
Usually mets from GI tract (stomach) to the ovary
What characteristic features do Krukenberg tumours in ovarian cancer possess on histology?
“Signet-ring” cells on histology
What are risk factors for ovarian cancer?
- Age (peak @60)
- BRCA1/BRCA2 genes (family history)
- Increased number of ovulations
- Obesity
- Smoking
- Recurrent use of clomifene
What is clomifene used for and which cancer does it increase the risk of?
Treating infertility in women who do not ovulate.
Includes those with PCOS
*Selective estrogen receptor modulator)
What factors increase the number of ovulations?
Early-onset periods
Late menopause
No pregnancies
What are protective factors against ovarian cancer?
Factors reducing lifetime number of ovulations:
- COCP
- Breastfeeding
- Pregnancy
How can ovarian cancer present?
Following symptoms (lower threshold for older women):
- Abdominal bloating
- Early satiety
- Loss of appetite
- Pelvic pain
- Urinary symptoms (FU)
- Weight loss
- Abdo/pelvic mass
- Ascites
- Hip/Groin pain (compression of obturator nerve by ovarian mass)
According to NICE, guidelines a 2-week-wait referral for ovarian cancer must be made if physical examination reveals which 3 things?
- Ascites
- Pelvic mass (unless clearly due to fibroids)
- Abdominal mass
What initial investigations are done in primary/secondary care for ovarian cancer?
CA125 blood test (>35 IU/mL significant)
USS pelvis
Secondary care only:
- CT scan
- Histology
- Paracentesis (ascitic tap)
If woman under 40 yo with complex ovarian mass, test for possible germ cell tumour: AFP, HCG.
What is used to stage ovarian cancer?
FIGO (Federation international Gynae and OBs)
*Stages
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
How is ovarian cancer managed?
Specialist gynae oncology MDT
Combination of:
- Surgery
- Chemotherapy
90% of vulva cancers are what cell type?
What other cell type can they also be - less commonly?
Squamous cell carcinomas
Less common - malignant melanomas
What are risk factors for vulval cancer?
Advanced age (75 years +)
Immunosuppression
HPV infection
Lichen sclerosus - around 5% of women with this get vulval cancer
What is Vulval intraepithelial neoplasia (VIN)?
Premalignant condition affecting squamous epithelia of skin that precedes vulval cancer
In which age group does the VIN subtype High grade squamous intraepithelial lesion occur?
Younger women - aged 35 - 50 years
In which age group does the VIN subtype differentiated VIN occur?
Older women 50 - 60 years, associated with lichen sclerosus
How is VIN diagnosed?
Biopsy
What are treatment options for VIN?
Watch and wait (close followup)
Wide local excision (remove lesion)
Imiquimod cream
Laser ablation
Vulval cancer can present with symptoms of:
Older women usually (75+)
Vulval ump Ulceration Bleeding Pain Itching Lymphadenopathy in the groin
Vulval cancer most frequently affects _____________ (part of the female genitals)
Labia majora
How does labia majora affected by vulval cancer appear?
Irregular mass
Fungating lesion
Ulceration
Bleeding
How is vulval cancer diagnosed?
Biopsy of lesion
Sentinel node biospy to demonstrate lymph node spread
Further imaging for staging (CT abdomen + pelvis)
What grading system is used to stage vulval cancer?
FIGO (Federation International Gynae and Obs)
How is vulval cancer managed?
Depends on the stage
Wide local excision (remove cancer)
Groin lymph node dissection
Chemotherapy
Radiotherapy
