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Obs & Gynae > Gynae cancers > Flashcards

Gynae cancers Flashcards

1
Q

Cervical cancer tends to affect women of which age?

A

Younger

Peak in reproductive years

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2
Q

80% of cervical cancers affect which type of cell?

A

Squamous cell carcinomas

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3
Q

The 2nd most common type of cervical cancer after squamous cell carcinomas is what?

A

Adenocarcinoma

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4
Q

The leading cause of cervical cancer is what?

A

HPV

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5
Q

Children aged 12-13 years are vaccinated against certain strains of _____ to reduce risk of cervical cancer

A

HPV

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6
Q

Aside from cervical cancers, HPV can also give rise to which cancers?

A 
Anal
Vulval
Vaginal
Penis
Mouth
Throat

*HPV is primarily a sexually transmitted infection

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7
Q

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.

A

Type 16

Type 18

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8
Q

Is there a treatment for HPV infection?

A

No

*Can be vaccinated against though

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9
Q

HPV produces two proteins E6 and E7. What is the role of these proteins?

A

Both inhibit tumour suppressor genes

E6 inhibits p53

E7 inhibits pRb

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10
Q

What are risk factors for cervical cancer?

A
  1. Increased risk of catching HPV
    - early sexual activity
    - increased sexual partners
    - sexual partners with more partners
    - not using condoms
  2. Non-engagement with cervical screening
  3. Other risk factors
    - Smoking
    - HIV
    - COCP >5 years of use
    - Increased number of full-term pregnancies
    - Family history
    - Exposure to diethylstilbestrol during fetal development
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11
Q

How can cervical cancer be detected in otherwise asymptomatic women?

A

Cervical smear tests

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12
Q

What are presenting symptoms that must be followed up for possible cervical cancer?

A

Abnormal vaginal bleeding (IMB, PCB, PMB)

Vaginal discharge

Pelvic pain

Dyspareunia

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13
Q

What investigations must be done for possible cervical cancer?

A

Cervix examination with speculum

Swabs (exclude infection)

If abnormal appearance of cervix, urgent cancer referral for colposcopy.

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14
Q

Ulceration
Inflammation
Bleeding
Visible tumour

On colposcopy suggests what?

A

Cervical cancer

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15
Q

Can a negative cervical screening test exclude cervical cancer, even if the smear result was normal?

A

No, it cannot exclude

Referral for colposcopy if suspicion remains

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16
Q

Cervical intraepithelial neoplasia is what?

A

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)
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17
Q

Cervical intraepithelial neoplasia is graded during which investigation?

A

Colposcopy

*NOT with cervical screening

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18
Q

What is dyskarosis?

A

Precancerous changes found on smear results

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19
Q

How often is the cervical smear test performed?

A

Every 3 years 25-49

Every 5 years 50-64

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20
Q

What are exceptions to the usual routine cervical smear test?

A

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

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21
Q 
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?

A

Cytology results for cervical cancer

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22
Q

Aside from HPV, what other infections can be identified and reported on the smear test?

A

Bacterial vaginosis
Candidiasis
Trichomoniasis

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23
Q

Actinomyces-like organisms are found with women with an ___________.

Do not require treatment unless symptomatic - otherwise require removal.

A

IUD (coil)

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24
Q

HPV negative smear is managed how?

A

Continue routine screening

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25
Q

Inadequate sample on cervical smear is managed how?

A

Repeat smear after 3 months

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26
Q

HPV positive with normal cytology on a cervical smear is managed how?

A

Repeat HPV test after 12 months

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27
Q

HPV positive with abnormal cytology on a cervical smear is managed how?

A

Referral for colposcopy

*For definitive diagnosis

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28
Q

Which 2 stains are used in colposcopy to differentiate abnormal areas?

A

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

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29
Q

What procedures can be performed during the colposcopy to get a tissue sample?

A

Punch biopsy

LLETZ (large loop excision of the transformational zone)

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30
Q

What is cone biopsy used as as a treatment for?

A

Cervical intraepithelial neoplasia and very early-stage cervical cancer

*Sample take and sent to histology to assess for malignancy

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31
Q

What are the risks of cone biopsy?

A 
Pain
Bleeding
Infection
Scar formation with cervix stenosis
Increased risk of miscarriage and preterm labour
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32
Q

Which staging system is used to stage cervical cancer?

A

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

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33
Q

CIN and Early-stage 1A cervical cancer is treated how?

A

LLETZ or cone biopsy

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34
Q

Stage 1B-2A cervical cancer is treated how?

A

Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy

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35
Q

Stage 2B-4A cervical cancer is treated how?

A

Chemotherapy and radiotherapy

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36
Q

Stage 4B cervical cancer is treated how?

A

Combination of surgery, radiotherapy, chemotherapy and palliative care

37
Q

How does 5-year survival with cervical cancer differ from stage 1A to stage 4?

A

98% survival with 1A

15% survival with 4

38
Q

Pelvic exenteration is a surgical treatment for advanced cervical cancer.

What does it involve?

A

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.

39
Q

Which monoclonal antibody can be used in conjunction with chemotherapy in treatment of recurrent/metastatic cervical cancer?

What growth factor does it target?

A

Bevacizumab (Avastin)

VEGF-A

40
Q

What is the current HPV vaccine in the NHS called?

Which strains does it protect against?

A

Gardasil

Strains 6, 11, 16 and 18

41
Q

Strains 6 and 11 of HPV cause what?

A

Genital warts

42
Q

Strains 16 and 18 of HPV cause what?

A

Cervical cancer

43
Q

80% of endometrial cancers are ___________.

A

Adenocarcinomas

44
Q

Endometrial cancer is dependent on which hormone?

A

Oestrogen

45
Q

Woman presents with PMB.
Also is obese and diabetic.

What is the likely diagnosis?

A

Endometrial cancer

*PMB, obesity and diabetes are major risk factors

46
Q

What are the 2 important types of endometrial hyperplasia?

A

Hyperplasia without atypia

Atypical hyperplasia (more potential for cancer)

47
Q

Endometrial hyperplasia can be treated using which class of drugs?

Give 2 forms of this class of drugs.

A

Progesterogens

Two types: IUD (Mirena coil), continous oral progestogens (medroxyprogesterone)

48
Q

What are risk factors for endometrial cancer?

A

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)

49
Q

How does PCOS lead to more unopposed oestrogen?

A

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
50
Q

How are women with PCOS given more endometrial protection?

A

Need more progesterone

  • COCP
  • IUD (Mirena coil)
  • Cyclical progestogens to induce withdrawal bleed
51
Q

Why is obesity a risk factor for endometrial hyperplasia/cancer?

A

Adipose tissue is source of estrogen.

*Adipose tissue contains aromatase which converts testosterone into oestrogen.

More fat = more estrogen

52
Q

Why is tamoxifen use a risk factor for endometrial hyperplasia/cancer?

A

Tamoxifen has anti-oestrogenic effect on breast tissue

BUT

has a oestrogenic effect on endometrium -»> increases risk of endometrial cancer

53
Q

What are non-estrogen-related risk factors for endometrial hyperplasia/cancer?

A

T2DM

PCOS

HNPCC (Lynch syndrome)

54
Q

How does T2DM increase risk of endometrial cancer?

A

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

55
Q

What are protective factors against endometrial cancer?

A
  • COCP
  • Mirena
  • Increased pregnancies
  • Cigarette smoking
56
Q

What is the MOST IMPORTANT presenting symptom of endometrial cancer?

A

Postmenopausal bleeding

*Other possible symptoms:

  • PCB
  • IMB
  • HMB
  • Abnormal vaginal discharge
  • Haematuria
  • Anaemia
  • Raised platelets
57
Q

What are 3 investigations for diagnosing and excluding endometrial cancer?

A

USS transvaginal (endometrial thickness)

Pipelle biopsy (highly sensitive for endometrial cancer)

Hysteroscopy (with endometrial biopsy)

58
Q

Difference between pipelle biopsy and hysteroscopy with endometrial biopsy?

A

Both used for endometrial cancer diagnosis

Pipelle biopsy quicker and less invasive alternative to hysteroscopy for excluding cancer in lower-risk women.

59
Q

What grading system is used to stage endometrial cancer?

A

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
60
Q

How is stage 1/2 endometrial cancer managed?

A

Total abdominal hysterectomy
with
Bilateral salpingo-oophorectomy

(TAH and BSO)

Other treatment options:

  • Radical hysterectomy
  • Radiotherapy
  • Chemotherapy
  • Progesterone (to slow progression of cancer)
61
Q

What hormone can be used to slow the progression of endometrial cancer?

A

Progesterone

*Opposes oestrogen levels

62
Q

Why does ovarian cancer usually present late and lead to a worse prognosis?

A

Due to non-specific symptoms

*70%+ women with ovarian cancer present after spread beyond pelvis

63
Q

What are the 4 types of ovarian cancer?

A

Epithelial cell tumours (most common is serous tumour)

Dermoid cysts/germ cell tumours

Sex cord/Stromal tumours

Metastasis

64
Q

Which type of ovarian cancer is most associated with ovarian torsion?

A

Dermoid cysts/germ cell tumour

65
Q

A Krukenberg tumour is mets from where usually?

A

Usually mets from GI tract (stomach) to the ovary

66
Q

What characteristic features do Krukenberg tumours in ovarian cancer possess on histology?

A

“Signet-ring” cells on histology

67
Q

What are risk factors for ovarian cancer?

A
  • Age (peak @60)
  • BRCA1/BRCA2 genes (family history)
  • Increased number of ovulations
  • Obesity
  • Smoking
  • Recurrent use of clomifene
68
Q

What is clomifene used for and which cancer does it increase the risk of?

A

Treating infertility in women who do not ovulate.

Includes those with PCOS

*Selective estrogen receptor modulator)

69
Q

What factors increase the number of ovulations?

A

Early-onset periods
Late menopause
No pregnancies

70
Q

What are protective factors against ovarian cancer?

A

Factors reducing lifetime number of ovulations:

  • COCP
  • Breastfeeding
  • Pregnancy
71
Q

How can ovarian cancer present?

A

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)
72
Q

According to NICE, guidelines a 2-week-wait referral for ovarian cancer must be made if physical examination reveals which 3 things?

A
  • Ascites
  • Pelvic mass (unless clearly due to fibroids)
  • Abdominal mass
73
Q

What initial investigations are done in primary/secondary care for ovarian cancer?

A

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.

74
Q

What is used to stage ovarian cancer?

A

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)

75
Q

How is ovarian cancer managed?

A

Specialist gynae oncology MDT

Combination of:

  • Surgery
  • Chemotherapy
76
Q

90% of vulva cancers are what cell type?

What other cell type can they also be - less commonly?

A

Squamous cell carcinomas

Less common - malignant melanomas

77
Q

What are risk factors for vulval cancer?

A

Advanced age (75 years +)
Immunosuppression
HPV infection
Lichen sclerosus - around 5% of women with this get vulval cancer

78
Q

What is Vulval intraepithelial neoplasia (VIN)?

A

Premalignant condition affecting squamous epithelia of skin that precedes vulval cancer

79
Q

In which age group does the VIN subtype High grade squamous intraepithelial lesion occur?

A

Younger women - aged 35 - 50 years

80
Q

In which age group does the VIN subtype differentiated VIN occur?

A

Older women 50 - 60 years, associated with lichen sclerosus

81
Q

How is VIN diagnosed?

A

Biopsy

82
Q

What are treatment options for VIN?

A

Watch and wait (close followup)
Wide local excision (remove lesion)
Imiquimod cream
Laser ablation

83
Q

Vulval cancer can present with symptoms of:

A

Older women usually (75+)

Vulval ump
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in the groin
84
Q

Vulval cancer most frequently affects _____________ (part of the female genitals)

A

Labia majora

85
Q

How does labia majora affected by vulval cancer appear?

A

Irregular mass
Fungating lesion
Ulceration
Bleeding

86
Q

How is vulval cancer diagnosed?

A

Biopsy of lesion

Sentinel node biospy to demonstrate lymph node spread

Further imaging for staging (CT abdomen + pelvis)

87
Q

What grading system is used to stage vulval cancer?

A

FIGO (Federation International Gynae and Obs)

88
Q

How is vulval cancer managed?

A

Depends on the stage

Wide local excision (remove cancer)
Groin lymph node dissection
Chemotherapy
Radiotherapy

Obs & Gynae (13 decks)

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