Gynae cancers Flashcards
When to do hysteroscopy and biopsy?
If 4mm or more (endometrial thickness) –> do hysteroscopy and endometrial biopsy
Types of cervical cancer?
squamous cell cancer (80%)
adenocarcinoma (20%)
Features of cervical cancer?
may be detected during routine cervical cancer screening
abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
vaginal discharge
RFs for cervical cancer?
Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer. Other risk factors include:
smoking
human immunodeficiency virus
early first intercourse, many sexual partners
high parity
lower socioeconomic status
combined oral contraceptive pill*
Mechanism that HPV causes cervical cancer?
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
regularity of cervical screening?
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
cervical screening cannot be offered to women over 64
What happens to cervical screening in pregnancy?
cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears.
Explain how cervical smears are tested?
sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
Mx of negative hrHPV?
return to normal recall, unless
the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
the untreated CIN1 pathway
follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
follow-up for borderline changes in endocervical cells
Mx of positive hrHPV?
samples are examined cytologically
if the cytology is abnormal → colposcopy this includes the following results: this includes the following results: borderline changes in squamous or endocervical cells. low-grade dyskaryosis. high-grade dyskaryosis (moderate). high-grade dyskaryosis (severe). invasive squamous cell carcinoma. glandular neoplasia
if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months:
- if the repeat test is now hrHPV -ve → return to normal recall
- if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
- If hrHPV -ve at 24 months → return to normal recall
- if hrHPV +ve at 24 months → colposcopy
Mx of inadequate cervical screen sample?
If the sample is ‘inadequate’
repeat the sample within 3 months
if two consecutive inadequate samples then → colposcopy
Mx of individuals who have been treated for CIN?
should be invited 6 months after treatment for a test of cure repeat cervical sample in the community.
WHen should a woman >65yo be screened for cervical cancer?
A recent cervical cytology sample is abnormal.
They have not had a cervical screening test since 50 years of age and they request one.
WHen should a cervical sample not be taken?
if the woman:
Is menstruating.
Is less than 12 weeks postnatal.
Is less 12 weeks after a termination of pregnancy, or miscarriage.
Has a vaginal discharge or pelvic infection — treat the infection and take the sample on another occasion.
Situations where more frequent cervical screening required?
kidney failure and require dialysis - screen at siagnosis
about to undergo organ transplantation - screen within a year before transplantation
are starting sytotoxic drugs for rheum disorders - if the screening history is incomplete at the start of treatment.
HIV positive - at Dx and annually therafter
Define CIN 1, 2, and 3
CIN1 — one-third of the thickness of the surface layer of the cervix is affected.
CIN2 — two-thirds of the thickness of the surface layer of the cervix is affected.
CIN3 — sometimes called high-grade or severe dysplasia or stage 0 cervical carcinoma in situ. The full thickness of the surface layer is affected.
Appearance of CIN on colposcopy?
ceto-white epithelium (AWE).
• V ascular abnormalities, especially mosaic and punctuation.
• B izarre or grossly abnormal vessels are suggestive of micro-invasive
carcinoma.
Mx of CIN 1, and 2,3
CIN 1:
C onservative monitoring with colposcopy and/or cytology every
6mths.
• LLETZ if persistent.
CIN2,3:
LLETZ
- follow-up cytology and high risk HPV test-of-cure at 6mths.
Complications of LLETZ?
Short term • Haemorrhage. • Infection. • Vaso-vagal reaction. • Anxiety (disproportionately high in colposcopy clinic attenders).
Long term
• Cervical stenosis (dysmenorrhoea and/or diffi culty in follow-up).
• Cervical incompetence and premature delivery (evidence suggests
absolute risk of adverse effect on neonatal outcome is very low).
RFs for endometrial cancer?
obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome hereditary non-polyposis colorectal carcinoma
Ix for endometrial cancer?
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
hysteroscopy with endometrial biopsy
protective factors for endometrial cancer?
COCP and smoking
Mx of endometrial hyperplasia?
simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
atypia: hysterectomy is usually advised
Simple vs complex endometrial hyperplasia?
depends on the
glandular:stromal ratio (much less stroma in complex hyperplasia).
Histology of endometrial carcinoma?
Back-to-back atypical glandular
cells (i.e. no stromal component) = endometrial carcinoma.
Causes of unopposed oestrogen?
E ndogenous:
• p eripheral conversion in adipose tissue of androstenedione to
oestrone
• o estrogen-producing tumour (granulosa cell tumour)
• p olycystic ovarian syndrome or anovulatory cycles at menarche or
during climacteric period (lack of progesterone as no luteal phase).
Exogenous:
• o estrogen-only HRT
• t amoxifen (oestrogen agonist in endometrial tissue).
When to perform an endometrial biopsy?
Perform endometrial sampling if ET ≥ 4mm or persistent bleeding in woman with ET <4mm (in which case consider formal hysteroscopy).
RFs for ovarian cancer?
BRCA1 and 2, lynch syndrome
increasing age
nulliparity
family history
What cancers is lynch syndrome associated with?
Also known as Hereditary Non Polyposis Colorectal Cancer
• Associated with colorectal, ovarian and endometrial cancer
protective factors for ovarian cancer?
multiparity, COCP
Px of ovarian cancer?
Asymptomatic • Non specific GI symptoms: bloating, NV, change in bowel habit, early satiety • Chronic pelvic pain • Incidental finding
What is a red flag for ovarian Ca?
A new diagnosis of IBS
over the age if 50 is a red flag
Ix for ovarian cancer?
First Step: CA
125 and Transvaginal Ultrasound Scan (TVUS)
then RMI (RMI > 200 = >75% Risk of Ovarian Cancer)
if greater than 200 –>Gynae MDT 2ww for CT abdo pelvis
How to identify type of ovarian cancer?
Exploratory laparoscopy - offers dx and provides tx
Peritoneal washings - Peritoneal biopsies - TAH and BSO - Lymph node dissection - Omentectomy
Tumour markers for suspected ovarian cancer?
CA125 in all women
if less than 40yo - measure levels of AFP and beta-hCG as well as serum CA125, to identify women who may not have epithelial ovarian cancer.
When might CA125, Carcinoembryonic antigen (CEA) and CA19.9 be raised?
CA125 - raised in 80% of epithelial cancers
CEA - raised in colorectal cancers
CA19.9 0 raised in mucinous tumours (more likely to have normal CA125). Also pancreatic and breast
