Gynae Malignancy Flashcards
Most common gynae malignancy
Endometrial cancer
THE major risk factor for endometrial cancer
UNOPPOSED OESTROGEN
Risk factors/causes of unopposed oestrogen
High BMI
Anovulation - PCOS or perimenopause.
Granulosa cell tumours - secrete oestrogen.
Oestrogen replacement - Tamoxifen.
Nulliparity
DM
Hereditary non-polyposis colorectal cancer.
Clinical features of endometrial cancer
Postmenopausal bleeding.
Irregular PV bleeding.
Menorrhagia.
Investigating endometrial cancer
TVUS - primary care Ix, measure thickness of endometrium.
Endometrial biopsy for histology examination.
Diagnostic hysteroscopy if unable to obtain biopsy.
Classification of endometrial cancer
Most are adenocarcinomas.
FIGO staging 1-4.
FIGO stage 3 endometrial cancer
Over all = local/regional spread and invasion.
3A = spread to ovary.
3B = Spread to vaginal
3C = Spread to para-aortic lymph nodes
Management of endometrial cancer
Total hysterectomy + bilateral salpingo-oophorectomy + lymphadenectomy
Adjuvant radiotherapy/pallative chemotherapy e.g. carboplatin.
Prognosis of endometrial cancer
Five year survival is close to 80%.
Cervical cancer common age presentations
in 30s and in 80s
Major risk factors for cervical cancer
Highly related to sexual activity and HPV
Risk factors for cervical cancer
Early age of sexual intercourse (less than 16yrs)
Multiple sexual partners.
STI
Multiparity
COCP use
History of cervical intra-epithelial neoplasia
Cigarrettes.
CIN pathophysiology, staging and treatment
This is a pre-malignant stage where cervical cells are changing, most likely due to HPV.
Unable to see with naked eye. Picked up on smears and then colposcopy.
CIN 1 = confined to lower 1/3 of epithelium.
CIN2 = 1/3 to 2/3 thickness of epithelium.
CIN3 = covers more than 2/3 of epithelium.
CIN 1 Rx = re-assess in 1 year as can regress to normal.
CIN2 and 3 Rx = ablation or excision (LEEP).
Clinical symptoms of cervical cancer
POST COITAL BLEEDING
Inter-menstrual bleeding.
Vaginal discharge (offensive) and vaginal pain.
In later stages can get urinary symptoms.
Classification of cervical cancer
Most are squamous cells.
FIGO stages 1-4
FIGO stage 3 cervical cancer
Carcinoma reached pelvis wall or lower third of vagina. Causes hydronephrosis.
Investigations for cervical cancer
Cervical biopsy
Management of cervical cancer
Stage 1ai= cone biopsy
Stages 1b-2b= hysterectomy and consider lymph nodes.
Stage 2b plus = chemo-radiotherapy.
Most oncogenic HPV and oncoprotein they affect
16, 18 and 33 HPV and E6 and E7 oncoprotein.
How is HPV transmitted
Sexually
When is the HPV vaccine offered
Girls, before first sexual intercourse as only effective if no present HPV, around 12yrs of age.
Screening timetable for HPV
25-49yrs - every 3 years 50-64yrs - every 5 years Continue in 65+ if Hx of abnormal tests. HIV +ve - annual. Transgender males still qualify for screening if they retain their cervix.
What does the screening test look for
Historically - dyskaryosis of cervical epithelial (i.e. CIN)
From 2019 - Presence of HPV.
Results of cervical screen smear
No changes/normal = continue screening programme.
Low-grade dyskaryosis/borderline changes = test for HPV. If this is +ve –> Colposcopy. If this is -ve –>continue with screening programme.
High-grade dyskaryosis = Colposcopy.
HPV testing = triage
Colposcopy procedure
Apply chemical - acetic acid which is taken up by neoplastic cells and turn them white or iodine solution which stains normal tissues brown.
Take punch biopsy to confirm diagnosis.
What strains does the HPV vaccine cover
6, 11, 16, and 18
Ovarian cancer prognosis and why
Leading cause of death from gynae cancer, mostly asymptomatic so presents late.
Main age of diagnosis of ovarian cancer
75-85years
Clinical features of ovarian cancer
Asymptomatic? Abdo pain and bloating, abnormal PV bleeding, weight loss, loss of appetite, early satiety, fatigue. Can have palpable mass, urinary and bowel symptoms.
Blood test in primary care for ovarian cancer
CA125, raised in 80% of cancers. Over 35 IU/ml arrange an ultrasound scan of the abdomen and pelvis.
Investigations for ovarian cancer
CA125.
TVUS to image ovaries.
Diagnosis via biopsy.
Risk factors for ovarian cancer
BRCA 1 and 2 genes (tumour suppressor genes)
FHx of ovarian or other cancers.
Increase in the number of ovulatory cycles = nulliparity, early menarche, late menopause.
IVF
HRT
Endometriosis
Cigarettes, obesity, exposure to asbestos.
Factors which REDUCE the risk of ovarian cancer
Multiparity
Breastfeeding
Use of COCP
Early menopause.
RMI
risk of malignancy index = U x M x CA125
U = ultrasound score (multilocality, solid area, metastasis, ascites, bilateral lesions)
M = menopausal status (pre =1 or post =3)
CA125 level
Low risk = under 25
Medium risk = 25-250
High risk = over 250
Other causes of a raised CA125
Peritoneal trauma Endometriosis PID Ovarian cyst torsion Pregnancy HF Other cancers e.g. lung, pancreatic.
Management of ovarian cancer
Surgical = hysterectomy plus bilateral sapling-oophorectomy. Lymph nodes if appropriate. Chemotherapy = platinum agents
Age group most commonly affected by vulval cancer
over 50s, mostly 70-80yr olds
Most common type of vulva carcinoma
Squamous.
Aetiology of vulva carcinoma
HPV
Vulval intra-epithelial neoplasia.
Lichen sclerosus.
Paget’s disease.
Presentation of vulva carcinoma
Squamous cell carcinomas are rarely itchy (unlike VIN and lichen sclerosis)
Most present as lump or ulceration.
Vulval irriation or pain Lump Bleeding or discharge PV due to ulceration. Dysuria. Enlarged groin lymph nodes.
Diagnosis of vulva carcinoma
Biopsy
Lymph nodes for vulva carcinoma
Inguinal nodes
Treatment of vulva carcinoma
Surgerical - local excision, lymph node removal, vulvectomy,
Radiotherapy +/- chemotherapy - shrink tumours pre-op.
Lichen Sclerosus pathophys
Auto-immune. Inflammatory dermatitis. Elastic tissue turns to collagen. Pre-malignant.
Signs and symptoms of lichen sclerosus
Itchy, sore.
Pale white atrophic area
Purpura
Changes occur in figure of 8/hour-glass shape around vulva.
Investigations for lichen sclerosus
Clinical appearance diagnosis.
Biopsy if uncertain on diagnosis.
Skin swab.
Management of lichen sclerosus
Topical steroids - Clobetasol propionate.
Review annually due to risk of malignancy.
Vulval intra-epithelial neoplasia pathophys
Pre-malignant, pre-invasive neoplasia.
Most common cause of VIN and risk factors.
HPV mostly HPV16. Smoking and immunocompromised.
Clinical features of VIN
Itching and burning. Lumps/warts. Itch and irritation Pain Asymptomatic White or erythematous lesions on examination
Diagnosis of VIN
Biopsy most show loss of squamous cell epithelium organisation.
Management of VIN
Can regress and resolve on its own. Local excision. Imiquimod cream Vulvectomy (not recommended) Follow up closely due to pre-malignancy.
Risks and protective cancers and the COCP
Increased risk of breast and cervical cancer
Protective against ovarian and endometrial cancer
3 inadequate smears in a row?
refer for colposcopy!
Treatment for low grade CIN
LLETZ - large loop excision of transformed zone
Sister Mary Joseph Nodule
Ovarian cancer metastasis to umbilicus
Endometrial cancer TVUS
Refer for biopsy and hysteroscopy if thickness greater than 20mm pre-menopause and 4mm if post-menopause.
Smearing during pregnancy
do it 12 weeks after birth.
Level for a high CA125
Greater or equal to 35units/ml
What cancer does PCOS increase the risk of?
Endometrial
Sign seen in low-grade HPV cervical squamous cell carcinomas
Koilocytosis - ‘halo’ in cell.
