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Yr4: Obstetrics & Gynaecology > Gynae: Oncology > Flashcards

Gynae: Oncology Flashcards

1
Q

At what age is cervical cancer most common?

A

Mainly affects sexually active women between 30-45yrs (CKS NICE)

Peak incidence 30-34yrs

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2
Q

What type of cancer are most cervical cancer?

What type is the next most common type?

A
  • Squamous cell carcinoma- 80%
  • Adenocarcinoma

*Very rarely there are other types e.g. small cell

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3
Q

Cervical cancer is strongly associated with…?

A

HPV (human papilloma virus)

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4
Q

How is HPV transmitted?

Aside from cervical cancer, what other cancers is HPV associated with?

A
  • Sexually transmitted infection
  • Anal, vulval, vaginal, penile, mouth & throat cancers
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5
Q

Is there any treatment for infection with HPV?

A

No treatment

Most cases resolve spontaneously within 2yrs

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6
Q

Which types of HPV are associated with cervical cancer?

A
  • Strains 16 & 18 → cervical cancer
  • Strains 6 & 11 → genital warts
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7
Q

Explain how HPV increases risk of cervical cancer

A
  • P53 and pRb are tumour suppressor genes
  • HPV produces two proteins: E6 and E7
    • E6 inhibits p53
    • E7 inhibits pRb
  • Inhibiting tumour suppressor genes promotes development of cervical cancer
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8
Q

State some risk factors for cervical cancer, group your answers into:

  • Increased risk catching HPV
  • Later detection precancerous & cancerous changes
  • Others
A
  • Increased risk of catching HPV **REMEMBER HPV IS NUMBER 1 RISK FACTOR:
    • Early sexual activity
    • Increased number of sexual partners
    • Sexual partners who have had more partners
    • Not using condoms
  • Non-engagement with cervical screening
  • Others:
    • Smoking
    • HIV
    • COCP for more than 5yrs
    • Increased number full-term pregnancies
    • FH
    • Exposure to diethylstilbestrol during fetal development (was used to prevent miscarriages before 1971 so becoming less relevant)
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9
Q

Describe typical presentation of cervical cancer

A

May be detected during cervical smears in asymptomatic women or it may present with:

  • Abnormal vaginal bleeding
    • Intermenstrual
    • Post-coital
    • Post-menopausal
  • Vaginal discharge
  • Pelvic pain
  • Dyspareunia

**NOTE: symptoms are non-specific and in most cases not caused by cervical cancer

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10
Q

What cervical features, on examination, may be suggestive of cervical cancer?

A
  • Ulceration
  • Inflammation
  • Bleeding
  • Visible tumour

If appearance suggests cervical cancer must make urgent 2WW referral for colposcopy

Additional note from ZtoF: The NICE Clinical Knowledge Summaries (2017) recommend against unscheduled cervical screening with a smear test. They also advise against using the result of cervical screening to exclude cervical cancer where it is suspected for another reason, even if the smear result was normal.

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11
Q

What is cervical intraepithelial neoplasia?

How is CIN diagnosed?

A

Dysplasia= presence of cells of an abnormal type within a tissue, which may signify a stage preceding the development of cancer.

HENCE, CIN describes abnormal changes of the cells that line the cervix.

*CIN NOT CANCEROUS, PRE-MALIGNANT

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12
Q

What is the difference between dysplasia found in colposcopy and dyskaryosis found in smear test?

A
  • Dysplasia= presence of abnormal cells in a tissue, pre-malignant change/may develop into cancer
  • Dyskaryosis= abnormalities in cellular nuclei
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13
Q

Describe the three grades for CIN

A
  • CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
  • CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
  • CIN III: severe dysplasia, very likely to progress to cancer if untreated

CIN III is sometimes called cervical carcinoma in situ.

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14
Q

Who is invited to cervical screening programme and how often? (As general rule, will discuss exceptions in next FC)

A
  • Women aged 25-49yrs invited every 3yrs
  • Women aged 50-64yrs invited every 5yrs

*Must also invite transgender men who still have cervix

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15
Q

Cervical screening is offered every 3yrs to women aged 25-49yrs and every 5yrs to women aged 50-64yrs; however, there are some exceptions to the programme. State these

A
  • Women with HIV are screened annually
  • Women over 65 may request a smear if they have not had one since aged 50
  • Women with previous CIN may require additional tests (the follow up is complicated but as first step women treated with CIN 1, 2 or 3 should have cervical smear in community 6 months after treatment)
  • Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
  • Pregnant women due a routine smear should wait until 12 weeks post-partum
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16
Q

Discuss what cervical screening involves

A
  • Often performed by a nurse. Involves speculum examination and collecting cells from cervix using small brush. Cells are deposited from the brush into a preservative fluid (“liquid based cytology”).
  • Samples initially tested for HPV:
    • If sample is HPV negative → cells not examined
    • If sample is HPV positive → cells examined under microscope for precancerous changes (dyskaryosis- changes in cell nucleus)
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17
Q

When, during cycle, is cervical smear best performed?

A

Mid cycle

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18
Q

Infections such as bacterial vaginosis, candidiasis and trichomoniasis may be identified and reported on smear results; true or false?

A

True

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19
Q

What might you find during smear test of woman with intrauterine device?

Does this require treatment?

A
  • Actinomyces-like organisms
  • Don’t require treatment unless symptomatic. If woman symptomatic consider removal of IUD
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20
Q

Discuss what the Public Health England Guidelines are for the following cervical screening results:

  • Inadequate sample
  • HPV negative
  • HPV positive with normal cytology
  • HPV positive with abnormal cytology
A
  • Inadequate sample → repeat the smear after at least three months (if two consecutive samples inadequate do colposcopy)
  • HPV negative → continue routine screening
  • HPV positive with normal cytology → repeat test after 12 months
    • If repeat test then HPV -ve → return to routine screening
    • If repeat test still HPV +ve with normal cytology → repeat again after 12 months
    • If 2nd repeat test still HPV +ve at 24 months → colposcopy
    • If 2nd repeat test HPV -ve at 24 months → return to normal screening
  • HPV positive with abnormal cytology → refer for colposcopy
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21
Q

Describe what is involved in colposcopy

A

Performed by specialist. Insert colposcope to magnify cervix and allow in depth examination of cervical epithelium.

During colposcopy stains are used to identify abnormal areas:

  • Acetic acid: abnormal cells (with increased nuclear to cytoplasmic ratio) turn white e.g. CIN, cervical cancer
  • Schiller’s iodine test: iodine will stain healthy cells brown (due to glycogen), abnormal cells won’t stain

A biopsy can also be taken this may be:

  • Punch biopsy
  • Large loop excision of the transformational zone
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22
Q

Discuss the FIGO (International Federation of Gynaecology & Obstetrics) staging system for cervical cancer

A
  • Stage 1: Confined to the cervix
    • 1A: <7mm wide
    • 1B: >7mm wide
  • Stage 2: Invades the uterus or upper 2/3 of the vagina
    • A: upper ⅔ vagina
    • B: parametrial involvement
  • Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
    • A: lower ⅓ vagina
    • B: pelvic wall
  • Stage 4: Invades the bladder, rectum or beyond the pelvis
    • A: bladder or rectum
    • B: distant sites outside pelvis

*NOTE: any tumour causing hydronephrosis or a non-functioning kidney is considered stage III

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23
Q

Discuss the management of cervical cancer

A

MDT management dependent on stage and the individual. Usual treatment options:

  • CIN → LLETZ or cone biopsy
  • Stage 1A → gold standard is hysterectomy +/- lymph node dissection but if pts want to maintain fertility can have cone biopsy
  • Stage 1B-2A → radical hysterectomy with removal of lymph nodes may also have: chemotherapy, radiotherapy
  • Stage 2B-4A → chemotherapy & radiotherapy
  • Stage 4B → combination of radiotherapy and/or chemotherapy & palliative care
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24
Q

What is a large loop excision of the transformation zone (LLETZ)?

What would you advise a woman who has had LLETZ?

A
  • Performed during colposcopy. Give local anaesthetic. Use diathermy loop to removal abnormal epithelial tissue from cervix
  • Advise woman that:
    • May get abnormal bleeding & discharge for a few weeks following LLETZ
    • Avoid tampons and sexual intercourse as increases risk of infection
    • May increase risk of preterm labour (depth dependent)
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25
Q

What is a cone biopsy?

State some risks of a cone biopsy

A
  • Give general anaesthetic and remove cone-shaped piece of cervix using scalpel. Send sample for histology
  • Risks:
    • Pain
    • Bleeding
    • Infection
    • Scar formation → stenosis cervix
    • Increased risk miscarriage
    • Increased risk preterm labour
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26
Q

What is pelvic exenteration?

A

Pelvic exenteration is an operation that may be used in advanced cervical cancer. It involves removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum. It is a vast operation and has significant implications on quality of life.

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27
Q

What monoclonal antibody can be used in combination with other chemotherapies for metastatic or recurrent cervical cancer?

A
  • Bevacizumab (Avastin)
  • Targets VEGF-A hence reduces development of new blood vessels
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28
Q

State some short term complications of radiotherapy for cervical cancer

State some long term complications of radiotherapy for cervical cancer

A

Short term

  • Diarrhoea
  • Vaginal bleeding
  • Radiation burns
  • Dysuria
  • Tiredness

Long term

  • Ovarian failure
  • Fibrosis of bowel, skin, bladder or vagina
    • Bladder: urgency incontinence
    • Bowel: rectal bleeding, constipation, urgency, incontinence
  • Lymphoedema
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29
Q

Discuss the prognosis of cervical cancer

A

5yr survival drops significantly with more advanced cancer from around 98% with stage 1A to 15% stage 4

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30
Q

For the HPV vaccine, discuss:

  • Who it should be given to
  • When should be given
  • What current vaccine is called
  • What strains it protects against
A
  • Boys & girls
  • BEFORE become sexually active (aim is to stop them contracting and spreading HPV once sexually active)
  • Gardasil
  • Protects against strains 6, 11, 16, 18
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31
Q

What type of cancer are most endometrial cancers?

A

Adenocarcinoma (80%)

32
Q

Endometrial cancers are ____ dependent

A

Oestrogen dependent

33
Q

What is the average age of pts with endometrial cancer?

A

60yrs

34
Q

For endometrial hyperplasia, discuss:

  • What it is
  • Types
  • Prognosis
  • Treatment
A
  • Precancerous condition in which there is thickening of the endometrium
  • Types:
    • Hyperplasia without atypia
    • Atypical hyperplasia
  • Prognosis: most cases return to normal over time, 5% progress to endometrial cancer
  • Treatment depends on whether with atypia or without:
    • Without atypia:
      • Progesterone therapy e.g:
        • IUS (e.g. Mirena coil)
        • Continuous oral progestogens (e.g. medroxyprogesterone, levonorgestrel)
    • With atypia:
      • Not wanting future pregnancy: hysterectomy
      • Wanting future pregnancy/post menopausal: progesterone therapy
35
Q

State some risk factors for endometrial cancer

*Risk factors are same for endometrial hyperplasia

A

Anything that opposes to patient to unopposed oestrogen is a risk factor:

  • Increased age
  • Earlier onset of menstruation
  • Late menopause
  • Oestrogen only hormone replacement therapy
  • No or fewer pregnancies
  • Obesity
  • Polycystic ovarian syndrome
  • Tamoxifen

Others not related to unopposed oestrogen:

  • Hereditary non-polyposis colorectal carcinoma
  • Diabetes mellitus
36
Q

Explain why obesity is a risk factor for endometrial cancer

A
  • Adipose tissue is a source of oestrogen; in fact it is the primary source of oestrogen in post-menopausal women
  • Aromatase converts androgens e.g. testosterone → oestrogens
  • More adipose tissue, more conversion of androgens into oestrogens
  • This ‘extra oestrogen’ is unopposed in women not ovulating (e.g. PCOS, post-menopausal) as there’s no corpus luteum to produce progesterone
37
Q

Explain why tamoxifen increases risk of endometrial cancer

A

Tamoxifen is a SERM:

  • Agonist: endometrium & bone
  • Antagonist: breast
38
Q

Explain why T2DM is a risk factor for endometrial cancer

A
  • Increased production of insulin
  • Insulin may stimulate endometrial cells/hyperplasia

*NOTE: insulin resistance in PCOS further adds to why they are at increased risk alongside anovulation/no corpus luteum

39
Q

State some protective factors against endometrial cancer

A
  • Combined contraceptive pill
  • Mirena coil
  • Increased pregnancies
  • Cigarette smoking

****Smoking appears to be protective against endometrial cancer in postmenopausal women by being anti-oestrogenic. Interestingly, it is not protective against other oestrogen dependent cancers, such as breast cancer (where it increases the risk). Smoking may have anti-oestrogenic effects in several ways:

  • Oestrogen may be metabolised differently in smokers
  • Smokers tend to be leaner, meaning they have less adipose tissue and aromatase enzyme
  • Smoking destroys oocytes (eggs), resulting in an earlier menopause
40
Q

Describe the typical presentation of endometrial cancer- highlighting the “number 1 presenting symptom”

A
  • Post menopausal bleeding (in exams, post-menopausal bleeding is endometrial cancer until proven otherwise)
  • Postcoital bleeding
  • Intermenstrual bleeding
  • Unusually heavy menstrual bleeding
  • Abnormal vaginal discharge
  • Haematuria
  • Anaemia
  • Raised platelet count
41
Q

Discuss the 2WW referral criteria for endometrial cancer

A

Refer via 2-week-wait urgent cancer referral for endometrial cancer if:

  • >55yrs with postmenopausal bleeding (more than 12 months after the last menstrual period)
  • *Can consider referring those <55yrs*

NICE also recommends referral for a transvaginal ultrasound in women who are:

  • >55yrs with unexplained vaginal discharge who are:
    • Presenting for fist time
    • Or have thrombocytosis
    • Or report haematuria
  • >55yrs with visible haematuria plus:
    • raised platelets
    • or anaemia
    • or elevated glucose levels
42
Q

What investigations are used to diagnose and exclude endometrial cancer?

A
  • First line= transvaginal ultrasound to assess for endometrial thickness
  • Pipelle biopsy (can be done in outpatient clinic for lower risk women. Do speculum examination and insert thin through cervix into uterus and tube fills with sample endometrial tissue and is examined. Quicker & less invasive than other biopsy)
  • Hysteroscopy with endometrial biopsy
43
Q

What endometrial thickness on transvaginal ultrasound is normal post-menopause?

A

<4mm

***Depending on local guidelines, a normal transvaginal ultrasound (endometrial thickness < 4mm) and normal pipelle biopsy are sufficient to demonstrate a very low risk of endometrial cancer and discharge the patient.

44
Q

Describe the FIGO (International Federation of Gynaecology and Obstetrics) staging system for endometrial cancer

A
  • 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
45
Q

Discuss the management of endometrial cancer

A

MDT management depending on stage and individual:

  • Stage 1 & 2: total abdominal hysterectomy with bilateral salpingo-oophorectomy (known as TAH and BSO)
  • Other options:
    • Radical hysterectomy with lymph node dissection
    • Radiotherapy
    • Chemotherapy
    • Progesterone therapy in those who not suitable for surgery or other treatments to slow progression
46
Q

Discuss the prognosis of endometrial cancer

A

Most cases diagnosed early stage and disease confined to uterus has 5yr survival of 96%

47
Q

Ovarian cancer often presents late; true or false?

A

True; often presents late (in 70% spread beyond pelvis) due to non-specific symptoms

48
Q

Ovarian tumours can be divided into non-neoplastic (no malignant potential) and neoplastic (malignant potential). State some examples of non-neoplastic ovarian tumours

A

Non-neoplastic functional

  • Follicular cysts
  • Corpus luteum cysts

Non-neoplastic pathological

  • Endometrioma (also called chocolate cysts)
  • Polycystic ovaries
  • Theca lutein cysts (due to raised hCG e.g. due to molar pregnancy)
49
Q

Ovarian tumours can be divided into non-neoplastic (no malignant potential) and neoplastic (malignant potential). State some examples of neoplastic ovarian tumours- highlight most common type

A
  • Epithelial cell tumours (most common ~90% all cases)
    • Serous tumours (most common ~80% all cases)
    • Clear cell tumours
    • Mucinous tumours
    • Endometrioid carcinomas
  • Germ cell/dermoid tumours
  • Sex-cord stromal tumours
    • Fibroma (most common type of sex-cord stromal)
    • Sertoli-Leydig cell tumours
    • Granulosa cell tumours
50
Q

What is a Krukenberg tumour?

What is it’s characteristic appearance on histology?

A
  • Krukenberg tumour is a metastases in the ovary (usually from GI cancer- particularly stomach cancer)
  • Characteristic ‘signet ring’ cells on histology
51
Q

What is the average age of presentation for ovarian cancer?

A

~60yrs

52
Q

State some risk factors for ovarian cancer

A
  • Increasing age
  • FH of ovarian cancers and certain other cancers (e.g. breast, melanoma, stomach, prostate)
  • BRCA1 & BRCA2 genes
  • Increased number of ovulations
    • Nulliparity
    • Early menarche
    • Late menopause
  • Obesity
  • Smoking
  • Recurrent use of clomifene
  • Endometriosis
53
Q

State some protective factors against ovarian cancer

A

High number of ovulations increases risk of ovarian cancer hence any factors that decrease number of ovulations will reduce risk:

  • COCP
  • Breastfeeding
  • Pregnancy
  • Early menopause
  • Tubal ligation
54
Q

Describe typical presentation of ovarian cancer

A

Can present with non-specific symptoms; symptoms may include:

  • Abdominal bloating
  • Early satiety
  • Loss of appetite
  • Pelvic pain
  • Urinary symptoms
    • Frequency
    • Urgency
  • Weight loss
  • Abdominal or pelvic mass
  • Ascites
  • Hip or groin pain (if ovarian mass compresses obturator nerve)
55
Q

What is Meig’s syndrome?

A

Meigs syndrome is defined as the presence of ascites and pleural effusion in association with a benign, usually solid ovarian tumour.

56
Q

Discuss the 2WW referral criteria for ovarian cancer

A

Refer via 2WW if suspect ovarian cancer and physical examination reveals:

  • Ascites
  • Pelvic mass (unless clearly due to fibroids)
  • Abdominal mass
57
Q

In which women should you carry out further investigations for ovarian cancer, starting with a CA125 blood test?

A

Women >50yrs presenting with:

  • New symptoms IBS/change in bowel habit
  • Abdominal bloating
  • Early satiety
  • Pelvic pain
  • Urinary frequency
  • Urinary urgency
  • Weight loss
58
Q

What investigations might you do for a woman with suspected ovarian cancer? Include initial investigations that may be done in primary or secondary care and further investigations that would be done in secondary care

A

Initial investigations

  • CA125 blood test (>35IU/mL is significant)
  • Pelvic ultrasound

**NOTE: if CA125 raised then arrange urgent ultrasound of pelvis. If this is suggestive of ovarian cancer an urgent referral should be made. If CA125 is normal, or raised with normal ultrasound, should consider and investigate other causes.

Further investigations in secondary care

  • CT TAP scan: establish diagnosis & stage
  • Biopsy:
    • CT guided
    • Laparoscopy
    • Laparotomy
  • Paracentesis: if have ascites can test for cancer cells
59
Q

CA125 is very specific; true or false?

A

FALSE; not very specific

60
Q

State some non-malignant causes of raised CA-125

A
  • Endometriosis
  • Fibroids
  • Adenomyosis
  • Pelvic infection
  • Liver disease
  • Pregnancy
61
Q

What additional investigations do women under 40yrs with complex ovarian mass require?

A
  • Alpha-fetoprotein (a-FP)
  • Human chorionic gonadotropin (HCG)

… to look for markers of possible germ cell tumour

62
Q

What tool is used to estimate the risk of an ovarian mass being malignant? Describe this tool

A

Risk of Malignancy Index (RMI):

  • Menopausal status
  • Ultrasound findings
  • CA125
63
Q

Discuss the FIGO (International Federation of Gynaecology & Obstetrics) staging system for ovarian cancer

A
  • Stage 1: confined to ovary
  • Stage 2: spread beyond ovary but not beyond pelvis
  • Stage 3: spread beyond pelvis but not beyond abdomen
  • Stage 4: spread outside abdomen (distant mets)
64
Q

Discuss the management of ovarian cancer

A

MDT management. Often involves combination of:

  • Surgery
  • Chemotherapy (platinum based)
65
Q

Discuss the prognosis of ovarian cancer

A

As usual, dependent on stage. Most women present late so hence worse prognosis

  • 80% of women have advanced disease at presentation
  • the all stage 5-year survival is 46%
66
Q

Vulval cancer is common; true or false?

A

FALSE; rare compared to other gynae cancers

67
Q

What type of cancers are most vulval cancers?

A
  • Squamous cell carcinomas (90%)
  • Other types may include malignant melanoma
68
Q

State some risk factors for vulval cancer

A
  • Increasing/advanced age (>75yrs)
  • Immunosuppression
  • HPV infection
  • Lichen sclerosus (~5% will develop vulval cancer)
69
Q

What is VIN (vulval intraepithelial neoplasia)?

What investigation is required to diagnose VIN?

A
  • Premalignant condition affecting squamous epithelium of skin that can precede vulval cancer.
  • Biopsy
70
Q

What is a high grade squamous intraepithelial lesion?

What is it associated with?

Who common in?

A
  • Type of VIN
  • Associated with HPV
  • Younger women aged 35-50yrs
71
Q

What is differentiated VIN?

What is it associated with?

Who is it common in?

A
  • Type of VIN
  • Associated with lichen sclerosus
  • Older women aged 50-60yrs
72
Q

Discuss the management of VIN

A

Options include:

  • Watch & wait with close follow up
  • Wide local excision to remove lesion
  • Imiquimod cream
  • Laser ablation
73
Q

Describe typical presentation of vulval cancer

A

May be incidental finding or present with symptoms:

  • Vulval lump
  • Ulceration
  • Bleeding
  • Pain
  • Itching
  • Lymphadenopathy in groin

Labia majora most commonly affected.

74
Q

Discuss the 2WW referral criteria for vulval cancer

A

Consider urgently referring (appointment within two weeks) women with any of the following unexplained vulval signs or symptoms:

  • Vulval lump
  • Ulceration
  • Bleeding
75
Q

What investigations may be done for suspected vulval cancer?

A
  • Biopsy (“Keye’s punch biopsy” at edge of lesion to include normal epithelium)
  • Sentinel lymph node biopsy
  • CT abdomen & pelvis for staging
76
Q

Outline the FIGO staging for vulval cancer

A
  • Stage 1: carcinoma confined to vulva
  • Stage 2: carcinoma extending to lower ⅓ of vagina, lower ⅓ urethra or anus
  • Stage 3: lymph nodes (non-uclerated)
  • Stage 4: spread to bladder or rectal musosa, ulcerated lymph nodes, disease fixed to pelvic bone or distant mets

CHECK- different

77
Q

Discuss the management of vulval cancer

A

MDT management:

  • Wide local excision to remove cancer
  • Vulvectomy
  • Groin lymph node dissection
  • Chemotherapy
  • Radiotherapy

Yr4: Obstetrics & Gynaecology (24 decks)

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