Gynae oncology Flashcards
What is the appearance of a normal cervix after puberty?
-Columnar tissue at centre of ectocervical surface (= ectopy)
-Squamous epithelium surrounding it
-Transformation zone between the two where columnar cells transform to squamous (ie squamous metaplasia)
What is a cervical ectropion?
-Endocervical epithelium extends into ectocervix
-Prone to bleeding and infection but often asymptomatic
-Cauterise if necessary
When are cervical smears offered to people with a cervix?
-Every 3 years for those aged 25-49
-Every 5 years for those aged 50-64
(Those with HIV are screened annually due to increased risk)
What are cervical smear samples assessed for?
-Dyskaryosis (precancerous changes)
-Tested for HPV
NB CIN grading is only done after colposcopy
What different steps are taken following smear results?
-Inadequate sample –> repeat in 3 months
-Normal cytology but HPV positive –> repeat HPV in 12 months
-Borderline / mild dyskaryosis –> test for high-risk HPV
–If negative –> continue routine screening
–If positive –> colposcopy referral
-Moderate dyskaryosis –> refer for urgent colposcopy
-Severe dyskaryosis –> refer for urgent colposcopy
-Suspected invasive carcinoma –> refer for urgent colposcopy
What does a colposcopy involve?
-Visualisation / magnification of the cervix
-Iodine solution and acetic acid stains used to visualise abnormal areas
What does the CIN staging denote?
Grading system for the level of dysplasia in cervical intraepithelial dysplasia
CIN I = mild dysplasia, affecting 1/3 of the thickness of the epithelial layer, likely to self-resolve
CIN II = moderate dysplasia, affecting 2/3 of the thickness of the epithelial layer, likely to progress to cancer if left untreated
CIN III = severe dysplasia, very likely to progress to cancer
–aka cervical carcinoma in situ
What does the FIGO staging for cervical cancer denote?
Stages the level of spread of cervical cancer
Stage 1 = confined to cervix
Stage 2 = invades uterus / upper 2/3 of vagina
Stage 3 = invades pelvic wall / lower 1/3 of vagina
Stage 4 = invades bladder, rectum or beyond pelvis
What are the different management options for different stages of cervical cancer?
CIN and early stage 1 = LLETZ or cone biopsy
Stage 1-2 = radical hysterectomy and lymphadenectomy, chemo + RT
Stage 2-4 = chemo + RT
Stage 4 (late) = surgery, chemo, RT and palliative
What is the difference between a LLETZ and a cone biopsy?
Large Loop Excision of the Transformation Zone
-Removal of abnormal epithelial tissue during colposcopy
-Done under LA
Cone biopsy
-Used to treat CIN and early stage 1 cancer
-Done under GA
-Removal of cone-shaped piece of cervix using scalpel
What are the high-risk HPV types?
16, 18, 31, 33
(6 + 11 cause genital warts)
How does cervical cancer present?
-Irregular smear
-Post-coital bleeding
-IMB / PMB
-Menorrhagia
-Abnormal discharge (often blood-stained)
-Pain (late sign)
How does the unopposed oestrogen hypothesis relate to endometrial cancer?
-Increased oestrogen exposure induces endometrial hyperplasia –> malignant change
-Greater life-time exposure = greater risk
-NB unopposed oestrogen = oestrogen without progesterone
What risk factors are there for endometrial cancer?
-Increasing age (>45)
-Nulliparity
-Early menarche and late menopause
-Obesity (peripheral conversion of androgens to oestrogen)
-HRT
-Tamoxifen therapy
-Chronic anovulation
What protective factors are there for endometrial cancer?
-Smoking
-Pregnancy
-Diet and exercise
-IUS, COCP, early menopause
How does endometrial cancer present?
-PMB = MOST COMMON PRESENTATION (10% of these women will have malignancy)
-IMB / PCB / menorrhagia
-Pelvic mass
How can you investigate endometrial cancer?
-TVUSS (endometrial thickening >4mm)
-Endometrial pipelle / hysteroscopy and endometrial biopsy
-MRI for staging / CT abdo/chest if high risk of spread
What does the FIGO staging of endometrial cancer denote?
Stage 1 = confined to the uterus
Stage 2 = local spread to the cervix
Stage 3 = spread to pelvis (adnexa, vagina, nodes)
Stage 4 = distant spread (bowel, bladder lungs)
How is endometrial cancer managed?
-Myometrium acts as a barrier so most patients present early and have a high cure rate
-Total abdominal hysterectomy + bilateral saplingo-oopherectomy
-RT / palliative
What risk factors are there for ovarian cancer?
Anything that causes an increase in the number of ovulations
-Nulliparity, early menarche, late menopause
-FHx
-BRCA gene (1 more than 2)
-Increased age
-Endometriosis
-Smoking
-HRT
PROTECTIVE = COCP, pregnancy
How does ovarian cancer present?
-Often asymptomatic
-75% present at stage 3 or 4
-Abdo pain
-Swelling / bloating (ascites)
-Urinary urgency
-Weight loss / loss of appetite / early satiety
What is the risk of malignancy index? (RMI)
Estimates risk of an ovarian mass being malignant, and hence the prognosis, taking into account 3 factors:
1. Menopausal status
2. US findings
3. Ca125 level (raised = >35)
How would you investigate ovarian cancer?
-USS / CT / MRI
-Ca125
-AFP, hCG, LDH (germ cell tumours)
-Paracentesis of ascites if present
What does the FIGO staging denote for ovarian cancer?
Stage 1 = confined to the ovary
Stage 2 = local spread to uterus, Fallopian tube, bladder / rectum but confined to pelvis
Stage 3 = peritoneal mets / para-aortic lymphadenopathy
Stage 4 = distant spread eg to liver
What risk factors are there for vulval cancer?
-Typically affects older women (50% >70)
-Associated with high risk forms of HPV
-Lichen sclerosus and VIN can develop into carcinoma
-Smoking
-Immunodeficiency
-PMHx or FHx of melanoma
How does vulval cancer present?
NB very rare, only 5% of gynae cancers
-Often asymptomatic
-A lump, ulcer or itchy patch may arise
-Skin may be thicker, lighter / darker than surrounding skin
What is the most common type of vulval cancer?
-Squamous cell carcinoma
How are vulval cancers managed?
-Triple incision vulvectomy / sentinel groin lymph node dissection
-Radical vulvectomy if confined to vulva
-Chemo/RT if spread
If VIN:
-Wide local excision
-Imiquimod cream
-Laser ablation
