Gynae Oncology Flashcards
Most common types of cervical cancer?
SCC (80%)
adenocarcinoma (20%)
RFs for cervical cancer?
HPV !!!!!! (16,18,31)
incr. risk of exposure to HPV (young age at sexual intercourse, UPSI, incr. no. of sexual partners)
non-engagement with cervical screening programme
smoking
HIV, immunocompromised
COCP
multiparity
FHx
diethylstilbestrol exposure
Presentation of cervical ca?
asymptomatic (picked up through cervical screening)
abnormal vaginal bleeding (PMB, PCB, IMB)
vaginal discharge
pelvic pain
dyspareunia
ulceration, inflammation, bleeding, visible tumour on speculum exam
If suspected cervical ca on speculum exam, what to do?
urgent referral to colposcopy
do not take smear test
Colposcopy procedure?
colposcope used to visualise cervix
stains can be used
acetic acid (abnormal cells turn white ‘acetowhite’_
iodine (abnormal cells don’t stain)
can perform punch biopsy or LLETZ for tissue sample
When is LLETZ indicated?
Large Loop Excision of Transition Zone
CIN II and III
‘see and treat’ during colposcopy
Complications post-LLETZ?
bleeding
discharge
infection
if repeated or large biopsy -> incr. risk of cervical incompetence -> incr. risk of pregnancy loss or pre-term labour
Indications for Cone Biopsy?
CIN
Cervical Ca Stage 1A
Complications of Cone Biopsy?
pain
bleeding
infection
stenosis of cervix (scarring)
incr. risk of miscarriage and pre-term labour
Staging of Cervical Ca?
FIGO staging
Stage 1 - cervix
1A - microscopic
1B - gross lesion
Stage 2 - uterus or upper 2/3 of vagina
2A - no parametrial involvement
2B - obvious parametrial involvement
Stage 3 - pelvic sidewall or lower 1/3 of vagina
3A - no extension to sidewall
3B - extension to sidewall +/- hydronephrosis
Stage 4 - extension
4A - bladder or rectum
4B - distant mets
Management of Stage 1A cervical ca?
gold standard is hysterectomy +/- LN clearance
fertility-preserving -> cone biopsy with close follow up
Management of Stage 1B/2A cervical ca?
radical hysterectomy + LN clearance
chemo (cisplatin)
radiation (brachytherapy or external beam)
Management of stage 2b and 3 cervical ca?
chemo (cisplatin)
radiation (brachytherapy or external beam)
Management of stage 4 cervical ca?
palliative chemorads
Sx -> anterior/posterior/total pelvic exenteration
5yr survival rate of cervical cancer?
Stage 1 - 96%
Stage 2 - 54%
Stage 3 - 38%
Stage 4 - 5%
Post-menopausal bleeding is….?
endometrial cancer until proven otherwise
What type of cancer is endometrial ca?
80% adenocarcinoma
oestrogen-dependent cancer (unopposed oestrogen stimulates growth)
Risk Factors for endometrial ca?
exposure to unopposed oestrogen:
incr. age
early menarche
late menopause
oestrogen only HRT
nulliparity
obesity
PCOS
tamoxifen
T2DM
HNPCC
Protective factors against endometrial ca?
COCP
Mirena
incr. pregnancies
smoking
Endometrial protection in PCOS?
COCP
Mirena
Cyclical progesterones to induce withdrawal bleed
Presentation of endometrial ca?
PMB!!!!!!!!
PCB
IMB
unusually heavy menstrual bleeding
abnormal vaginal discharge
haematuria
anaemia
raised platelet count
When to refer for endometrial ca?
‘2 week wait’ in all postmenopausal bleeding
TVUS in > 55yrs with visible haematuria or unexplained vaginal discharge
Investigations for endometrial ca?
TVUS (endometrial thickness >4mm)
Pipelle biopsy (highly sensitive, useful for exclusion)
Hysteroscopy with endometrial biopsy
Staging of endometrial ca?
FIGO Staging
Stage 1 - confined to uterus
Stage 2- invades cervix
Stage 3 - invades ovaries, fallopian tubes, vagina or LNs
Stage 4 - invades bladder, rectum or beyond pelvis
What is endometrial hyperplasia?
precancerous condition involving thickening of the endometrium
hyperplasia with atypia
hyperplasia without atypia
Mx of endometrial hyperplasia?
without atypia -> manage with progesterones (Mirena IUS) and surveillance
with atypia -> treat as cancerous, TAHBSO
Mx of endometrial ca?
Stage 1 - TAHBSO
Stage 2 - Radical hysterectomy + LN assessment
Stage 3 + 4 - maximal de-bulking sx + chemorads
Prognosis of endometrial ca?
usually good
75% present with Stage 1
Stage 1 has 90% 5yr survival rate
Types of ovarian ca?
epithelial cell tumours
germ cell tumours
sex cord stromal tumours
metastasis (Kruckenburg tumour -> from GI ca)
Types of epithelial cell tumours?
serous tumours (most common)
endometrioid carcinomas
clear cell tumours
mucinous tumours
undifferntiated
Types of germ cell tumours?
teratomas/dermoid cysts
associated with ovarian torsion
raised AFP and hCG
Types of sex cord stromal tumours?
Sertoli-Leydig cell tumours
granulosa cell tumours
What is a Kruckenburg tumour?
ovarian mets from GI tract ca
‘signet-ring’ cells on histology
Risk Factors for ovarian ca?
age (peak 60)
BRCA1 and BRCA2
incr. no. of ovulations (early menarche, late menopause, nulliparity)
obesity
smoking
recurrent use of clomifene
Protective factors for ovarian ca?
pregnancy
breast-feeding
COCP
Presentation of ovarian ca?
non-specific -> often late presentation
abdominal bloating
early satiety
anorexia
pelvic pain
urinary symptoms
weight loss
ascites
abdo or pelvic pain
When to refer for suspected ovarian ca?
2 week wait if:
ascites
pelvic mass
abdo mass
CA125 if > 50 with:
new IBS
abdo bloating
early satiety
pelvic pain
urinary frequency
weight loss
Risk of Malignancy Index includes?
Menopausal Status
US findings
Ca 125
multiply 3, RMI > 250 requires referral to gynae
Red flag US findings for ovarian ca?
multilocular cyst
solid area
mets
bilateral lesions
ascites
Investigations for ovarian ca?
RMI (CA125, pelvic US)
CT (staging)
histology
paracentesis
women <40 with complex ovarian mass:
AFP
HCG
Causes of raised CA125?
ovarian ca
endometriosis
fibroids
adenomyosis
pelvic infection
liver disease
pregnancy
Staging of ovarian ca?
Stage 1 - confined to ovary
Stage 2 - spread past the ovary, but inside the pelvis
Stage 3 - spread past the pelvis, but inside the abdomen
Stage 4 - spread past the abdomen
Mx of ovarian ca?
de-bulking sx and chemotherapy
Types of vulval ca?
90% are SCC
malignant melanomas
RFs for vulval ca?
advanced age (>75yrs)
immunosuppression
HPV infection
lichen sclerosus
VIN
How many women with lichen sclerosus get vulval ca?
about 5%
Presentation of vulval ca?
incidental finding
lump
fungating lesion
ulceration
bleeding
pain
itching
lymphadenopathy in groin
Investigations of vulval ca?
refer suspected vulval ca under 2wk wait pathway
biopsy of lesion
sentinel node biopsy
CT for staging
Mx of vulval ca?
WLE, partial or radical vulvectomy
groin LN dissection
chemorads depending on staging
Staging of vulval ca?
FIGO staging
Stage 1 - confined to vulva
Stage 2 - extending to lower 1/3 of vagina, urethra or anus
Stage 3 - upper 2/3 of vagina or urethra, bladder, rectum or LNs
Stage 4 - ulcerated LNs, pelvic bone or distant mets
