Gynae Oncology Flashcards
What is cervical entropion?
More irregular redness resulting from minor lacerations during childbirth
What is cervical ectopy?
Are puberty, rising oestrogen levels cause the cervix to evert
Columnar tissue lining the cervical canal is everted on to the centre of the cervix
This appears as a red area around the os, and is a normal finding in younger women
What is cervical intraepithelial neoplasia (CIN)?
The presence of atypical cells within the squamous epithelium of the cervix
This is a histological diagnosis made only on biopsy
What are the different grades of CIN?
CIN1 - mild dysplasia- atypical cells are found only in the lower third of the epithelium
CIN2 - moderate dysplasia - atypical cells are found in the lower two thirds of the epithelium
CIN3 - severe dysplasia - atypical cells occupy the full thickness of the epithelium- this is carcinoma in situ
How is CIN managed?
Without treatment, a third of women will develop cervical cancer over the next 10 years- however it depends on the grade
If mild dysplasia (CIN1), may only require repeat colposcopy.
If more dysplasia, excision with LLETZ - large loop excision of the transformation zone - to depth of 8mm
If abnormality is not completely visible, do cone biopsy
What is CGIN?
Cervical glandular intraepithelial neoplasia
Rare
Arises within the cervical anal
Precursor to cervical adenocarcinoma
Definitely requires treatment
How common is cervical cancer, and in whom does it occur?
12th most common cancer in women
Most common between ages of 45 and 55 years
What are the risk factors for cervical cancer?
Smoking Unprotected sexual intercourse Previous STI HIV On immunosuppressants
How does cervical cancer present?
Post coital bleeding, Intermenstrual bleeding, post menopausal bleeding
Persistent, offensive, blood stained discharge
Pain in late disease
Swollen leg- thrombosis in the pelvis
How is cervical cancer investigated?
Speculum
BE
PR
Colposcopy Cervical biopsy FBC UandEs LFTs MRI pelvis Ct abdomen and chest
How is cervical cancer staged?
0 - carcinoma in situ
1 - confined to cervix
2 - disease beyond cervix but not to pelvic wall or lower 1/3 of vagina
3 - disease to pelvic wall or lower 1/3 vagina
4 - invades bladder, rectum, or metastasis
How does cervical cancer spread?
Direct or local to vagina, bladder, parametrium, bowel
Lymphatic- para metrial nodes, internal, external, common iliac etc
Blood borne- lungs and liver
What are the treatment options for cervical cancer?
LLETZ
Hysterectomy
Radical hysterectomy
Fertility sparing - trachelotomy - removal of cervix, and stitch placed to give support in the case of future pregnancy
Radiotherapy/chemotherapy if later stages - platinum based chemo
What is the histological type of cervical cancer?
SCC in 70%
Adenocarcinoma in 25%
Small cell or TCC
What is the five year survival of cervical cancer?
67%
How common is ovarian cancer and what age does it typically affect?
Fifth most common cause of cancer in women
6000 new cases a year in the uk
Effects women usually between the age of 60 and 70
What are risk factors for ovarian cancer?
Anything that prolongs time spent ovulating
Multiparty Late menopause Early menarche HRT Endometriosis Difficulties conceiving - IVF BRCA1/2 Turners syndrome
How does ovarian cancer typically present?
Abdominal pain Pressure effects on the bladder or rectum Dyspnoea GI upset and anorexia Abnormal vaginal bleeding Asymptomatic
On examination:
Adnexal mass
Shifting dullness
Irregular abdominal mass - omental cake
How is ovarian cancer staged?
Stage 1 - limited to one or both ovaries
Stage 2 - pelvic extension or implants
Stage 3 - microscopic peritoneal implants outside of the pelvis, or limited to the pelvis with extension to the small bowel or omentum
Stage 4 - distant mets
How does ovarian cancer spread?
Direct spread- omental cake, invasion to bowel/bladder
Haematogenous - liver and spleen
Lymphatic - para-aortics to diaphragmatic lymph nodes
What investigations are indicated in ovarian cancer?
Pelvic USS Ca125 in 80% Ca19.9 for mets from pancreas CEA for mets from bowel AFP, hcg, LDH CXR FBC, UandEs, LFTs Ct Paracentesis of ascites
What is the management of ovarian cancer?
TAH and BSO, with omentectomy, lymph node sampling, peritoneal biopsies with peritoneal washings or ascitic fluid for cytology
Adjuvant chemotherapy with platinum
What is the five year survival of ovarian cancer?
Typically presents late
75% of cases of ovarian cancer presents as stage 3/4 disease
1- 75-90%
2- 45-60%
3- 30-40%
4- less than 20%
What is the histology of ovarian cancer?
Epithelial - derived from mullerian epithelium - 85%
Sex cord or stromal
Germ cell
How are the BRCA genes implicated in ovarian cancer?
BRCA1 - 39% will get ovarian ca by 70
BRCA2 - 11-16% get ovarian ca by 70
What are the risk factors for endometrial cancer?
Obesity - increased oestrogen Diabetes PCOS - Anovulatory cycles Age - peak 65-75 Early menarche Late menopause Nulliparity Unnopposed oestrogen therapy FH of breast, ovary, colon cancer Tamoxifen Prior pelvic irradiation Sex cord stromal tumour of the ovary
What are protective factors for endometrial cancer?
Pregnancy
Diet and exercise
IUS
Reduced menstrual history eg early menopause of COCP
How does endometrial cancer spread?
Direct - through cavity to cervix, Fallopian tubes to ovaries
Lymphatic - pelvic to para aortic nodes
Haematogenous - rare to liver, lungs
What investigations are required in endometrial cancer?
Speculum and bimanual exam Biopsy with or without hysteroscopy USS to assess endometrial thickness MRI - invasion Ct
What are the treatment options in endometrial cancer?
Hysterectomy with oophorectomy
Laparoscopy best for obese women
Radiotherapy/chemo - high grade, high stage tumours
High dose progestogens- can reverse the premalignant phase of hyperplasia. Also for palliative
What is the staging of endometrial cancer?
1- limited to body of uterus
2- limited to body if uterus and cervix
3- extension to uterine serosa, peritoneal cavity or lymph nodes
4- extension to adjacent organs or beyond true pelvis
What is the premalignant stage of endometrial cancer?
Hyperplasia with atypia - excessive proliferation of endometrial glands and stroma
Comes with atypia had much higher risk of progression to cancer
What are the different histological types of endometrial cancer?
Endometrioid adenocarcinoma - 80-85%
Papillary serous 10%
Clear cell 4%
What is the average age of diagnosis of invasive and noninvasive vulval cancer?
Invasive - 70
Non-invasive - 50
What are the risk factors for vulval cancer?
Age - 50% over 70 HPV Smoking Immunodeficiency Lichen sclerosis Melanoma- personal or family history
What is the premalignant form of vulval cancer?
Vulgar intraepithelial neoplasia - abnormal cells found only in the surface later of vulval cancer
The higher the grade, the greater the chance of invasive carcinoma
How does vulval cancer present?
Asymptomatic
Itching
Pain
Bleeding (PMB)
On examination: Skin often thicker and lighter than skin around it Raised mass- red, pink, white Ulcerated mass Warty mass
How do vulval cancers spread?
Local invasion of adjacent structures
Lymph nodes - inguinal, inguinofemoral
What investigations are indicated for vulval cancer?
Examination to assess direct spread - PR, PV, inguinal lymphadenopathy
Biopsy
MRI to assess spread
What is the management of vulval cancer?
Wide local excision if suspicious area Vulvectomy Lymphadenectomy Radiotherapy Chemotherapy
What is the average age of diagnosis of invasive and noninvasive vulval cancer?
Invasive - 70
Non-invasive - 50
What are the risk factors for vulval cancer?
Age - 50% over 70 HPV Smoking Immunodeficiency Lichen sclerosis Melanoma- personal or family history
What is the premalignant form of vulval cancer?
Vulgar intraepithelial neoplasia - abnormal cells found only in the surface later of vulval cancer
The higher the grade, the greater the chance of invasive carcinoma
How does vulval cancer present?
Asymptomatic
Itching
Pain
Bleeding (PMB)
On examination: Skin often thicker and lighter than skin around it Raised mass- red, pink, white Ulcerated mass Warty mass
How do vulval cancers spread?
Local invasion of adjacent structures
Lymph nodes - inguinal, inguinofemoral
What investigations are indicated for vulval cancer?
Examination to assess direct spread - PR, PV, inguinal lymphadenopathy
Biopsy
MRI to assess spread
What is the management of vulval cancer?
Wide local excision if suspicious area Vulvectomy Lymphadenectomy Radiotherapy Chemotherapy
What is the five year survival rate of vulval cancer?
Local - 86%
Regional - 54%
Distant - 16%
How common is endometrial cancer?
Most common genital tract cancer
4th most common cancer in women
How common is vulval carcinoma?
Accounts for 5% of genital tract cancers
What is the management of abnormal smear tests? Mild, moderate and severe dysplasia
Normal - repeat in three years Mild dysplasia - repeat in 4-6 months Mild on two occasions - colposcopy Moderate - colposcopy Severe/CIN - colposcopy GLandular IN - urgent colpsocopy/hysterectomy
Mild/moderate must be tested for HPV first, if positive refer for colposcopy
Annual screening in immunosuppressed patients!
