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GOSH > Gynae oncology > Flashcards

Gynae oncology Flashcards

1
Q

Where does CIN usually develop on the cervix?

A

Transformation zone

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2
Q

What strains of HPV are covered in the most recent vaccine? What was covered in the old ones?

A

new ones: 6, 11, 16 and 18 (Gardasil)

old ones: 16 and 18 only (Cervarix)

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3
Q

How does HPV lead to CIN?

A

Persistent high levels of oncogenic (16 and 18) HPV can lead to CIN

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4
Q

Other than exposure to the HPV virus, what are other risk factors for cervical cancer?

A 
Smoking
Immunosuppression 
Multiple sexual partners
Lower social class
(COCP)
Non-attendance of cervical screening programme
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5
Q

When is the HPV vaccine given, how is is given and who long does it last for?

A

All girls aged 12-13

three injections over period of 12 months

protection for at least 8 years after completing three-dose course

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6
Q

How regularly do women have to attend smear tests as part of the cervical screening programme?

A

3-yearly from 25-50

5-yearly from 50-64

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7
Q

By what mechanism is a smear test carried out?

A

Liquid-based cytology

plastic broom swept over transformation zone - aims to remove thin layer of cells.

placed in liquid transport medium

examined microscopically for any cells with ‘dyskaryotic’ features

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8
Q

Other than looking for evidence of cancer/neoplasia, what else can a smear test find?

A

HPV infection

chlamydia

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9
Q

What are the four management categories that smear test results fall in to?

A

1) routine recall
2) repeat cytology
3) referral to colposcopy (standard or urgent)
4) referral to gynaecology

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10
Q

What is colposcopy?

A

Examination of cervix with bright light and magnification to identify any abnormal areas.

Whole transformational zone should be indentified/

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11
Q

What are the two solutions used in colposcopy?

A

Lug’s solution

Acetic acid

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12
Q

How is CIN diagnosed and classified?

A

Can only be diagnosed by biopsy (taken at colposcopy)

CIN1: lower 1/3 of epithelium
CIN2: lower 2/3 of epithelium
CIN3: full thickness of epithelium

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13
Q

What does CIN stand for? What does it mean in real-terms?

A

Cervical intraepithelial neoplasia

Pre-cancerous change

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14
Q

How would you manage CIN1?

A

Think about treatment Vs no treament.

Follow up:

Treatment - cytology in 6 months (procede as results dictate)

No treatment - cytology 12 months +/- colposcopy

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15
Q

How would you manage CIN2/3?

A

LLETZ - large loop excision of the transformation zone (under LA)

Follow up:

Cytology at 6 months

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16
Q

What can be a complication of having had the LLETZ procedure?

A

Premature labour

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17
Q

What is CGIN?

A

Cervical glandular intraepithelial neoplasia

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18
Q

How would you treat CGIN?

A

LLETZ (unlikely to revert to normal without treatment)

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19
Q

Why is low grade CIN not necessarily treated?

A

Can go back to normal

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20
Q

What can CGIN go on to develop?

A

Cervical adenocarcinoma

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21
Q

What might you see in CGIN?

A

Skip lesions

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22
Q

What histopathology is most common in cervical cancer?

A

Mainly squamous cell
or
adenocarcinomas

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23
Q

How might someone with cervical cancer present (if in earlier stages)?

A

Abnormal bleeding is most common symptom eg. PCB
IMB
postmenopausal bleeding

Persistent, offensive, blood-stained discharge

Vaginal discomfort

Urinary symptoms

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24
Q

How would you examine someone who you suspected had cervical cancer?

A

Abdo exam
Speculum examination
Bimanual examination
PR

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25
Q

How would you investigate someone with suspected cervical cancer?

A 
Swabs for chlamydia
Colposcopy and biopsy
FBC, U&Es, LFTs
MRI pelvis - first line imagining
CT abdo and chest - if you think it may have spread
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26
Q

Where are common sources of direct/local spread in cervical cancer?

A

Vagina, bladder, parametric, bowel

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27
Q

Where are common sources of lymphatic spread in cervical cancer?

A

parametrical nodes
iliac nodes
obturator nodes
pre-sacral and para-aortic nodes

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28
Q

Where are common sources of haemotogenous spread in cervical cancer?

A

lungs and liver

29
Q

How is cervical cancer staged? What are the different stages?

A

FIGO staging

0: no evidence of primary tumour

Tisb: CIS (pre-invasive)

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: involvement of bladder and rectum OR distance mets.

30
Q

How is cervical cancer managed?

A

MDT - treatment depends on stage, desire for future fertility and comorbidities

Radiotherapy or surgery, or combination. Chemotherapy can also be given. Surgery is preferred.

Preserving fertility (usually stage 1/2):
LLETZ
Tracilaectomy and node removal

not-preserving fertility (can be used at all stages): hysterectomy

Surgery not offered from 1B2 onwards

Chemoradiotherapy > radiotherapy alone.
Radiotherapy: external beam and brachytherapy
Cis-Platin based chemotherapy

31
Q

What is the follow up of cervical cancer?

A

6 weeks post-treatment
every 3-4 months for 1-2 years
annually for 5 years

32
Q

What type of cancer is most common in uterine cancer?

A

adenocarcinoma

33
Q

What are some risk factors for uterine cancer?

A

Obesity (~1/3 of all cases)

Diabetes

Sedentary life-style

Menstrual factors: early menarche, late menopause, low parity

Anovulatory amenorrhoea, e.g. PCOS

Endometrial hyperplasia

Unopposed oestrogen HRT

Oestrogen-secreting ovarian tumours

Tamoxifen

FH of colorectal, endometrial or breast cancer

(Smoking and COCP slightly reduces the risk)

34
Q

How do higher oestrogen levels/prolonged oestrogen exposure increase risk of uterine cancer?

A

Leads to endometrial hyperplasia

Hyperplasia predisposes to cytological atypia

Atypical hyperplasia is precancerous

35
Q

How might uterine cancer present?

A

PMB - vaginal bleeding 1 year after cessation of periods

premenopausal women: irregular heavy or inter-menstrual bleeding (esp. if <40 yrs old)

36
Q

What examinations and investigations would you do if you suspected uterine cancer?

A 
Abdo 
Speculum (exclude other causes)
Transvaginal ultrasound (assess endometrial thickness)
Endometrial biopsy
Pipette
Hysteroscopy 
MRI of pelvis
CT abdo and chest if high-risk cancer
37
Q

How does uterine cancer spread?

A

Myometrium acts as a barrier - early presentation = high cure rate

Direct: cervix, fallopian tube, ovaries

Across peritoneal cavity

Lymphatic: pelvis, para-aorta (RARELY INGUINAL)

Haematogenous: liver, lungs

38
Q

How is uterine cancer staged?

A

Stage I – confined to body of uterus

Stage II - involving the cervix

Stage III - spread outside the uterus

Stage IV - with bowel, bladder or distant organ involvement

39
Q

How is uterine cancer treated?

A

Stage 1: Total abdo hysterectomy
Bilateral salpingo-oophorectomy
+/- peritoneal washings

Stage 2: radical hysterectomy, lymphadenectomy

Stage 3 + 4: de-bulking surgery, radiation and chemotherapy

40
Q

How is uterine cancer followed up following surgery?

A

6 weeks post surgery
Every 3-4 month for 2 years
Annually up to 5 years

41
Q

What are some risk factors for ovarian cancer?

A 
Increasing age
Smoking
Obesity
Lack of exercise
Nulliparity/infertility/use of fertility treatments
Early menopause/late menarche
HRT
Endometriosis
Genetic eg. BRCA1 and BRCA2 (BRCA1 = higher risk)
42
Q

How might ovarian cancer present?

A

Abdominal pain and swelling (bloating). Ascites.

Pressure effects on the bladder (frequency) and rectum

Dyspnoea (due to pleural effusion)

Dyspepsia

Gastrointestinal upset and anorexia

Abnormal vaginal bleeding

Painful pelvic/abdo mass

Abdo, pelvis, back pain = late signs

Up to 15% of patients will remain asymptomatic at diagnosis

TYPICALLY PRESENTS LATE: STAGE 3/4

43
Q

What might you find on examination of someone with ovarian cancer?

A

Adnexal or pelvic mass
shifting dullness
irregular abdominal mass (mental cake)

44
Q

What are the three main groups of primary ovarian tumours?

A

Depends on what type of cell the cancer developed from

Epithelial MOST COMMON eg. serous, endometrioid, mutinous, undifferentiated, undifferentiated

Sex cord or stromal: fibroma, fibrosarcoma

Germ cell: teratoma, choriocarcinoma

Can be benign, malignant or borderline

45
Q

How would you investigate someone for ovarian cancer?

A

Pelvic ultrasound, abdo ultrasound

Bloods: CA125
CA19.9
CEA
AFP
HCG
LDH
FBC
U&amp;Es
LFTs

Calculate RMI 1 score - if >200/250, refer to MDT

Chest xray
CT abdo and pelvis

Paracentesis of ascites

46
Q

How is ovarian cancer staged?

A

Stage I - limited to one or both ovaries

Stage II - one or both ovaries + pelvic extension or implants

Stage III - one or both ovaries + microscopic peritoneal implants outside of the pelvis; or limited to the pelvis with extension to the small bowel or omentum

Stage IV - one or both ovaries + distant metastases

47
Q

How is ovarian cancer treated?

A

Exploratory laparotomy (if ovarian cancer suspected): histology, staging and debulking.

Standard surgical staging: TAH (total abdo hysterectomy)
BSO (bilateral salpingo-oophorectomy)
Omenectomy
Lymph node sampling
+
Peritoneal biopsies
Peritoneal washings or as citing fluid = cytology

Younger women, may consider unilateral ovary removal - but not as safe

Adjuvant chemotherapy (platinum based - placlitaxel and carboplatin) - stages II-IV
Given every 3 weeks, 6 cycles
48
Q

How successful is ovarian cancer treatment?

A

75% respond to initial therapy BUT over 55% relapse within 2 years

49
Q

What is the follow up procedure for ovarian cancer after surgery?

A

6 weeks post surgery
every 3-4 months for 1-2 years
annually for up to 5 years

50
Q

What marker is used to detect progression of ovarian cancer?

A

Serum CA125 level

51
Q

Why isn’t ovarian cancer screened for?

A

Expensive

No premalignant condition

High sensitivity and poor specificity

No proof of benefit to screened population

52
Q

What are risk factors for vulval cancer?

A 
HPV
HSV
SLE
psoriasis
smoking
53
Q

How might vulval cancer present? What can it be confused with?

A

Itchiness and soreness

Skin changes white, red, grey or raised

Vulval lump

Vulval bleeding

lichen sclerosis may present similarly

54
Q

What are some risk factors for vaginal cancer?

A 
Vulval intra-epithelial neoplasia (pre-malignant)
Lichen sclerosus
HPV
Smoking
SLE
Immunosuppression
Diethylstilbestrol (DES)
Paget's disease
55
Q

What are the later symptoms of cervical cancer?

A

Painless haematuria

Urinary frequency

Painless fresh rectal bleeding

Altered bowel habit

Leg oedema, pain
Hydronephrosis
(indicates pelvic wall involvement)

Dull pain in suprapubic region

56
Q

What might be found on examination in someone with cervical cancer?

A

Speculum: White/red patches on cervix
Erosion, ulcer, tumour

Bimanual: pelvic bulkiness/masses

Rectal examination: mass or bleeding

Mets:
Leg oedema Hepatomegaly
Pulmonary effusion/bronchial obstruction

57
Q

What is the cut off for normal endometrial thickness, that may indicate uterine cancer?

A

3/4 mm

Anything thicker = higher risk of being endometrial/uterine cancer

58
Q

Above what age are epithelial tumours most common?

A

50 yrs

59
Q

In what age range are germ cell ovarian tumours most common?

A

< 35 yrs

60
Q

What are the differential diagnoses you may consider in someone with ovarian-cancer-like symptoms?

A 
benign tumour/cyst
Fibroids
Other pelvic malignancy
Endometriosis
Other causes of ascites
Other causes of altered bowel habit
61
Q

What are some complications associated with ovarian cancers?

A

Tumour: Rupture
Torsion
Infection

Chemotherapy: Bone marrow depression
Infection
Neurotoxicity
Nephrotoxicity
Ototoxicity
Advanced disease: Malnutrition
Electrolyte imbalance
Bowel obstruction
Infection
Ascites
Pleural effusion
62
Q

What are the three familial syndromes associated with ovarian tumours?

If you suspect this in a patient, what should you do?

A

Site-specific (FHx of ovarian cancer)

BRCA

non-polypoidal colon cancer (also increases risk of ovarian, breast and endometrial cancers)

Refer to genetic counselling service

63
Q

What is 5-year survival for ovarian cancer?

A

46%

64
Q

What are the two different types of VIN?

A

usual: higher incidence in younger women
HPV-related (covered by vaccine)
Higher risk of HPV malignancies

Differentiated: more common in older patients with chronic derma logical conditions
More invasive potential
Not HPV related

65
Q

What are the differentials in someone with ?vulval cancer?

A 
lichen planus
Ulcers
Dermatitis
Fungal infection
Boils/cysts eg. Bertholin's cysts
66
Q

How is vulval cancer staged?

A

Stage 1: tumour confined to vulva

Stage 2: Extension in to perineal structures eg. urthera or vagina. NO NODES.

Stage 3: as above, with Positive inguino-femoral lymph nodes

67
Q

Which women should be referred to gynae if vulval cancer suspected?

A

Unexplained vaginal lump

Unexplained vulval bleeding or ulceration

Persistent symptoms that do not resolve with treatment

68
Q

How is vulval cancer managed?

What are the complications associated with this?

A

Surgery - radical or wide local excision

multi-focal: radical vulvectomy

Groin node dissection (unless stage 1a)

Reconstruction common

Complications: wound breakdown and infection
Introital stenosis
Urinary/foetal incontinence
Lymphedema

69
Q

What is the 5 year survival rate for someone with ovarian cancer who doesn’t have any nodes? What about with nodes?

A

> 80%

< 50%

GOSH (33 decks)

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