Gynae oncology Flashcards
Where does CIN usually develop on the cervix?
Transformation zone
What strains of HPV are covered in the most recent vaccine? What was covered in the old ones?
new ones: 6, 11, 16 and 18 (Gardasil)
old ones: 16 and 18 only (Cervarix)
How does HPV lead to CIN?
Persistent high levels of oncogenic (16 and 18) HPV can lead to CIN
Other than exposure to the HPV virus, what are other risk factors for cervical cancer?
Smoking Immunosuppression Multiple sexual partners Lower social class (COCP) Non-attendance of cervical screening programme
When is the HPV vaccine given, how is is given and who long does it last for?
All girls aged 12-13
three injections over period of 12 months
protection for at least 8 years after completing three-dose course
How regularly do women have to attend smear tests as part of the cervical screening programme?
3-yearly from 25-50
5-yearly from 50-64
By what mechanism is a smear test carried out?
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
Other than looking for evidence of cancer/neoplasia, what else can a smear test find?
HPV infection
chlamydia
What are the four management categories that smear test results fall in to?
1) routine recall
2) repeat cytology
3) referral to colposcopy (standard or urgent)
4) referral to gynaecology
What is colposcopy?
Examination of cervix with bright light and magnification to identify any abnormal areas.
Whole transformational zone should be indentified/
What are the two solutions used in colposcopy?
Lug’s solution
Acetic acid
How is CIN diagnosed and classified?
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
What does CIN stand for? What does it mean in real-terms?
Cervical intraepithelial neoplasia
Pre-cancerous change
How would you manage CIN1?
Think about treatment Vs no treament.
Follow up:
Treatment - cytology in 6 months (procede as results dictate)
No treatment - cytology 12 months +/- colposcopy
How would you manage CIN2/3?
LLETZ - large loop excision of the transformation zone (under LA)
Follow up:
Cytology at 6 months
What can be a complication of having had the LLETZ procedure?
Premature labour
What is CGIN?
Cervical glandular intraepithelial neoplasia
How would you treat CGIN?
LLETZ (unlikely to revert to normal without treatment)
Why is low grade CIN not necessarily treated?
Can go back to normal
What can CGIN go on to develop?
Cervical adenocarcinoma
What might you see in CGIN?
Skip lesions
What histopathology is most common in cervical cancer?
Mainly squamous cell
or
adenocarcinomas
How might someone with cervical cancer present (if in earlier stages)?
Abnormal bleeding is most common symptom eg. PCB
IMB
postmenopausal bleeding
Persistent, offensive, blood-stained discharge
Vaginal discomfort
Urinary symptoms
How would you examine someone who you suspected had cervical cancer?
Abdo exam
Speculum examination
Bimanual examination
PR
How would you investigate someone with suspected cervical cancer?
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
Where are common sources of direct/local spread in cervical cancer?
Vagina, bladder, parametric, bowel
Where are common sources of lymphatic spread in cervical cancer?
parametrical nodes
iliac nodes
obturator nodes
pre-sacral and para-aortic nodes
Where are common sources of haemotogenous spread in cervical cancer?
lungs and liver
How is cervical cancer staged? What are the different stages?
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.
How is cervical cancer managed?
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
What is the follow up of cervical cancer?
6 weeks post-treatment
every 3-4 months for 1-2 years
annually for 5 years
What type of cancer is most common in uterine cancer?
adenocarcinoma
What are some risk factors for uterine cancer?
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)
How do higher oestrogen levels/prolonged oestrogen exposure increase risk of uterine cancer?
Leads to endometrial hyperplasia
Hyperplasia predisposes to cytological atypia
Atypical hyperplasia is precancerous
How might uterine cancer present?
PMB - vaginal bleeding 1 year after cessation of periods
premenopausal women: irregular heavy or inter-menstrual bleeding (esp. if <40 yrs old)
What examinations and investigations would you do if you suspected uterine cancer?
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
How does uterine cancer spread?
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
How is uterine cancer staged?
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
How is uterine cancer treated?
Stage 1: Total abdo hysterectomy
Bilateral salpingo-oophorectomy
+/- peritoneal washings
Stage 2: radical hysterectomy, lymphadenectomy
Stage 3 + 4: de-bulking surgery, radiation and chemotherapy
How is uterine cancer followed up following surgery?
6 weeks post surgery
Every 3-4 month for 2 years
Annually up to 5 years
What are some risk factors for ovarian cancer?
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)
How might ovarian cancer present?
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
What might you find on examination of someone with ovarian cancer?
Adnexal or pelvic mass
shifting dullness
irregular abdominal mass (mental cake)
What are the three main groups of primary ovarian tumours?
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
How would you investigate someone for ovarian cancer?
Pelvic ultrasound, abdo ultrasound
Bloods: CA125 CA19.9 CEA AFP HCG LDH FBC U&Es LFTs
Calculate RMI 1 score - if >200/250, refer to MDT
Chest xray
CT abdo and pelvis
Paracentesis of ascites
How is ovarian cancer staged?
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
How is ovarian cancer treated?
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
How successful is ovarian cancer treatment?
75% respond to initial therapy BUT over 55% relapse within 2 years
What is the follow up procedure for ovarian cancer after surgery?
6 weeks post surgery
every 3-4 months for 1-2 years
annually for up to 5 years
What marker is used to detect progression of ovarian cancer?
Serum CA125 level
Why isn’t ovarian cancer screened for?
Expensive
No premalignant condition
High sensitivity and poor specificity
No proof of benefit to screened population
What are risk factors for vulval cancer?
HPV HSV SLE psoriasis smoking
How might vulval cancer present? What can it be confused with?
Itchiness and soreness
Skin changes white, red, grey or raised
Vulval lump
Vulval bleeding
lichen sclerosis may present similarly
What are some risk factors for vaginal cancer?
Vulval intra-epithelial neoplasia (pre-malignant) Lichen sclerosus HPV Smoking SLE Immunosuppression Diethylstilbestrol (DES) Paget's disease
What are the later symptoms of cervical cancer?
Painless haematuria
Urinary frequency
Painless fresh rectal bleeding
Altered bowel habit
Leg oedema, pain
Hydronephrosis
(indicates pelvic wall involvement)
Dull pain in suprapubic region
What might be found on examination in someone with cervical cancer?
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
What is the cut off for normal endometrial thickness, that may indicate uterine cancer?
3/4 mm
Anything thicker = higher risk of being endometrial/uterine cancer
Above what age are epithelial tumours most common?
50 yrs
In what age range are germ cell ovarian tumours most common?
< 35 yrs
What are the differential diagnoses you may consider in someone with ovarian-cancer-like symptoms?
benign tumour/cyst Fibroids Other pelvic malignancy Endometriosis Other causes of ascites Other causes of altered bowel habit
What are some complications associated with ovarian cancers?
Tumour: Rupture
Torsion
Infection
Chemotherapy: Bone marrow depression Infection Neurotoxicity Nephrotoxicity Ototoxicity
Advanced disease: Malnutrition Electrolyte imbalance Bowel obstruction Infection Ascites Pleural effusion
What are the three familial syndromes associated with ovarian tumours?
If you suspect this in a patient, what should you do?
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
What is 5-year survival for ovarian cancer?
46%
What are the two different types of VIN?
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
What are the differentials in someone with ?vulval cancer?
lichen planus Ulcers Dermatitis Fungal infection Boils/cysts eg. Bertholin's cysts
How is vulval cancer staged?
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
Which women should be referred to gynae if vulval cancer suspected?
Unexplained vaginal lump
Unexplained vulval bleeding or ulceration
Persistent symptoms that do not resolve with treatment
How is vulval cancer managed?
What are the complications associated with this?
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
What is the 5 year survival rate for someone with ovarian cancer who doesn’t have any nodes? What about with nodes?
> 80%
< 50%
