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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
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 ```
26
Where are common sources of direct/local spread in cervical cancer?
Vagina, bladder, parametric, bowel
27
Where are common sources of lymphatic spread in cervical cancer?
parametrical nodes iliac nodes obturator nodes pre-sacral and para-aortic nodes
28
Where are common sources of haemotogenous spread in cervical cancer?
lungs and liver
29
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.
30
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
31
What is the follow up of cervical cancer?
6 weeks post-treatment every 3-4 months for 1-2 years annually for 5 years
32
What type of cancer is most common in uterine cancer?
adenocarcinoma
33
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)
34
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
35
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)
36
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 ```
37
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
38
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
39
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
40
How is uterine cancer followed up following surgery?
6 weeks post surgery Every 3-4 month for 2 years Annually up to 5 years
41
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) ```
42
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
43
What might you find on examination of someone with ovarian cancer?
Adnexal or pelvic mass shifting dullness irregular abdominal mass (mental cake)
44
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
45
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
46
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
47
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 ```
48
How successful is ovarian cancer treatment?
75% respond to initial therapy BUT over 55% relapse within 2 years
49
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
50
What marker is used to detect progression of ovarian cancer?
Serum CA125 level
51
Why isn't ovarian cancer screened for?
Expensive No premalignant condition High sensitivity and poor specificity No proof of benefit to screened population
52
What are risk factors for vulval cancer?
``` HPV HSV SLE psoriasis smoking ```
53
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
54
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 ```
55
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
56
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
57
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
58
Above what age are epithelial tumours most common?
50 yrs
59
In what age range are germ cell ovarian tumours most common?
< 35 yrs
60
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 ```
61
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 ```
62
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
63
What is 5-year survival for ovarian cancer?
46%
64
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
65
What are the differentials in someone with ?vulval cancer?
``` lichen planus Ulcers Dermatitis Fungal infection Boils/cysts eg. Bertholin's cysts ```
66
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
67
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
68
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
69
What is the 5 year survival rate for someone with ovarian cancer who doesn't have any nodes? What about with nodes?
>80% < 50%

GOSH (33 decks)

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