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gynae oncology Flashcards

1
Q

what is endometrial hyperplasia?

A

abnormal proliferation of the endometrial layer of the uterus

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2
Q

what are the risk factors for endometrial hyperplasia?

A

unopposed oestrogen causes the endometrium to proliferate

  • obesity
  • PCOS
  • HRT (some forms)
  • tamoxifen
  • oestrogen secreting ovarian tumour
  • nulliparity

hereditary non-polyposis CRC
diabetes

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3
Q

how does endometrial hyperplasia present?

A

irregular bleeding
intermenstrual bleeding
post menopausal bleeding
menorrhagia

vaginal discharge

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4
Q

what are the two types of endometrial hyperplasia?

A

hyperplasia without atypica - less likely to become malignant
atypical hyperplasia - premalignant condition

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5
Q

what investigations should we do for endometrial hyperplasia?

A

Transvaginal USS - can see thickening of endometrium

endometrial biopsy

hysteroscopy and curettage - more accurate than above

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6
Q

how is endometrial hyperplasia managed?

A

reassure
address risk factors

progesterone treatment - Levonorgestrel IUS for 5 years or oral progesterone for 6 months

follow up:

  • endometrial biopsies 6 monthly until 2 negative
  • for those at high risk e.g. BMI >35 , annual biopsies there after

hysterectomy if not responding to treatment after 1 yr of progesterone, atypical hyperplasia or relapse after treatment

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7
Q

what are the different types of endometrial cancer

A

adenocarcinoma - type 1 - most common
types 2: papillary serous tumours, clear cell, carcinosarcomas
(rarely sarcomas)

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8
Q

what is the aetiology behind endometrial cancer?

A

Stimulation of the endometrium by oestrogen (in absence of progesterone = unopposed oestrogen)
this result in proliferation of endometrium = endometrial hyperplasia (pre-malignant condition) which can be simple, complex or atypical and can develop into cancer
progesterone is released from corpus luteum after ovulation and protects the endometrium from oestrogen effects and thus anything causing anovulation can result in increased risk.

endometrial cancers metastasise to para-aortic and pelvic nodes and then lung, bone, brain and intraperitoneum

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9
Q

which type of cancers of the endometrial cancers are most likely to have metastasised at presentation?

A

type 2

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10
Q

what are the risk factors for endometrial cancer?

A

upposed oestrogen:

  • tamoxifen,
  • PCOS - anovulation and high Oestrogens
  • HRT oestrogen only
  • obesity - peripheral conversion of androgens to oestrogen
  • early menarche/ late menopause - anovulation is more likely at extremes of age
  • granulosa cell tumours (ovarian tumours) - secrete oestrogen

other:

  • age (more common 65-75yrs)
  • immunosuppression e.g. HIV
  • lynch syndrome
  • diabetes / insulin resistance
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11
Q

what are the differentials for endometrial cancer?

A

cervical polyps/ cancer
endometrial hyperplasia
endometrial polyps

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12
Q

what are the clinical features of endometrial cancer?

A

abnormal bleeding - PMB, PCB, IMB
clear white vaginal discharge - less common
signs of mets: abdo pain/ distension, SoB, weight loss

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13
Q

what can you find on examination of someone with endometrial cancer?

A

abdo/pelvic mass

evidence of vaginal/vulval atrophy or cervical lesions

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14
Q

what investigations can be done for someone presenting with endometrial cancer ?

A

transvaginal USS - first line
pipelle/ curettage biopsy
hysteroscopy and biopsy - high risk patient = gold standard
MRI abdo/ pelvis
surgical exploration - also take samples of omentum (due to mets going here)

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15
Q

what suspicious findings are found on transvaginal USS of someone with endometrial cancer?

A 
endometrial thickening (>4mm) 
mixed echoes
calcifications 
mass 
free fluid
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16
Q

when is a biopsy of endometrium indicated ?

methods for this biopsy and comparison

A

if >4mm and post menopausal
pipelle doesn’t sample as deep as curettage (remember neither of them can sample myometrium for sarcomas)

these can confirm histology

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17
Q

what is the FIGO staging for endometrial cancer?

A

1: confined to uterus
2. uterus and cervix
3. uterus +/- cervix and beyond e.g. vagina, ovaries, serosa, pelvic/aortic nodes but all within pelvis
4. bladder/ bowel or distant sites

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18
Q

how is endometrial cancer managed (by stage) ?

A

stage 1: total abdominal hysterectomy + bilateral salpingo-oophorectomy. laparoscopic or open. peritoneal washings taken too

stage 2: radical hysterectomy, remove and assess lymph nodes. may be offered adjuvant radiotherapy

stage 3: maximal debulking surgery + chemoradiotherapy

stage 4: maximal debulking surgery. majority are palliative with low dose radiotherapy or high dose oral progesterones

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19
Q

what is cervical ectropion?

A

the endocervix of cervix becomes everted and is exposed to the vagina

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20
Q

what is the histology of the cervix? use this to explain pathophysiology of cervical ectropion.

A

ectocervix - stratified squamous epithelium. part that faces vagina
endocervix - within cervix - columnar epithelium

in cervical ectropion, the stratified squamous cells of ectocervix undergo metaplastic change and become simple columnar cells. this change is induced by high oestogen

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21
Q

what are the risk factors for cervical ectropion?

A 
adolescence
COCP
pregnancy 
menstruating age 
overall anything increasing O
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22
Q

what are the clinical features of cervical ectropion?

A

mostly asymptomatic
vaginal discharge - the glandular epithelium will secrete
bleeding - post coital - the glandular epithelium has fine blood vessles that can be easily broken (also intermenstrual bleeding)

on speculum exam - cervix appears red

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23
Q

what are the differentials for cervical ectropion?

A

cervical cancer/ CIN
cervicitis
pregnancy

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24
Q

what investigations can be carried out who may have cervical ectropion?

A

pregnancy test
twiple swabs - any suggestion of infection then endocervical and high vaginal swabs
cervical smear - rule out CIN

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25
how is cervical ectropion managed?
normal variant does not need treatment unless symptomatic first line - COCP if symptoms persist can remove columnar epithelium typically by curettage or electrocautery
26
what is the aetiology of cervical cancer?
majority are squamous cell carcinomas, the rest are adenocarcinomas develop from CIN over a course of 10-20yrs most common site of metastasis = lung, liver, bone, bowel majority caused by HPV
27
what is HPV? how is it linked to cervical cancer?
HPV = virus , many subtypes most women have been infected and clear infection within 2 years. however some women fail to clear the infection or get repeated infections this increases risk of CIN developing more over some are high risk strains (16 and 18) and carry oncogenes - p53 suppression
28
what are the risk factors for cervical cancer?
HPV- early age of first intercourse, multiple sexual partners smoking immunodeficiency long term use of COCP (possibly because condoms not used)
29
how is cervical cancer prevented?
``` screening - cervical smear vaccines - Gardasil - 6,11,16,18 - cervarix - 16,18 - ideally before intercourse - 3 IM injections over 6 months - still need smears ```
30
what are the clinical features of cervical cancer?
abnormal bleeding - PMB, PCB, IMB vaginal discharge dyspareunia pelvic pain may be asymptomatic and picked up from screening 2 peaks of incidence (24-35 and then >55) advanced disease - weight loss, loin pain that radiates down thighs (radiculopathy), oedema, hydronephrosis, rectal bleeding, haematuria
31
what is found on examination of someone with cervical cancer?
cervix - irregular, febrile, bleeding, mass bimanual - pelvic mass abdominal - hepatomegaly, hydronephrosis, rectal mass/ bleeding
32
what investigations would you do for someone presenting with cervical cancer?
premenopausal - test for chlamydia (if positive treat and if symptoms don't clear then colposcopy, if negative then colposcopy) post menopausal - urgent colposcopy and biopsy colposcopy - magnifies and uses stains (acetic acid to stain areas white that are abnormal) basic bloods CT CAP/ MRI pelvic / PET
33
describe the staging for cervical cancer?
0 - carcinoma in situ 1 - confined to cervix (A= only microscopic, B= gross) 2 - beyond cervix but not pelvic side walls or involves vagina but not lower 1/3. (A = no parametrial involvement, B= parametrial involvement) 3 - extends beyond pelvic side walls or lower 1/3 vagina, hydronephrosis 4 - extends to bladder/ rectum (A), distant (B)
34
how is cervical cancer managed?
consider stage and MDT approach (don't forget psychological aspect) surgical - stage 1a: radical trachelectomy if fertility is to be preserved otherwise hysterectomy - stage 1b/2a: radical hysterectomy - stage 4a: anterior/ posterior/ total pelvic extenteration radiotherapy - stage 1b to 3 (offered in conjugation with chemo = gold standard) chemo= cisplatin based - neoadjuvant or adjuvant
35
what is a radical trachelectomy?
remove cervix and upper vagina
36
how often are women treated for cervical cancer followed up?
reviewed every 4 months for 1st 2 years then 6-12 months for 3 years all follow ups include examination of vagina and cervix
37
what are the complications of treatment for cervical cancer?
surgery - infection, VTE, haemorrhage, bladder dysfunction, short vagina, vesicovaginal fistula and lymphocyst formation radiotherapy - vaginal dryness, vaginal stenosis, radiation cystitis, radiation proctitis, loss of ovarian function
38
what is the pathophysiology behind CIN?
atypical changes to the transformation zone of the cervix whereby the columnar epithelium is replaced by squamous metaplasia. this is natural and occurs from vaginal acidity in young women. however if this is exposed to carcinogens (HPV) there is risk of CIN developing CIN is premalignant
39
what are the histological characteristics of CIN ?
nuclear polymorphism increased mitotic activity basal hyperplasia
40
what are the different grades of CIN?
CIN I: low grade dyskaryosis, mild dysplasia. can spontaneously resolve. can extend 1/3 of squamous epithelium CIN II: high grade dyskaryosis, moderate dysplasia. can resolve spontaneously or progress. extends 2/3 of squamous epithelium CIN III: high grade dyskaryosis, severe dysplasia. high risk of developing into cervical cancer, even after removed. extends into final 3rd of squamous epithelium. develops into carcinoma within 10 years if untreated
41
what is the difference between dyskaryosis and CIN?
dyskaryosis - cytological appearance | CIN = histological
42
what is the UK cervical screening programme?
every 3 years for women 25-49 and then every 5 years from 50-64 cells are collected with a smear instrument (using speculum) and put into medium with Papanicolaou's stain = pap smear) this stains the cells so they can be examined under microscopy = liquid based cytology
43
what can the results of a pap smear show?
``` inadequate - not enough cells, incorrect label etc normal - no abnormal cells found abnormal cells found = borderline changes = low grade dyskaryosis = high grade dyskaryosis (moderate or severe) = invasive squamous cell carcinoma = glandular neoplasia ```
44
how do we manage women depending on their smear results?
negative - continue on screening programme in 3 years low grade dyskaryosis - - HPV test - negative - continue on screening in 3 yrs - positive - colposcopy high grade - colposcopy
45
in colposcopy stains are used to see abnormal cells. what stains can be used?
acetic acid = turns abnormal cells white | iodine - normal cells go brown
46
how is high grade CIN treated?
LLETZ biopsy - large loop excision of transformation zone under general anaesthetic
47
what are cervical polyps?
benign growths protruding from inner surface of cervix
48
what is the pathophysiology of cervical polyps?
may be due to chronic inflammation, abnormal response to oestrogen or congestion of cervical vasculature develop from endocervix (columnar epithelium) more common in older women and multigravidum
49
what are the clinical features of cervical polyps?
may be asymptomatic abnormal bleeding - PMB, PCB, IMB, menorrhagia vaginal discharge on speculum can see polyp growth
50
what investigations should be done for someone with cervical polyps?
swabs - rule out infection smear - rule out CIN histological examination - for definitive diagnosis
51
how should cervical polyps be managed?
remove due to small risk of malignant transformation polyp grasped with polypectomy forceps and twisted larger ones may need diathermy loop excision send for histological exam to rule out malignancy
52
what are the complications of cervical polyp removal?
infection, haemorrhage, rarely uterine perforation
53
how can ovarian cysts be classified?
simple - fluid filled sacs complex - irregular, contain solid material, blood, septations or vascularity neoplastic - have malignant potential non-neoplastic
54
what are the types of non-neoplastic ovarian cysts?
functional - follicular or corpus luteal cysts pathological - PCOS or endometriomas
55
what are the types of benign neoplastic ovarian cysts?
epithelial - serous , mucinous or breners germ cell - cystic teratomas (contain teeth, hair) other - fibroma, thecoma , adenoma
56
how do fibromas (ovarian cysts) appear?
solid, small | meigs syndrome
57
what is meigs syndrome?
triad of: - benign ovarian tumour - ascites - pleural effusion
58
what are the risk factors for ovarian cysts?
non neoplastic ones have their own risk factors | benign epithelial have same risk factors as ovarian cancer
59
how do ovarian cysts present?
asymptomatic dull ache in lower abdo/ back mass felt swollen abdomen dyspareunia pressure effects - bladder (frequency), bowel (constipation), veins (varicose) hormones secreted may lead to virilisation rupture/ torsion - acute severe pain and fever and shock
60
what investigations should be done for ovarian cysts?
need to rule out malignancy - pregnancy test - urinalysis - bloods - FBC, UEs, LFTs, - aFP, LDH and bHCG for <40s due to germ cell tumour - CA125 - USS - transvaginal/ abdominal - pelvic examination for mass other: - diagnostic laparoscopy - FNA - CT CAP
61
what is the risk of malignancy index?
A way to calculate the risk of an ovarian cyst being malignant Ux M x Ca125 U = USS findings. look for acites, multilocular cysts, solid areas, metastasis, bilateral lesions. (1 =1 point, 2 or more = 3 points M = post menopause = 3 points, pre menopause =1 point Ca125
62
what RMI value is low, moderate and high risk? and how should each be managed?
``` 0-25 = low risk - follow up 1 year with USS and Ca125 if <5cm 25-250 = moderate - bilateral oophorectomy and if malignancy then follow up with oncology >250 = high risk - refer for staging laparotomy ```
63
what is the normal Ca125 value?
<35
64
what are the complications of ovarian cysts?
torsion haemorrhage (more likely in malignant ones) rupture infertility
65
what is pseudomyxoma peritonei
rupture of mucinous ovarian cyst - can disseminate mucinous cells which produce mucins which can build up in viscera and cause death needs debulking
66
how are ovarian cysts managed?
expectant management: - small simple cysts (<50mm) - generally do not require follow up - if 50-70mm = yearly USS surgery: - persistent cysts, >5-10cm, symptomatic, complex - in young children/ women do cystectomy rather than oophorectomy
67
how is ovarian torsion managed?
laparoscopically uncoil may need oophorectomy if vascular compromise - may need salpingoophorectomy
68
what are the different types of ovarian cancer?
serous cystadenocarcinoma - most common mucinous cystadenocarcinoma germ cell - teratomas , dermoids stromal - Sertoli, theca, granulosa cell tumours
69
what are the risk factors for ovarian cancer?
ovulation appears to cause surface irritation to ovaries and thus anything increasing ovulation: - early menarche, late menopause, nulliparous, women > 65 also unopposed oestrogen, obesity, lynch syndrome, BRCA positive and smoking
70
what are serous cystadenocarcinomas and mucinous cystadenocarcinomas characterised by?
serous - psammona bodies | mucus - mucin vacuoles
71
what are protective factors for ovarian cancers?
parity, breast feeding , COCP
72
what cancers does lynch syndrome increase risk of?
endometrial, ovarian and bowel
73
what can be offered to BRCA positive women?
prophylactic massectomy and bilateral salpingo-oophorectomy
74
what are the clinical features of ovarian cancer?
asymptomatic vague - dyspepsia, IBS like, urinary frequency, incontinence, tired, constipation chronic pain due to pressure on bladder/ bowel. also dyspareunia acute pain - rupture, torsion, haemorrhage. necrosis can give pain and fever bleeding per vagina later: weight loss, abdo distention, pleural effusion, DVT
75
what investigations should be done for someone presenting with ovarian cancer?
same as for ovarian cysts | + CT CAP, CXR, surgical exploration and histopathology
76
describe the staging of ovarian cancers
1: limited to ovaries 2: spread to pelvic organs 3: spread to rest of peritoneal cavity , omentum and lymph nodes 4: distant mets, liver and lung
77
what are the causes of a raised CA125?
endometriosis, uterine fibroids, pregnancy, menstruation, PID inflammatory bowel - diverticulosis, liver cirrhosis ovarian cancer
78
what is krunkenburg tumour?
refers to ovarian cancers that have metastasized to gut / stomach
79
how do we manage ovarian cancers?
surgery - staging laparotomy for those with high RMI to aim to debulk adjuvant chemo - can use CA125 to assess progress sometimes may need adjuvatnt chemo to shrink tumour before resection chemo = carboplatin chemo for palliative follow up for 5 years by measuring Ca125
80
is there a screening programme for ovarian cancer?
no , no pre-malignant stage | CA125 is too non-specific
81
what are the risk factors for vulval cancer?
``` HPV mostly in women >65 HSV lichen sclerosus and lichen planus smoking ```
82
what is the main type of vulval cancer?
squamous cell carcinoma
83
what is VIN? how does it present
abnormal cells in vulva and at risk of becoming cancerous (pre-malignant) there are 2 types - undifferentiated and differentiated can resolve spontaneously presents like vulval cancer - itching, pain etc
84
what are the symptoms of vulval cancer?
itching, pain, tenderness, soreness raised thickened patches of skin that can be white, red or dark a lump/ wart like growth bleeding/ open sore (pain when urinating)
85
how is vulval cancer diagnosed?
examination and biopsy under local anaesthetic other tests: - cervical smear test (due to common risk factor and more likely to get CIN from HPV than VIN) - cystoscopy - abnormal cells in bladder - lymph node biopsy may require CT CAP or CXR for mets
86
what staging is used for vulval cancer?
I - confined to vulva 2 - spread to near by structures - vagina, urethra, anus 3 - spread to nearby lymph nodes 4 - spread to other body parts
87
what is the treatment for vulval cancers?
surgery to remove cancerous tissue from vulva and any lymph nodes that may be malignant some also have radio/chemotherapy radical wide local excision = cancer removed and margin of healthy tissue radical partial vulvectomy = larger section of vulvula removed (one or both labia) and clitoris radical vulvectomy = whole vulvula (inner and outer) + clitoris psychological support
88
how can lymph nodes be assessed in vulval cancer?
sentinel node biopsy | groin lymphadenectomy - all removed - risk of lymphoedema or infection
89
how is VIN treated?
recommended that abnormal area is removed either chemically (imiquimod) or surgical excision otherwise conservative treatment with antihistamines

gynaecology (7 decks)

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