Gynae Oncology Flashcards
what is the most common gynae cancer in the UK
endometrial cancer
what is the age range which endometrial cancer present in most commonly?
> 50% of endometrial cancer are presented > 50 yrs old
65-75 most common
what is incidence of endometrial cancer in developed world comparing to the developing countries?
10x higher risk for developed countries since higher incidence of obesity
what is the definition of the post-menstral bleeding?
it is when vaginal bleeding 1 year post menopause of the women
what are the symptoms of endometrial cancer in a post-menopausal women
PMB (1 in 10 will have endometrial cancer or atypical hyperplasia)
PV discharge (rare) but can have pyometra (pus-filled uterus) instead of bleeding
fixed and bulky uterus occurs with advanced disease
what % of postmenopausal patient who have pyometra will have an underlying carcinoma
50%
what are the symptoms of endometrial cancer in a pre-menopausal women
menstrual disturbance (heavy or irregular period)
only 1% can be picked up from routine cervical smear test
what are some signs that the endometrial carcinoma has spread?
abdo distension, fatigue, diarrhoea, N+V
persistent cough, swelling or new-onset neuro symptoms
abdo pain, enlarged lymph nodes
what is the ultimate underlying aetiology of the endometrial cancer?
when there is excess unopposed oestrogen regardless of endogenous or exogenous
what are the risk factors of endometrial cancer?
obesity - oestrogen production in the fat tissue
diabetes - 4x higher risks esp if obese
reduced progesterone production
- PCOS - an-ovulation
- early menarche (< 12 yrs)
- late menopause (> 52)
- nulliparity
age (65-75)
unopposed oestrogen therapy (wrong HRT given)
tamoxifen use - weak osteogenic agonist on uterus
previous pelvic irrigation
sex cord stromal tumour of the ovary - granulosa theca cell - produces endogenous oestrogen
what are the familial risk factor of endometrial cancer?
previous FH of breast, ovary, endometrial cancer and colon cancer
associated with the HER-2 gene and HNPCC genes
what are some protective factors for endometrial carcinoma?
smoking
early manopause
multiparous (less exposure to the unopposed oestrogen)
COCP, IUS
what are the different types of endometrial cancer
adenocarcinoma - 90%
serous papillary carcinoma - 5%
clear cell carcinoma - 4%
sacroma - 1%
what is the pre-malignant stage of endometrial cancer?
endometrial hyperplasia
risk of progression of endometrial hyperplasia into endometrical carcinoma
simple - 3%
complex - 3%
complex with atypia - 20-25% in 20 years
treatment of endometrial hyperplasia
simple - progesterone to shed endometrium
complex - progesterone to shed endometrium
complex with atypia - hysterectomy
family not complete and complex with atypia - progesterone first then hysterectomy when completed
ix for endometrial carcinoma
examination
- speculum to exclude any other causes eg cervical/vaginal lesions, STI
- bimanual - to identify any advance disease (fixed, bulky adnexal)
Pipelle in clinic - endometrial scratching for samples)
TVUSS - to identify thickness of the endometrium, identify any polyps/cystic spaces and free fluids
hysteroscopy +/- biopsy - to confirm diagnosis
MRI - to see depth of invasion and cervical involvement
CT abdo/chest - distent mets in liver and lungs
mode of spread of endometrial carcinoma
direct - to ovaries, fallopian tubes, cervix, peritoneum (from peritoneum to omentum which then seeds to the surface of liver and colon)
lymph - to para-aortic lymph node - lungs
blood - liver and lungs
what are the stagings of endometrial cancer
I - confined to the uterus
II - confined to uterus and cervix
III - an extension to the serosa of uterine and peritoneum +/- lymph node
IV - mets to bowels, bladder or any other distant organs
management of endometrial cancer?
stage 1 - surgery (can do brachytherapy)
stage 2 - surgery (can do brachytherapy) +/- adjuvant chemo, adjuvant radio
stage 3/4 - surgery + chemo +/- adjuvant radio
palliative - supportive, palliative chemo, palliative radio, homronal (progesteron to shed endometrium for symptomatic relieve)
what is the 2nd most common cancer in the UK?
ovarian cancer
what is the 3rd most common cancer in the UK?
cervical cancer
what is the most common cancer < 35 yrs old
cervical cancer
aetiology of cervical cancer
during puberty, the cervix evert and become ectropion
the everted tissue is columnar tissue but will change to squamous cells over years due to the acidic environment in the vagina
during this change from columnar to squamous cells in the transformation zone, HPV attacks and causes neoplasia of the cervix and so CIN forms which then leads to cervical cancer
what are the HPV type which can cause cervical cancer
HPV 16/18
what are the HPV type which can cause genital warts
HPV 6/11
what are the pre-malignant stages of cervical cancer
cervical intra-epithelial neoplasia CIN 1 = 1/3 of the cervix is involved CIN 2 = 2/3 of the cervix is involved CIN 3 - 3/3 of the cervix is involved CIN 4 = cancerous
what is the schedule of screening programme like for cervical cancer
starts from 25 (unlikely to occur before 25 and often have cervical changes)
25-49 = every 3 years
50 - 64 = every 5 years
> 65 = only when not previously scanned or smear abnor
how is the cervical cancer screening test done?
by smear test to the swab the cervix
what is the 5 years survival rates of cervical cancer
stages dependent but overall 67% for 5 years
how is colposcopy done?
it is done by inserting a speculum and staining the cervix initially with 5% acetic acid to look for dyskaryotic cells (appears acetic-white), then stain with iodine in the general cervical area (appears yellow if abnor cells present)
what is colposcopy
it is a procedure that looks at the cervix under a microscope with staining and magnification with bright light
when should you consider a colposcopy
when 3 consecutive inadequate smear tests
any abnor smear test
any abnor smear test with HPV +ve
is short term HPV infection problematic
no
70% will resolve in 1 year
90% will resolve in 2 years
RF for cervical cancer
exposure to HPV
- early 1st sexual experience
- multiple sexual partners
- not using barrier methods
- previous STI
smoking
HIV/immunosuppressed
what protein does HPV produce to cause HPV
E6 and E7 produced by HPV 16/18 to turn off tumour suppressor genes
what are some symptoms/signs of cervical cancer
PCB, IMB, PMB (rare)
persistent, offensive, blood stain discharge
late signs
- weight loss
- pain (loin if a ureteric obstruction, butt or back if mets)
- heavy PB bleed
- fistula might form
- swollen leg - thrombosis in the pelvis - mets already happened
examination/Ix for cervical cancer
Ex
- speculum - to exclude STI causes and visualise
- bimanual - can find hard cervix, fornices loss, fixed cervix
- PR - to assess if mets
Ix
- colposcopy - to visualise and staining for dsykaryosis cells
- MRI - to assess tumor size etc
- CXR - if MRI +ve then to check for distant mets eg in the lungs
- FBC, U&Es, LFT
what should you be aware of if cancer is suspected when doing an LLETZ
might cause excessive bleeding if cancer present when doing LLETZ
what is the most common type of cervical cancer
squamous - 70%
adeno-squamous - 25%
adenocarcinoma
small cells
where does cervical cancer spread to directly?
vagina, bladder, parametrium, bowel
where does cervical cancer spread through lymph nodes?
surrounding lymph nodes
para-aortic nodes - that’s why lungs and lungs
where are the most common mets destination for cervical cancer
lungs and liver
what are the stagings of cervical cancer like?
stage 1 - confined to the cervix
stage 2 - cervix and lower 1/3 of vagina
stage 3 - lower 1/3 of vagina and spread to pelvic wall
stage 4 - invasion to the bladder etc
what is the treatment for stage 0 cervical cancer
LLETZ/ local excision
what is the treatment for stage 1a cervical cancer
local excision/trachelectomy/TAH
what is the treatment for stage 1b and 2 cervical cancer
Werthim’s - radical abdomenal hysterectomy + lymphoadenectomy
what is the treatment for stage 2a and 3 cervical cancer
chemoradiation
what is the treatment for stage 4 cervical cancer
chemoradiation
palliative
what happens when the women is pregnant and have cervical cancer
deliver at 35 weeks then treat according to stages
management of cervical cancer for women who still desire children
trachelectomy - cut off the part of the affected cervix then place a stitch in situ to support further pregnancy
what is the age for peak incidence of ovarian cancer
75-85
what reduces the risk of ovarian cancer
COCP
pregnancy
what is the underlying aetiology of ovarian cancer?
inc risk when the ovary has to ovulate more because each ovulation has a chance of neoplasia and so inc no. of ovulation leads to inc risk of ovarian cancer
what are some of the RF for ovarian cancer
nulliparity
early menarche or late menopause
endometriosis - chronic inflammation
difficulty conceiving
BRCA 1 and 2, HNPCC
Turner’s syndrome - dysgerminoma
which genetic syndromes have a higher risk of ovarian cancer
Turner’s syndrome - can have dysgerminoma which is a type of germ cell tumour
risk of ovarian cancer if you have BRCA 1
40%
risk of ovarian cancer if you have BRCA 2
20%
risk of ovarian cancer if you have HNPCC
12%
what is the most common type of ovarian cancer
epithelial ovarian cancer
what is the overall 5 years survival rate of ovarian cancer
43%
what are the signs of symptoms of ovarian cancer
IBS type symptoms - abdo pain, bloating
pressure on bladder and rectum
PV bleeds
GI upset, anorexia, weight loss
dyspnoea
pelvic mass
when do the symptoms of ovarian cancer come on?
usually when the disease is spread to the abdo area (FIGO Stage III)
that’s why the prognosis of ovarian cancer is so bad
what are some examination findings of ovarian cancer
speculum - to exclude any possible STI Bi-manuals - adrenal/pelvic mass abdo exam - irregular mass (omental cake), shifting dullness resp exam - pleural effusion lymph nodes - supra-clavicular nodes
what are the investigation of ovarian cancer
tumour markers
- CA 125 - 50% of ovarian cancer will express the tumour marker
- Ca 19.9 - to identify pancreas mets
- CEA - bowel mets
- AFP, HCG and LDH - rare germ cell tumours
imaging
- pelvic USS - to identify the presence of a mass
- CT abdo and pelvis - mets
- CXR - lung mets and pleural effusion
- paracentesis to ascites
what is the sequence of referring and investigation for ovarian cancer
symptoms/mass present –> tumour makrer –> USS –> CT abdo and pelvic +CXR
if tumour markers +Ve –> repeat tumour makers + USS scan - if still raised then urgent referral
what is the treatment for ovarian cancer
if stage 1 and 2 - surgery + adjuvant chemo
if > stage 2 - neoadjuvant + surgery + adjuvant chemo
what are the surgery that is done to treat ovarian cancer
full laparotomy
- hysterectomy
- BSO
- omentectomy
- lymph node sampling - pelvic and aortic lymph node
- peritoneal biopsy
- pelvic washing + ascites sampling
what is commonly used chemo agent for ovarian cancer
cisplatin - 3 weekly
what are the staging of ovarian cancer
stage 1 - limit to ovaries
stage 2 - limit to pelvis
stage 3 - limit to abdo
stage - distant mets
what are 2 other important differentials for valvular cancer
bartholin’s cyst
lichen sclerosis lesions
what is the pre-malignant state of vulval cancer
VIN
vulvar intra-epithelial neoplasia
what is the risk of progression of VIN to vulval cancer
if VIN 3 - 88%
what is the most common type of vulval cancer
SCC - 90%
melanoma - 5%
BCC, sacroma, Barthlin gland carcinoma
how common is vulval cancer
4% of all gynae cancer
what is the average age of vulval cancer
if invasive = 70
if non-invasive = 50
what are the symptoms of vulval cancer
no symptoms most of the time lump bleeding (post-menopausal bleeding) pruritus (extreme itchiness) pain ulcer
what are some RF for vulval cancer
age - > 70 smoking HPV 16/18/31/33 immunodeficiency lichen sclerosis - 4% risk melanoma - FH
what clinical syndrome can inc risk of vulval cancer
lichen sclerosis
what are some signs of vulval cancer
skin often thicker and lighter or even darker (VIN)
red, swollen mass
warty mass
ulcerated mass
regional lymph node
treatment of vulval cancer
surgical - wide local excision of the suspicious area
- vulvectomy
ipsilateral/bilateral lymphadenectomy
radio
chemo
what is the 5 years survival rate of vulval cancer
86%
what is the staging of vulval cancer like?
Stage 1 - confined locally
stage 2 - invade to nearby perineal area - LN
stage 3 - invade to nearby perineal + LN
stage 4 - spread to other regions
