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Y4 - GOSH > Gynae Oncology > Flashcards

Gynae Oncology Flashcards

1
Q

what is the most common gynae cancer in the UK

A

endometrial cancer

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2
Q

what is the age range which endometrial cancer present in most commonly?

A

> 50% of endometrial cancer are presented > 50 yrs old

65-75 most common

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3
Q

what is incidence of endometrial cancer in developed world comparing to the developing countries?

A

10x higher risk for developed countries since higher incidence of obesity

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4
Q

what is the definition of the post-menstral bleeding?

A

it is when vaginal bleeding 1 year post menopause of the women

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5
Q

what are the symptoms of endometrial cancer in a post-menopausal women

A

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

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6
Q

what % of postmenopausal patient who have pyometra will have an underlying carcinoma

A

50%

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7
Q

what are the symptoms of endometrial cancer in a pre-menopausal women

A

menstrual disturbance (heavy or irregular period)

only 1% can be picked up from routine cervical smear test

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8
Q

what are some signs that the endometrial carcinoma has spread?

A

abdo distension, fatigue, diarrhoea, N+V

persistent cough, swelling or new-onset neuro symptoms

abdo pain, enlarged lymph nodes

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9
Q

what is the ultimate underlying aetiology of the endometrial cancer?

A

when there is excess unopposed oestrogen regardless of endogenous or exogenous

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10
Q

what are the risk factors of endometrial cancer?

A

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

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11
Q

what are the familial risk factor of endometrial cancer?

A

previous FH of breast, ovary, endometrial cancer and colon cancer

associated with the HER-2 gene and HNPCC genes

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12
Q

what are some protective factors for endometrial carcinoma?

A

smoking
early manopause
multiparous (less exposure to the unopposed oestrogen)
COCP, IUS

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13
Q

what are the different types of endometrial cancer

A

adenocarcinoma - 90%
serous papillary carcinoma - 5%
clear cell carcinoma - 4%
sacroma - 1%

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14
Q

what is the pre-malignant stage of endometrial cancer?

A

endometrial hyperplasia

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15
Q

risk of progression of endometrial hyperplasia into endometrical carcinoma

A

simple - 3%
complex - 3%
complex with atypia - 20-25% in 20 years

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16
Q

treatment of endometrial hyperplasia

A

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

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17
Q

ix for endometrial carcinoma

A

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

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18
Q

mode of spread of endometrial carcinoma

A

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

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19
Q

what are the stagings of endometrial cancer

A

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

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20
Q

management of endometrial cancer?

A

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)

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21
Q

what is the 2nd most common cancer in the UK?

A

ovarian cancer

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22
Q

what is the 3rd most common cancer in the UK?

A

cervical cancer

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23
Q

what is the most common cancer < 35 yrs old

A

cervical cancer

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24
Q

aetiology of cervical cancer

A

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

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25
Q

what are the HPV type which can cause cervical cancer

A

HPV 16/18

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26
Q

what are the HPV type which can cause genital warts

A

HPV 6/11

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27
Q

what are the pre-malignant stages of cervical cancer

A 
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
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28
Q

what is the schedule of screening programme like for cervical cancer

A

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

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29
Q

how is the cervical cancer screening test done?

A

by smear test to the swab the cervix

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30
Q

what is the 5 years survival rates of cervical cancer

A

stages dependent but overall 67% for 5 years

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31
Q

how is colposcopy done?

A

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)

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32
Q

what is colposcopy

A

it is a procedure that looks at the cervix under a microscope with staining and magnification with bright light

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33
Q

when should you consider a colposcopy

A

when 3 consecutive inadequate smear tests

any abnor smear test
any abnor smear test with HPV +ve

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34
Q

is short term HPV infection problematic

A

no
70% will resolve in 1 year
90% will resolve in 2 years

35
Q

RF for cervical cancer

A

exposure to HPV

  • early 1st sexual experience
  • multiple sexual partners
  • not using barrier methods
  • previous STI

smoking
HIV/immunosuppressed

36
Q

what protein does HPV produce to cause HPV

A

E6 and E7 produced by HPV 16/18 to turn off tumour suppressor genes

37
Q

what are some symptoms/signs of cervical cancer

A

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
38
Q

examination/Ix for cervical cancer

A

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
39
Q

what should you be aware of if cancer is suspected when doing an LLETZ

A

might cause excessive bleeding if cancer present when doing LLETZ

40
Q

what is the most common type of cervical cancer

A

squamous - 70%
adeno-squamous - 25%
adenocarcinoma
small cells

41
Q

where does cervical cancer spread to directly?

A

vagina, bladder, parametrium, bowel

42
Q

where does cervical cancer spread through lymph nodes?

A

surrounding lymph nodes

para-aortic nodes - that’s why lungs and lungs

43
Q

where are the most common mets destination for cervical cancer

A

lungs and liver

44
Q

what are the stagings of cervical cancer like?

A

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

45
Q

what is the treatment for stage 0 cervical cancer

A

LLETZ/ local excision

46
Q

what is the treatment for stage 1a cervical cancer

A

local excision/trachelectomy/TAH

47
Q

what is the treatment for stage 1b and 2 cervical cancer

A

Werthim’s - radical abdomenal hysterectomy + lymphoadenectomy

48
Q

what is the treatment for stage 2a and 3 cervical cancer

A

chemoradiation

49
Q

what is the treatment for stage 4 cervical cancer

A

chemoradiation

palliative

50
Q

what happens when the women is pregnant and have cervical cancer

A

deliver at 35 weeks then treat according to stages

51
Q

management of cervical cancer for women who still desire children

A

trachelectomy - cut off the part of the affected cervix then place a stitch in situ to support further pregnancy

52
Q

what is the age for peak incidence of ovarian cancer

A

75-85

53
Q

what reduces the risk of ovarian cancer

A

COCP

pregnancy

54
Q

what is the underlying aetiology of ovarian cancer?

A

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

55
Q

what are some of the RF for ovarian cancer

A

nulliparity
early menarche or late menopause

endometriosis - chronic inflammation
difficulty conceiving

BRCA 1 and 2, HNPCC

Turner’s syndrome - dysgerminoma

56
Q

which genetic syndromes have a higher risk of ovarian cancer

A

Turner’s syndrome - can have dysgerminoma which is a type of germ cell tumour

57
Q

risk of ovarian cancer if you have BRCA 1

A

40%

58
Q

risk of ovarian cancer if you have BRCA 2

A

20%

59
Q

risk of ovarian cancer if you have HNPCC

A

12%

60
Q

what is the most common type of ovarian cancer

A

epithelial ovarian cancer

61
Q

what is the overall 5 years survival rate of ovarian cancer

A

43%

62
Q

what are the signs of symptoms of ovarian cancer

A

IBS type symptoms - abdo pain, bloating
pressure on bladder and rectum
PV bleeds

GI upset, anorexia, weight loss

dyspnoea

pelvic mass

63
Q

when do the symptoms of ovarian cancer come on?

A

usually when the disease is spread to the abdo area (FIGO Stage III)

that’s why the prognosis of ovarian cancer is so bad

64
Q

what are some examination findings of ovarian cancer

A 
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
65
Q

what are the investigation of ovarian cancer

A

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
66
Q

what is the sequence of referring and investigation for ovarian cancer

A

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

67
Q

what is the treatment for ovarian cancer

A

if stage 1 and 2 - surgery + adjuvant chemo

if > stage 2 - neoadjuvant + surgery + adjuvant chemo

68
Q

what are the surgery that is done to treat ovarian cancer

A

full laparotomy

  • hysterectomy
  • BSO
  • omentectomy
  • lymph node sampling - pelvic and aortic lymph node
  • peritoneal biopsy
  • pelvic washing + ascites sampling
69
Q

what is commonly used chemo agent for ovarian cancer

A

cisplatin - 3 weekly

70
Q

what are the staging of ovarian cancer

A

stage 1 - limit to ovaries
stage 2 - limit to pelvis
stage 3 - limit to abdo
stage - distant mets

71
Q

what are 2 other important differentials for valvular cancer

A

bartholin’s cyst

lichen sclerosis lesions

72
Q

what is the pre-malignant state of vulval cancer

A

VIN

vulvar intra-epithelial neoplasia

73
Q

what is the risk of progression of VIN to vulval cancer

A

if VIN 3 - 88%

74
Q

what is the most common type of vulval cancer

A

SCC - 90%

melanoma - 5%
BCC, sacroma, Barthlin gland carcinoma

75
Q

how common is vulval cancer

A

4% of all gynae cancer

76
Q

what is the average age of vulval cancer

A

if invasive = 70

if non-invasive = 50

77
Q

what are the symptoms of vulval cancer

A 
no symptoms most of the time 
lump
bleeding (post-menopausal bleeding) 
pruritus (extreme itchiness) 
pain 
ulcer
78
Q

what are some RF for vulval cancer

A 
age - > 70 
smoking 
HPV 16/18/31/33
immunodeficiency 
lichen sclerosis - 4% risk 
melanoma - FH
79
Q

what clinical syndrome can inc risk of vulval cancer

A

lichen sclerosis

80
Q

what are some signs of vulval cancer

A

skin often thicker and lighter or even darker (VIN)

red, swollen mass
warty mass
ulcerated mass

regional lymph node

81
Q

treatment of vulval cancer

A

surgical - wide local excision of the suspicious area
- vulvectomy

ipsilateral/bilateral lymphadenectomy

radio
chemo

82
Q

what is the 5 years survival rate of vulval cancer

A

86%

83
Q

what is the staging of vulval cancer like?

A

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

Y4 - GOSH (12 decks)

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