Gynae Oncology

Question 1

What is the cervical screening program?

Answer 1

SMEAR INVITATION Every 3 years between the ages of 25-49

then every 5 years between the ages of 50 and 64

Question 2

How does the physiological transformation zone form and when does it become pathological?

Answer 2

During puberty oestrogen makes the cervix evert slightly exposing columnar epithelium to the acidic conditions of the vagina and turning it into SQUAMOUS cell - this is the transformation zone
Oncogenic factors (most often HPV) act on this zone and cause cervical intraepithelial neoplasia

Question 3

Which HPV strains confer the highest risk?

Answer 3

HPV 16 and 18 (cause 70% cervical cancers)

Question 4

What are the results of cervical screening and what should the next stage of treatment be?

Answer 4

MILD dyskaryosis - samples should be tested for high risk HPV strains
MODERATE or above should be sent for coloposcopy (2 week wait referral)

Question 5

How might cervical cancer present symptomatically?

Answer 5

PCB, PMB and IMB
Persistent, offensive, blood-stained discharge
Pain (late disease)
Swollen leg (due to thrombosis in the pelvis)

Question 6

Where is cervical cancer most likely to metastasise to?

Answer 6

Vagina, bladder and bowel
Nodes: parametrical, iliac, obturator and pre-sacral
Blood: liver and lungs

Question 7

What are some risk factors for cervical cancer?

Answer 7

HPV +++
Smoking
High parity
Herpes

Question 8

What are some risk factors for endometrial cancer?

Answer 8

OBESITY - aromatase leads to increased levels of oestrogen 
Early menarche 
Nulliparity
Late menopause 
COCP 
HRT 
Diabetes
Anovulatory amenorrhoea (PCOS)
Tamoxifen 
FH of bowel, breast or endometrial cancer 

Smoking appears to REDUCE the risk

Question 9

What are the most common types of endometrial cancer?

Answer 9

ADENOCARCINOMA - 90%
Serous papillary
Clear cell
Sarcoma

Question 10

What is the most common way for endometrial cancers to present?

Answer 10

POST-MENOPAUSAL BLEEDING - this should be at leats 1 year after stopping periods
(Pre-menopausal women might have irregular bleeding, heavy bleeding or IMB)

Question 11

What examinations should be done in a woman with suspected endometrial cancer?

Answer 11

Speculum to look or vaginal or cervical sources of the bleeding
Then do a bimanual examination - a fixed bulky and retroverted uterus might suggest endometrial Ca (only in advanced disease)

Question 12

What investigations should be ordered in a woman with suspected endometrial cancer?

Answer 12

TV USS - to look for endometrial thickening (should be <11mm)
Fine need biopsy / PIPELLE should be taken and sent for histology - can be done in clinic
MRI should be considered to assess depth of invasion of malignancy
CT abdo and chest to assess for malignancy spread

Question 13

What are the treatment options for endometrial cancer?

Answer 13

assess if the woman wants further children

• RADICAL HYSTERECTOMY and BSO possibly with lymph node resection
• EXTERNAL and INTERNAL radiotherapy are used sometimes
• CHEMOTHERAPY
• HORMONES - anastrozole

Question 14

What are some risk factors for ovarian cancer?

Answer 14

Nulliparity - ? ovulation more traumatic to ovary
HRT
Endometriosis
BRCA1 and BRCA2

PROTECTIVE: parity, breastfeeding and COCP

Question 15

How do we calculate how likely a woman is to have an ovarian malignancy?

Answer 15

RISK OF MALIGNANCY INDEX (RMI) … it takes into account three factors:

• Ca125
• Whether or not they have been through the menopause
• Findings on USS

Question 16

What are the three most common types of ovarian cancer?

Answer 16

Epithelial (most common)
Germ cells (actual ovum producing cells)
Sex cord stromal tumours

Question 17

What is another name for sex-cord stromal tumours of the ovary?

Answer 17

Sertoli-Leydig tumours

Question 18

How does ovarian cancer present?

Answer 18

Abdominal pain
Bloating 
Back pain 
Pressure on bladder or bowel causing urinary or bowel symptoms 
Dyspnoea
Anorexia and weight loss 

***always consider ovarian cancer in a woman presenting with IBS-like symptoms but at an older age

Question 19

What might you find on examination in a patient with ovarian cancer?

Answer 19

Might find an ADNEXAL MASS

Might also find evidence of shifting dullness (the ovarian cancer causes oedematous change)

Question 20

What investigations should be done in a patient with suspected ovarian cancer?

Answer 20

Pelvic USS
CA-125 (marker produced when peritoneum is irritated so can be associated with endometriosis and pregnancy or just normal menstruation)
CA19.9 - only produced by mucinous types of cancer
CEA - might also be detected in blood but again it is not specific
AFP, hCG and LDH
CXR
FBC, U&E and LFTCT abdo and pelvis
Paracentesis of ascitic fluid

Question 21

How is ovarian cancer managed?

Answer 21

Image guided biopsy
TAH and BSO +/- lymph node resection
Peritoneal washes
Chemotherapy with PLATINUM compounds

Question 22

How common are vulval cancers and how do they present?

Answer 22

They are very uncommon and only make up 4% of the gynaecological malingnacies (nearly exclusively in post-menopausal women)

just present as a lump or skin change on the vulva

Question 23

What type of malignancy are vulval cancers usually?

Answer 23

They are nearly always squamous cell carcinomas of the vulval skin

Question 24

How should vulval malignancy be treated?

Answer 24

WLE
Sentinel node biopsy
Chemoradiotherapy