Gynae-oncology Flashcards
Ovarian cancer: Overview
Ovarian cancer is the fifth most common malignancy in females. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis.
Ovarian cancer: Pathophysiology
- Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas.
- Interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.
Ovarian cancer: Risk factors
- Family history: mutations of the BRCA1 or the BRCA2 gene
- Many ovulations*: early menarche, late menopause, nulliparity
*It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.
Ovarian cancer: Clinical features (5)
Clinical features are notoriously vague:
- abdominal distension and bloating
- abdominal and pelvic pain
- urinary symptoms e.g. Urgency
- early satiety
- diarrhoea
Ovarian cancer: Investigations (2)
- CA125
- NICE recommends a CA125 test is done initially.
- Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
- If the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
- a CA125 should not be used for screening for ovarian cancer in asymptomatic women - Ultrasound
Ovarian cancer: Diagnosis
Diagnosis is difficult and usually involves diagnostic laparotomy
Ovarian cancer: Management
Usually a combination of surgery and platinum-based chemotherapy
Ovarian cancer: Prognosis
- 80% of women have advanced disease at presentation
- The all stage 5-year survival is 46%
ONCOgenes vs. TUMOUR SUPRESSOR genes
Tumour suppressor genes - loss of function results in an increased risk of cancer
Oncogenes - gain of function results in an increased risk of cancer
Endometrial cancer: Overview
Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection.
Endometrial cancer: Risk factors* (9)
- obesity
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
- diabetes mellitus
- tamoxifen
- polycystic ovarian syndrome
- hereditary non-polyposis colorectal carcinoma
*the combined oral contraceptive pill and smoking are protective
Endometrial cancer: Symptoms
- Postmenopausal bleeding is the classic symptom
- Premenopausal women may have a change intermenstrual bleeding
- Pain and discharge are unusual features
Endometrial cancer: Investigations
- Women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
- First-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
- Hysteroscopy with endometrial biopsy
Endometrial cancer: Management
- Localised disease is treated with total abdomina hysterectomy with bilateral salpingo-oophorectomy.
- Patients with high-risk disease may have post-operative radiotherapy
- Progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
Cervical cancer: HPV infection
Human papilloma virus (HPV) infection is the most important risk factor for developing cervical cancer. Subtypes 16,18 & 33 are particularly carcinogenic.
The other most common subtypes (6 & 11) are non-carcinogenic and associated with genital warts.
