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.
Cervical cancer: Overview
Around 50% of cases of cervical cancer occur in women under the age of 45 years, with incidence rates for cervical cancer in the UK are highest in people aged 25-29 years, according to Cancer Research UK. It may be divided into:
- squamous cell cancer (80%)
- adenocarcinoma (20%)
Cervical cancer: Features (3)
- may be detected during routine cervical cancer screening
- abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
- vaginal discharge
Cervical cancer: Risk factors
Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer. Other risk factors include:
- smoking
- human immunodeficiency virus
- early first intercourse, many sexual partners
- high parity
- lower socioeconomic status
- combined oral contraceptive pill*
Cervical cancer: Mechanism of HPV causing cervical cancer
- HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
- E6 inhibits the p53 tumour suppressor gene
- E7 inhibits RB suppressor gene
Cervical ectropion: Definition
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
The term cervical erosion is used less commonly now
This may result in the following features
- vaginal discharge
- post-coital bleeding
Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
