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GOSH > Gynae Oncology > Flashcards

Gynae Oncology Flashcards

1
Q

What is the cervical screening program?

A

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

then every 5 years between the ages of 50 and 64

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2
Q

What is the ectocervix
What is the endocervix?
What is the transformation zone? How does it form?
How does it relate to cancer?

A

Ectocervix (part that protrudes into vagina)=squamous

Endocervix (canal of cervix) =columner

Junction between 2=squamocolumner junction

Tranformation zone=zone where endocervix turns into ectocervix (turns into squamous)

  • during puberty oestrogen makes the cervix evert slightly exposing columnar epithelium to the acidic conditions of the vagina and turning it into SQUAMOUS cell
  • oncogenic factors (most often HPV) act on this zone and cause cervical intraepithelial neoplasia
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3
Q

Which HPV strains confer the highest risk?

What strains are vaccinated against? Who is vaccinated?

A

HPV 16 and 18 (cause 70% cervical cancers)

Girls AND boys aged 12-13 vaccinated against strains 6/11 (warts) 16/18 (cancer) are vaccinated against

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4
Q

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

A

first it tests for HPV

  1. if negative, no further tests
  2. if positive, do cytology
    - if cytology is -ve do repeat smear in 12 months
    - if cytology is abnormal do colposcopy
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5
Q

How might cervical cancer present symptomatically?

A

Cervical cancer

  • often asymptomatic and present through screening program
  • PCB IMB (PMB if 50+)
  • Persistent, offensive, blood-stained discharge
  • Pain (late disease)
  • Swollen leg (due to thrombosis in the pelvis)
  • Painful leg due to nerve compression
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6
Q

Where is cervical cancer most likely to metastasise to?

A

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

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7
Q

What are some risk factors for cervical cancer?

A

HPV +++
Smoking
High parity
Herpes

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8
Q

Examination for suspected cervical cancer?

Investigations?

A

Cervical cancer examination

  • speculum exam
  • bimanual exam
  • PR

Investigations
Bloods
-FBC, UsEs, LFTs

Histology

  • colposcopy
  • cervical biopsy

Staging

  • MRI-local extent
  • CT abdo and chest (mets)
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9
Q

What does a colposcopy involve?

A
  • Examine cervix with bright light and magnification

- biopsy

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10
Q

What is the treatment for cervical cancer?

A
  • Stage 1a1 If really small (micro invasive) then loop excision only
  • Stage 1a2+ If <4cm generally treated by surgery (radical hysterectomy with pelvic lymphadenectomy). May or may not remove tubes and ovaries (depending on the age)
  • Stage 1b3+ If tumour >4cm or if involve pelvis then radical radiotherapy+/- chemotherapy
  • If stage 4b (mets) then palliative chemo and or radiotherapy
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11
Q

What is fertility sparing treatment?

Who would this be given to ?

A

Radical trachelectomy (uterus anastomosed with vagina)

Option for women who:

  • under age of 40
  • wish to preserve fertility
  • have tumours <2cm in size
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12
Q

What is Cervical Intraepithelial Neoplasia (CIN)?

A
  • CIN is a precancerous condition with abnormal cells on cervix
  • if it breaks through the basement membrane it is invasive cancer
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13
Q

What is the treatment of CIN (1,2,3, and CGIN)

A

CIN 1-60% resolve spontaneously, manage conservatively for 2 years and loop excision if persistent

CIN 2 (high grade)>loop excision (young nulliparous women can be managed conservatively for 2 years)

CIN3 (high grade)> loop excision

CGIN (cervical glandular intraepithelial neoplasia) affects the endocervix> loop excision

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14
Q

What are some risk factors for ovarian cancer?

Protective factors?

A

More ovulation!!!

  • early periods
  • no children (nulliparity)
  • HRT containing oestrogen only
  • Endometriosis (chronic inflammatory)
  • BRCA1 and BRCA2

PROTECTIVE: parity/children, breastfeeding and COCP

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15
Q

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

A

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

  • Ca125
  • Whether or not they have been through the menopause
  • Findings on USS
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16
Q

What are the three most common types of ovarian cancer?

A

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

17
Q

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

A

Sertoli-Leydig tumours

18
Q

How does ovarian cancer present?

A

Very unspecific (can lead to late diagnosis)

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

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

19
Q

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

A
  • Might find an ADNEXAL or PELVIC MASS
  • Abdo mass ‘omental cake’
  • Might also find evidence of shifting dullness (the ovarian cancer causes oedematous change)
  • Distension
20
Q

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

A
  • Pelvic USS
  • Tumour markers
    - Ca125, CEA, Ca199, Ca153
    - AFP, HCG, LDH (in women <40 years to exclude germ cell tumours of ovary)
  • Bloods: FBC, UsEs, LFTs
  • Imaging: CT chest abdo pelvis for staging/MRI for detail of tumour
  • Special tests: biopsy of omentum and cytology of paracentesis (ascites/pleural effusion for those with advanced disease)
21
Q

How is ovarian cancer managed?

A

If looks resectable on imaging and good performance status
then do SURGERY WITH CHEMO AFTER
-TAH, BSO, omentectomy, +/- lymph node resection

If surgery not appropriate (outside peritoneum e.g. pleural effusion)

  • do biopsy to determine type
  • NEOADJUVANT CHEMO WITH INTERVAL DEBULKING SURGERY
  • 3 cycles chemo> CT to determine if successful>surgery>then 3 more cycles of chemo

Chemotherapy with PLATINUM compounds

-radiotherapy used for palliative only

22
Q

How common are vulval cancers?

Who are they common in?

How do they present?

A

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 (itching or ulcer)
  • groin lump
23
Q

What type of malignancy are vulval cancers usually?

A

They are nearly always squamous cell carcinomas of the vulval skin 90%
-other skin cancers can also occur at vulva e.g. melanoma

24
Q

How should vulval malignancy be managed?

A
  • punch/wedge biopsy
  • MRI scan and MDT discussion
  • treatment based on stage

Surgery

  • Wide local excision
  • Sentinal node biopsy if small unifocal cancer (remove all if cant do)

Radiotherapy
-curative or palliative

Chemo-no real role

25
Q

How may tamoxifen affect breast and endometrial cancer?

A
  • Tamoxifen inhibits oestrogen in breast at all ages

- Tamoxifen however stimulates oestrogen in the endometrium in POST MENOPAUSAL women (increased risk of endo cancer)

26
Q

What is Endometrial hyperplasia?

How is it classified?

What is the pre malignant condition and how is it treated?

A

Abnormally thick endometrium

  • classified as simple vs complex
  • AND with vs without atypia

Complex atypical hyperplasia is the pre malignant condition (up to 40% will have underlying carcinoma

  • Patients should be recommended hysterectomy
  • If patients decline hysterectomy, given progesterone treatment to thin wall (IUS, injections, oral)
27
Q

What are some risk factors for endometrial cancer?

What conditions?

Whats protective?

A

Any factor that increases oestrogen levels

  • OBESITY+++ - aromatase leads to increased levels of oestrogen
  • Menstrual factors: early menarche, late menopause, low parity /nulliparity
  • unopposed oestrogen HRT
  • Diabetes
  • Estrogen secreting tumours
  • Tamoxifen

Conditions

  • -Anovulatory amenorrhoea (PCOS)
  • FH of bowel, breast or endometrial cancer (HNPCC mutation carriers have 60% risk of endo cancer)

Smoking appears to slightly REDUCE the risk
COCP is protective

28
Q

What are the most common types of endometrial cancer?

A

Type 1 cancer (dependent on oestrogen)
-ADENOCARCINOMA - 90%

Type 2 cancer (not oestrogen dependent)

  • Serous papillary
  • Clear cell

Mixed
-Carcinosarcoma

**type 2 and carcinosarcoma are high risk cancers at risk of early mets

29
Q

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

A

POST-MENOPAUSAL BLEEDING

  • this should be at leats 1 year after stopping periods
  • 10% of these will have endo cancer

(Pre-menopausal women might have irregular bleeding, heavy bleeding or IMB) Especially if >40 years

30
Q

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

A
  • Speculum to look or vaginal or cervical sources of the bleeding (can take biopsy/pipelle)
  • Then do a bimanual examination - a fixed bulky and retroverted uterus might suggest endometrial Ca (only in advanced disease)
31
Q

What investigations should be ordered in a woman with suspected endometrial cancer? (think about that clinic)

What do you do once confirmed?

A
  • 2 WEEK WAIT FAST TRACK
  • Urgent TV USS - to look for endometrial thickening (should be <4.5mm in post menopausal age)
  • Urgent hysteroscopy and endometrial biopsy

Once confirmed diagnosis

  • Further scans (MRI for local invasion and CT for met spread especially in the high risk types)
  • MDT meeting
32
Q

What are the treatment options for endometrial cancer?

A

assess if the woman wants further children

  • RADICAL HYSTERECTOMY and BSO possibly with lymph node resection (depending of whether high risk type)
  • EXTERNAL and INTERNAL radiotherapy are used sometimes (adjuvant and palliative)
  • CHEMOTHERAPY (adjuvant and palliative)
  • HORMONES
  • high dose progesterone in young women with low grade early stage who want to preserve fertility)
  • potentially anastrozole
33
Q

What is the most common gynae cancer?

A

Endometrial cancer is the most common gynae cancer

followed by ovarian-which has worse prognosis due to late diagnosis

34
Q

Explain the following tumour markers:
Ca-125
Ca-199

A
  • CA-125 (marker produced when peritoneum is irritated so can be associated with ovarian cancer/ endometriosis / pregnancy or just normal menstruation)
  • CA199 - only produced by mucinous types of cancer
35
Q

What are PARP inhibitors and VEGF inhibitors

A
  • Targeted therapies used for maintenance in ovarian cancer
  • PARP inhibitors: patients with BRCA mutations
  • VEGF inhibitors-in selected patients with stage 4 disease
36
Q

What cancers are likely to metastasis to ovaries?

What cells may be seen in these cancer?

A
  • GI (stomach cancers) often metastasise to ovary

- Krukenberg tumor SIGNET RING CELLS

37
Q

What cancers are affected by COCP?

A

COCP increases risk of cervical and breast cancer

COCP reduces risk of endometrial and ovarian cancer

GOSH (29 decks)

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