Gynae Oncology Flashcards
What is the cervical screening program?
SMEAR INVITATION Every 3 years between the ages of 25-49
then every 5 years between the ages of 50 and 64
What is the ectocervix
What is the endocervix?
What is the transformation zone? How does it form?
How does it relate to cancer?
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
Which HPV strains confer the highest risk?
What strains are vaccinated against? Who is vaccinated?
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
What are the results of cervical smear and what should the next stage of treatment be?
first it tests for HPV
- if negative, no further tests
- if positive, do cytology
- if cytology is -ve do repeat smear in 12 months
- if cytology is abnormal do colposcopy
How might cervical cancer present symptomatically?
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
Where is cervical cancer most likely to metastasise to?
Vagina, bladder and bowel
Nodes: parametrical, iliac, obturator and pre-sacral
Blood: liver and lungs
What are some risk factors for cervical cancer?
HPV +++
Smoking
High parity
Herpes
Examination for suspected cervical cancer?
Investigations?
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)
What does a colposcopy involve?
- Examine cervix with bright light and magnification
- biopsy
What is the treatment for cervical cancer?
- 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
What is fertility sparing treatment?
Who would this be given to ?
Radical trachelectomy (uterus anastomosed with vagina)
Option for women who:
- under age of 40
- wish to preserve fertility
- have tumours <2cm in size
What is Cervical Intraepithelial Neoplasia (CIN)?
- CIN is a precancerous condition with abnormal cells on cervix
- if it breaks through the basement membrane it is invasive cancer
What is the treatment of CIN (1,2,3, and CGIN)
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
What are some risk factors for ovarian cancer?
Protective factors?
More ovulation!!!
- early periods
- no children (nulliparity)
- HRT containing oestrogen only
- Endometriosis (chronic inflammatory)
- BRCA1 and BRCA2
PROTECTIVE: parity/children, breastfeeding and COCP
How do we calculate how likely a woman is to have an ovarian malignancy?
RISK OF MALIGNANCY INDEX (RMI) … it takes into account three factors:
- Ca125
- Whether or not they have been through the menopause
- Findings on USS
What are the three most common types of ovarian cancer?
Epithelial (most common) SEROUS ADENOCARCINOMA
Germ cells (actual ovum producing cells)
Sex cord stromal tumours
What is another name for sex-cord stromal tumours of the ovary?
Sertoli-Leydig tumours
How does ovarian cancer present?
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
What might you find on examination in a patient with ovarian cancer?
- 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
What investigations should be done in a patient with suspected ovarian cancer?
- 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)
How is ovarian cancer managed?
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
How common are vulval cancers?
Who are they common in?
How do they present?
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
What type of malignancy are vulval cancers usually?
They are nearly always squamous cell carcinomas of the vulval skin 90%
-other skin cancers can also occur at vulva e.g. melanoma
How should vulval malignancy be managed?
- 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
