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
How may tamoxifen affect breast and endometrial cancer?
- Tamoxifen inhibits oestrogen in breast at all ages
- Tamoxifen however stimulates oestrogen in the endometrium in POST MENOPAUSAL women (increased risk of endo cancer)
What is Endometrial hyperplasia?
How is it classified?
What is the pre malignant condition and how is it treated?
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)
What are some risk factors for endometrial cancer?
What conditions?
Whats protective?
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
What are the most common types of endometrial cancer?
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
What is the most common way for endometrial cancers to present?
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
What examinations should be done in a woman with suspected endometrial cancer?
- 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)
What investigations should be ordered in a woman with suspected endometrial cancer? (think about that clinic)
What do you do once confirmed?
- 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
What are the treatment options for endometrial cancer?
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
What is the most common gynae cancer?
Endometrial cancer is the most common gynae cancer
followed by ovarian-which has worse prognosis due to late diagnosis
Explain the following tumour markers:
Ca-125
Ca-199
- 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
What are PARP inhibitors and VEGF inhibitors
- Targeted therapies used for maintenance in ovarian cancer
- PARP inhibitors: patients with BRCA mutations
- VEGF inhibitors-in selected patients with stage 4 disease
What cancers are likely to metastasis to ovaries?
What cells may be seen in these cancer?
- GI (stomach cancers) often metastasise to ovary
- Krukenberg tumor SIGNET RING CELLS
What cancers are affected by COCP?
COCP increases risk of cervical and breast cancer
COCP reduces risk of endometrial and ovarian cancer
