Gynae Oncology Flashcards
What is an ovarian cyst?
Fl filled sac in ovary
What are physiological cysts?
Cysts that predominate through menstrual cycle
What are the 2 general rules with ovarian cysts?
Do not raise concern unless symptomatic
Resolution should be confirmed by scanning 12 weeks later
What is the RMI
Risk Malignancy Index
Tool used to determine likelihood of a mass related to malignancy
What is a simple ovarian cyst?
One that contains fl only
What is a complex ovarian cyst?
Can be irregular and can contain solid material, blood or have septations or vascularity
Functional non-neoplastic ovarian cysts (2)
Follicular
Corpus Luteal cysts
How big is a ovarian follicular cyst
<3cm
What does an ovarian follicular cyst represent?
Developing follicle in 1st 1/2 menstrual cycle
How big is a corpus luteal cyst?
<5cm
When does a corpus luteal cyst occur?
In luteal phase of menstrual cycle after formation of corpus luteum
What are pathological ovarian cysts? (3)
Endometrioma
Polycystic ovaries
Theca lutein cyst
Another name for endometrioma
Chocolate cysts
Who gets endometriomas
Those with endometriosis
What is an endometrioma?
Bleeding into cyst
What are theca lutein cysts a consequence of?
raised hCG
When should theca lutein cysts resolve?
Upon resolution hCG levels
E.g.s of epithelial ovarian tumours (3)
Serous cystadenoma
Mucinous cystadenoma
Brenner tumour
Which is the most common type of malignant ovarian tumour?
Serous cystadenoma
What % serous cystadenoma are bilateral?
30%
Are mucinous cystadenomas usually unilateral or bilateral?
unilateral
Are mucinous cystadenomas usually unilocular or multiloculated?
Multiloculated
Are Brenner tumours usually uni or bilateral?
Unilateral
Brenner tumour - appearance
Solid grey/yellow
Which ovarian tumours contain teeth, hair, skin and bone?
Mature cystic teratoma (dermoid cysts)
Who do dermoid cysts occur in?
young pregnant women
What percentage dermoid cysts are bilateral?
10%
What is the most common type of ovarian stromal tumours?
Sex-cord tumours/fibromas
What are sex-cord tumours associated with?
Ascites/pleural effusion
How to investigate and manage pre-menopausal women (<40) for ovarian cysts
If simple cyst on USS - No CA125
LDH, aFP, hCG
Rescan in 6w
If persistent or >5cm - consider laparoscopic cystectomy or oophorectomy
Managing ovarian cysts in post-menopausal women - low RMI
Follow up in 1yr w/ USS + CA125 if <5cm
Managing ovarian cysts in post-menopausal women - moderate RMI
Bilateral oophorectomy
Managing ovarian cysts in post-menopausal women - High RMI
Refer for staging laparotomy
What type of ovarian cancer do post-menopausal women get?
Epithelial cell carcinoma
What type of ovarian cancer do pre-menopausal women get?
Germ cell tumours
Risk factors ovarian cancers
Incr ovulations: early menarche, late menpause, nulliparity
Familial - BRCA1/2, HNPCC
Protective factors against ovarian cancer (2)
Pregnancy + lactation
OCP
Is there a screening program for ovarian cancer in the UK?
No
How does ovarian cancer present early on?
Asymptomatic
S+S ovarian cancer
persistent bloating
Early satiety +/- loss appetite
Pelvic + abdo pain
Others - incr urgency/freq, vaginal bleeding
What could you find in a woman with ovarian cancer on examination?
Cahexia
Abdo pelvic mass
Ascites
Br tenderness
What does an ovarian adenocarcinoma spread?
Transcoloemic spread (directly into abdo + pelvis)
Stage 1a ovarian Ca
One ovary is affected, capsule intact
Stage 1b ovarian Ca
Both ovaries are affected, capsule is intact
Stage 1c ovarian Ca
One/both ovaries = affected, + capsule is not intact, or malignant cells in abdo cavity (ascites)
Stage 2 ovarian Ca
Disease is beyond the ovaries but confined to pelvis
Stage 3 ovarian Ca
Disease is beyond the pelvis but confined to the abdomen
In stage 3 ovarian Ca, which 3 structures are frequently involved?
Omentum
Small bowel
Peritoneum
Stage 4 ovarian Ca
Disease beyond abdomen
Investigations from ovarian cancer in primary care
CA-125 levels
Who in primary care gets their CA-125 levels tested?
Women >50y/o
Abdo Sx
If a patients CA-125 levels are >35 - what is the next step?
USS abdo + pelvis
How is RMI calculated?
U x M x CA125
U = USS score
M = Menopause index
What is used for staging of ovarian cancer?
CT pelvis and abdo
Ovarian Ca - if unfit for surgery, what Mx should be offered?
Palliative care
What surgical technique should be used to assess the level of spread of ovarian cancer?
Midline laparotomy
Surgical Management ovarian Ca
Total hysterectomy, bilateral oopherectomy + partial omentectomy
Biopsy of peritoneum in ovarian cancer: Mx of stage 1
Retroperitoneal LN biopsy
Biopsy of peritoneum in ovarian cancer: Mx of stage s+
Retroperitoneal LN removal
Chemotherapy - stage 1a/b ovarian Ca
No chemo!
Chemo - stage 1c ovarian Ca
6xyxles of carboplatin
Chemo - stage 2-4 ovarian Ca
Carbplatin +/- paclitaxel
Poor prognosis ovarian Ca (3)
Advanced stage
Poorly differentiated
Slow response to chemo
Follow up ovarian Ca
Continue to monitor CA125 CT scanning (detect residual disease or relapse)
Mx - heavy vaginal bleeding in ovarian Ca
High dose progestogens
Radiotherapy
Mx - ascites ovarian Ca
Drainage + dexamethasone
Mx - partial bowel obstruction ovarian Ca
Metoclopramide/enema
Mx - complete bowel obstruction ovarian Ca
Cyclizine
How should the last 24hours in ovarian cancer before death be Mx
Anxiolytics + analgesics
Which HPV are associated with cervical cancer
16 + 18
RF HPV/Cervical cancer (9)
Starting sex @ younger age Multiple sexual partners HIV Herpes Smoking <20 y/o COCP Low SE Exposure to DES
Timing smears <50 y/o
3 yearly
Timing smears >50
5 yearly
Where in the cervix does cancer tend to develop?
Squamocolumnar junction
What are the 2 premalignant cells of cervical cancer
CIN - Cervical intraepithelial neoplasia
CGIN - cervical glandular intraepithelial neoplasia
What does CIN transform into?
Squamous cell carcinoma
What does CGIN transport into?
Adenocarcinoma
Features of cervical dyskaryosis (4)
Disproportionate nuclear enlargement
Hyperchromasia
Mutlinucleation
Irregular chromatid distribution
When performing a colposcopy, what features are you looking for in cervical cancer?
Mosaicism
Punctuations
What is used to stain abnormal cells in colposcopy?
Acetic acid
Sx cervical cancer (5)
IMB Post-coital bleeding Pain Dysuria Abnormal smear
Stage 1 Cervical cancer
Microscopic <4cm
Stage 2 Cervical cancer
Parametrium - tissues outside uterus, around uterus
Stage 3 Cervical cancer
Pelvic side walsl
Stage 4 Cervical cancer
Distant Mets
Ix Cervical cancer
Cone biopsy
CHX
IVU
Cystoscopy + sigmoidoscopy
Tx stage 1 cerivcal cancer
LLETZ/radical hysterectomy
Tx stage 2 cervical cancer
Radical hysterectomy/chemoradiotherapy
Tx stage 3 cervical cancer
Chemoradiotherapy
Tx stage 4 cervical cancer
Chemoradiotherapy
5 year prognosis - stage 1 cervical cancer
80-93%
5 year prognosis - stage 4 cervical cancer
5-16%
Why has the incidence of endometrial cancer increased?
Increased obesity
Peak incidence endometrial cancer
60-75 y/o
What is the most common type of endometrial cancer?
Adenocarcinoma
Why does endometrial cancer occur
Unopposed oestrogen
What are the 4 stages of endometrial cancer
1 - Simple hyperplasia
2 - complex hyperplasia
3 - complex hyperplasia
4 - Adenocarcinoma
4 stages of endometrial cancer
1) Simple hyperplasia
2) Complex hyperplasia
3) Complex hyperplasia w/ atypia
4) Adenocarcinoma
RF Endometrial cancer (10)
Early menarche/late menopause Low parity PCOS HRT (O only) Tamoxifen use DM Age Obesity FHx HNPCC HTN
Features endometrial Ca (4)
PMB
Clear/white vaginal discharge
Abnorm cervical smears
Advanced? W loss/ abdo pain
What is the grading system used for endometrial cancer?
FIGO
Low FIGO endometrial cancer
I - endometrium only
High FIGO endometrial cancer
II - Myometrium
III - Other pelvic structures
IV - Distant mets
O/E endometrial Ca
Abdo/pelvic mass
Vulval/vag atrophy. cervical lesions
DDx endometrial Ca (6)
Vulval atrophy Vulval pre-malig/malig conditions Cervical polyps Cervical Ca Endometrial polyps Endometrial atrophy
Ix Endometrial Ca (3)
Pippelle biopsy
Pelvic USS
Hysteroscopy
Features of endometrial Ca on USS
> 4mm endometrial thickness
Endometrium = white glow
Tx Simple endometrial hyperplasia
W+W
Lose some weight
Tx Complex endometrial hyperplasia
W+W
Lose some weight
Mirena coil
Tx Complex endometrial hyperplasia + atypia
TAH
Tx endometrial adenocarcinoma
TAH