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Year 4 GOSH > Gynae Oncology > Flashcards

Gynae Oncology Flashcards

1
Q

Outline the cervical screening programme

A

Woman aged 25ys and older offered smear tests every 3 years up until age 49

Between ages 50 and 64 women are offered a smear test every 5 years

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2
Q

What changes occur in the uterus during puberty?

A

Rising levels of oestrogen at puberty cause a conformational change in the uterus

It starts to evert and the columnar epithelial (internal epithelial) cells become exposed the vaginal cavity

The acid levels cause the columnar epithelium to become squamous epithelium = transitional / transformational zone

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3
Q

What happens when oncogenic factors act on the transofrmational zone?

A

Give rise to pre-cancerous lesions = cervical intraepithelial neoplasia (CIN)

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4
Q

How many types of HPV are there and how many affect the genital tract?

A

> 100 types

40 of these affect the genital tract

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5
Q

Is HPV common?

A

Yes

ALL sexually active women are exposed to HPV and many of them will have HPV present in their genital tract

However, different types of HPV are more oncogenic than others

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6
Q

Which types of HPV cause 70% of cancers?

A

16 and 18

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7
Q

What does a smear test involve?

A

A speculum is inserted into the vagina and the cervix is visualised

A plastic broom is inserted into the external os and is rotated 5 full times clockwise

This swab is then snapped off into the sample pot and sent for liquid cytology

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8
Q

What is assessed in cells obtained from a smear test? (4)

A

Dyskaryosis:

1) Nucleus enlargement
2) Variations in size and shape of nuclei
3) Hyperchromasia (dark staining of nuclei due to inc amount of DNA)
4) Reduction in the amount of cytoplasm

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9
Q

When is a smear test be performed?

A

If +ve for HPV strains

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10
Q

What happens if a woman’s smear test shows moderate or above dyskariosis?

A

Referral for colposcopy - 2wk wait

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11
Q

What is a colposcopy?

A

Smear test will be repeated to get full visualisation of transformation zone of cervix

Cervix stained with 5% acetic acid:
- CIN appears white

Abnormal capillary patterns may be observed

  • Punctuation
  • Mosaicism

Punch biopsies may be taken

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12
Q

How is CIN classified?

A

Histological diagnosis ONLY made on biopsy

CIN1 - lower 1/3rd of epithelium
CIN2 - lower 2/3rds of epithelium
CIN3 - full thickness of epithelium

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13
Q

What is the management of low-grade CIN (CIN1)?

A

60% spontaneously regress

Follow up with colposcopy and cytology 6 months after initial

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14
Q

What is the management of CIN2 and 3?

A

LLETZ - large loop excision of the transformation zone

Under local anaesthetic

Excision up to 10mm deep

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15
Q

What are some advantages of the LLETZ procedure? (3)

A

1) Effective - 95% women have negative smears at 6 months
2) Cost-effective - pt can be treated at first hospital visit
3) Provides a specimen for pathological assessment - 1% of loop biopsies have an unsuspected microscopic cancer

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16
Q

What are some disadvantages of the LLETZ procedure? (3)

A

Potential impact on obstetric outcome

  • Small loops are not likely to affect
  • However if a large part of the cervix is removed it may lead to preterm delivery through cervical weakening
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17
Q

What is the maximum number of LLETZ procedures recommended?

A

3 - then consider hysterectomy

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18
Q

Other than the LLETZ procedure, what are other options for the treatment of CIN?

A

1) Cryotherapy
- Cervix frozen with liquid nitrogen
- Insufficient in high grade
- No specimen

2) Cone biopsy
- Cutting away cervix under GA
- %% can develop cervical stenosis or incompetence which can lead to obstetric complications

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19
Q

What follow up is required for women who undergo treatment for CIN1?

A

Cytology at 6 months

If normal, borderline nuclear change (BNC) or low-grade dyskaryosis = HPV test

If high-grade dyskaryosis = colposcopy

If no treatment - cytology at 12 months +/- colposcopy

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20
Q

What follow up is required for women who undergo treatment for CIN2 or 3?

A

Cytology every 6 months then yearly

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21
Q

What are the most common gynae cancers?

???????????

A

1) Uterine
2) Ovary
3) Cervical

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22
Q

What is the most common cancer in women under 35?

A

Cervical

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23
Q

What age ranges are most affected by cervical cancer?

A

Peaks in 30-39yr group and over 80s

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24
Q

What is the precursor lesion for carcinoma in the cervix?

A

Cervical intraepithelial neoplasia (CIN)

Histological diagnosis that needs persistent infection with HPV to develop

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25
Q

How many oncogenic types of HPV are there?

A

Approx 15

26
Q

What are the most common oncogenic types of HPV?

A

18, 19, 31, 33

27
Q

List some histological types of cervical cancer (7)

A

1) Squamous cell = 85-90%
2) Adenocarcinoma = 10-15%

Also (<1%)

3) Neuroendocrine tumour
4) Clear cell carcinoma
5) Glassy cell carcinoma
6) Sarcoma botryoides
7) Lymphoma

28
Q

What are some risk factors for CIN? (5)

A

1) Persistent HPV infection
2) Multiple partners (inc risk of HPV infection)
3) Smoking
4) Immunocompromised
5) COCP

29
Q

What vaccination is offered to protect from HPV?

A

Gardasil

Protects against types 16 and 18 (80% of cervical cancer cases)

And types 6 and 11 (90% of genital warts cases)

Offered to girls and boys in year 8

30
Q

What are some risk factors for cervical cancer? (4)

A

1) Exposure to HPV
2) COCP and high parity - ?direct hormonal link
3) Smoking - nicotine allows entry of HPV into cells
4) Immunosuppression

31
Q

How may cervical cancer present? (4)

A

Either incidental finding on smear or:

1) PCB, IMB, PMB
2) Persistent, offensive, blood-stained discharge
3) Pain (late disease)
4) Swollen leg (thrombus in pelvis = late disease)

32
Q

How may advanced cervical cancer present? (5)

A

1) Heavy PV bleeding
2) Ureteric obstruction
3) Weight loss
4) Bowel disturbance
5) Fistula - vesicovaginal most common

33
Q

What may be found on examination of cervical cancer?

A

Roughened hard cervix or ulcer

+/- loss of fornices
+/- fixed cervix

34
Q

How may cervical cancer spread? (4)

A

1) Direct
- Locally to parametrium, vagina, bowel and bladder, then to pelvic side wall

2) Lymphatic = early feature to pelvic LN
- Parametrial nodes, internal, external and common iliac nodes, obturator nodes, pre-sacral and para-aortic nodes

3) Ovarian spread rare with squamous

4) Haematological is late
- Liver and lungs

35
Q

What investigations are performed for cervical cancer?

A

1) Colposcopy
2) Histology
3) Bloods - U&Es, LFTs, FBC
4) CXR - staging and pre-op
5) MRI - for staging and examining LN
6) Vaginal and rectal examination - size of lesion and parametrial or rectal invasion

36
Q

What may colposcopy show in cervical cancer?

A

Irregular cervical surface
Abnormal vessels
Dense aceto white changes

37
Q

What histology may be performed in cervical cancer?

A

Punch biopsy
Small loop biopsy at colposcopy

Should not have LLETZ if cancer is suspected as it will bleed lots

38
Q

What examinations may be performed under GA in cervical cancer?

A 
Bimanual vaginal examination
Cystoscopy
Hysteroscopy
Fractional curettage (endocervix and uterine cavity)
PV / PR exam
Sigmoidoscopy
39
Q

How is cervical cancer staged?

A 
0 = Carcinoma in-situ
I = Confined to cervix
II = Disease beyond but not to pelvic wall or lower 1/3rd vagina
III = Disease in pelvic wall or lower 1/3rd vagina
IV = invades bladder, rectum or metastasis
40
Q

What is the management of cervical cancer?

A

Wertheim’s hysterectomy +/- radiotherapy / chemo (if LN involved)

Fertility sparing options include radical trachelectomy, repeated cone biopsies and laparoscopic pelvic node dissections

41
Q

What is a radical trachelectomy?

A

Vaginal procedure which involves removal of the cervix and paracervical tissue at the level of the internal os with the introduction of a cerclage suture

42
Q

What are some risks associated with a radical trachelectomy?

A

Inc risk of PROM, late miscarriage and preterm delivery

43
Q

What are some complications associated with Weirthem’s hysterectomy and lymadenectomy? (7)

A

1) Bleeding
2) Infection
3) DVT / PE
4) Ureteric fistula
5) Bladder dysfunction
6) Lymphoedema
7) Lymphocysts

44
Q

What are some complications associated with radiotherapy for the treatment of cervical cancer?

A

1) Acute bowel and bladder dysfunction - tenesmus, mucositis, bleeding
2) 5% later bowel and bladder dysfunction - ulceration, stricture, bleeding, fistula formation
3) Vaginal stenosis, shortening, dryness

45
Q

What are some complications associated with cone biopsies?

A

Post-op haemorrhage

Preterm labour in subseuqent pregnancies

46
Q

What is the 5 year survival of grades 0-IV of cervical cancer?

A 
0 = 100% 
I = 85%
II = 65%
III = 35%
IV = 7%
47
Q

What follow up is required for those who have received treatment for cervical cancer?

A

Reviewed at 6 weeks post treatment, every 3-4 months for 1-2yrs, annually for 5 years

48
Q

What are some poor prognostic indicators for cervical cancer?

A

1) LN involvement
2) Advanced clinical stage
3) Large primary tumour
4) Poorly differentiated tumour
5) Early recurrence

49
Q

What commonly causes death in cervical cancer?

A

Uraemia due to ureteric obstruction

50
Q

Where does cervical cancer usually recur?

A

Centrally

51
Q

What is the most common gynae cancer?

A

Endometrial

52
Q

Which age group is most affected by endometrial cancer?

A

9 out of 10 cases are in women 50yrs or older

53
Q

What is the pathophysiology of endometrial cancer?

A

Unopposed oestrogen leads to hyperplasia

Hyperplasia predisposes to cytological atypia

Atypical hyperplasia is precancerous and develops into invasive cancer in 10-50% over 20 years

54
Q

What is the histology of endometrial cancer?

A

Adenocarcinoma of columnar epithelial cells:

1) Endometroid adenocarcinoma = 87%
2) Adenosquamous (malignant squamous and glandular tissue) carcinoma = 6%
3) Clear cell or papillary serious carcinoma
4) Mixed mesodermal Mullerian tumours (MMTMT)

NB the latter three have high risk of advanced disease at presentation and recurrence, all GT3

55
Q

How is endometrial cancer graded?

A 
G1 = well differentiated
G2 = moderately differentiated 
G3 = poorly differentiated or high risk cell type
56
Q

How is endometrial cancer staged?

A 
I = confined to uterus
II = spread to cervix
III = spread to vagina, ovaries and / or LN
IV = spread to bladder, rectum, or further organs
57
Q

What is the aetiology of endometrial cancer?

A

Presence of unopposed oestrogen

Either endogenous or exogenous

58
Q

What can lead to increased endogenous oestrogen? (3)

A

1) Peripheral conversion in adipose tissue of androstenedione to oestrone
2) Oestrogen-producing tumour eg granulosa cell tumour
3) PCOS or anovulatory cycles at menarche or during climacteric period (lack of progesterone as no luteal phase)

59
Q

What can lead to increased exogenous oestrogen? (2)

A

1) Oestrogen only HRT

2) Tamoxifen - oestrogen agonist in the endometrial tissue

60
Q

What are some risk factors for endometrial cancer?

A

1) Inc endogenous / exogenous estrogen

2) Decreased endogenous progesterone:
- Nulliparity = pregnancy associated with increased progesterone levels
- PCOS = anovulatory cycle, no corpus luteum means no progesterone
- Early menarche / late menopause

3) Genetic predisposition
- HNPCC (Lynch II syndrome)

4) Breast cancer
- Shared lifestyle risk factors and tamoxifen usage

61
Q

What is HNPCC (Lynch II syndrome) associated with?

A

Inherited autosomal domina

High risk of colorectal, endometrial and ovarian tumours

40-60% endometrial cancer lifetime risk

Year 4 GOSH (16 decks)

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