Gynae Oncology Flashcards
Outline the cervical screening programme
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
What changes occur in the uterus during puberty?
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
What happens when oncogenic factors act on the transofrmational zone?
Give rise to pre-cancerous lesions = cervical intraepithelial neoplasia (CIN)
How many types of HPV are there and how many affect the genital tract?
> 100 types
40 of these affect the genital tract
Is HPV common?
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
Which types of HPV cause 70% of cancers?
16 and 18
What does a smear test involve?
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
What is assessed in cells obtained from a smear test? (4)
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
When is a smear test be performed?
If +ve for HPV strains
What happens if a woman’s smear test shows moderate or above dyskariosis?
Referral for colposcopy - 2wk wait
What is a colposcopy?
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
How is CIN classified?
Histological diagnosis ONLY made on biopsy
CIN1 - lower 1/3rd of epithelium
CIN2 - lower 2/3rds of epithelium
CIN3 - full thickness of epithelium
What is the management of low-grade CIN (CIN1)?
60% spontaneously regress
Follow up with colposcopy and cytology 6 months after initial
What is the management of CIN2 and 3?
LLETZ - large loop excision of the transformation zone
Under local anaesthetic
Excision up to 10mm deep
What are some advantages of the LLETZ procedure? (3)
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
What are some disadvantages of the LLETZ procedure? (3)
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
What is the maximum number of LLETZ procedures recommended?
3 - then consider hysterectomy
Other than the LLETZ procedure, what are other options for the treatment of CIN?
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
What follow up is required for women who undergo treatment for CIN1?
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
What follow up is required for women who undergo treatment for CIN2 or 3?
Cytology every 6 months then yearly
What are the most common gynae cancers?
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1) Uterine
2) Ovary
3) Cervical
What is the most common cancer in women under 35?
Cervical
What age ranges are most affected by cervical cancer?
Peaks in 30-39yr group and over 80s
What is the precursor lesion for carcinoma in the cervix?
Cervical intraepithelial neoplasia (CIN)
Histological diagnosis that needs persistent infection with HPV to develop
How many oncogenic types of HPV are there?
Approx 15
What are the most common oncogenic types of HPV?
18, 19, 31, 33
List some histological types of cervical cancer (7)
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
What are some risk factors for CIN? (5)
1) Persistent HPV infection
2) Multiple partners (inc risk of HPV infection)
3) Smoking
4) Immunocompromised
5) COCP
What vaccination is offered to protect from HPV?
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
What are some risk factors for cervical cancer? (4)
1) Exposure to HPV
2) COCP and high parity - ?direct hormonal link
3) Smoking - nicotine allows entry of HPV into cells
4) Immunosuppression
How may cervical cancer present? (4)
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)
How may advanced cervical cancer present? (5)
1) Heavy PV bleeding
2) Ureteric obstruction
3) Weight loss
4) Bowel disturbance
5) Fistula - vesicovaginal most common
What may be found on examination of cervical cancer?
Roughened hard cervix or ulcer
+/- loss of fornices
+/- fixed cervix
How may cervical cancer spread? (4)
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
What investigations are performed for cervical cancer?
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
What may colposcopy show in cervical cancer?
Irregular cervical surface
Abnormal vessels
Dense aceto white changes
What histology may be performed in cervical cancer?
Punch biopsy
Small loop biopsy at colposcopy
Should not have LLETZ if cancer is suspected as it will bleed lots
What examinations may be performed under GA in cervical cancer?
Bimanual vaginal examination Cystoscopy Hysteroscopy Fractional curettage (endocervix and uterine cavity) PV / PR exam Sigmoidoscopy
How is cervical cancer staged?
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
What is the management of cervical cancer?
Wertheim’s hysterectomy +/- radiotherapy / chemo (if LN involved)
Fertility sparing options include radical trachelectomy, repeated cone biopsies and laparoscopic pelvic node dissections
What is a radical trachelectomy?
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
What are some risks associated with a radical trachelectomy?
Inc risk of PROM, late miscarriage and preterm delivery
What are some complications associated with Weirthem’s hysterectomy and lymadenectomy? (7)
1) Bleeding
2) Infection
3) DVT / PE
4) Ureteric fistula
5) Bladder dysfunction
6) Lymphoedema
7) Lymphocysts
What are some complications associated with radiotherapy for the treatment of cervical cancer?
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
What are some complications associated with cone biopsies?
Post-op haemorrhage
Preterm labour in subseuqent pregnancies
What is the 5 year survival of grades 0-IV of cervical cancer?
0 = 100% I = 85% II = 65% III = 35% IV = 7%
What follow up is required for those who have received treatment for cervical cancer?
Reviewed at 6 weeks post treatment, every 3-4 months for 1-2yrs, annually for 5 years
What are some poor prognostic indicators for cervical cancer?
1) LN involvement
2) Advanced clinical stage
3) Large primary tumour
4) Poorly differentiated tumour
5) Early recurrence
What commonly causes death in cervical cancer?
Uraemia due to ureteric obstruction
Where does cervical cancer usually recur?
Centrally
What is the most common gynae cancer?
Endometrial
Which age group is most affected by endometrial cancer?
9 out of 10 cases are in women 50yrs or older
What is the pathophysiology of endometrial cancer?
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
What is the histology of endometrial cancer?
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
How is endometrial cancer graded?
G1 = well differentiated G2 = moderately differentiated G3 = poorly differentiated or high risk cell type
How is endometrial cancer staged?
I = confined to uterus II = spread to cervix III = spread to vagina, ovaries and / or LN IV = spread to bladder, rectum, or further organs
What is the aetiology of endometrial cancer?
Presence of unopposed oestrogen
Either endogenous or exogenous
What can lead to increased endogenous oestrogen? (3)
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)
What can lead to increased exogenous oestrogen? (2)
1) Oestrogen only HRT
2) Tamoxifen - oestrogen agonist in the endometrial tissue
What are some risk factors for endometrial cancer?
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
What is HNPCC (Lynch II syndrome) associated with?
Inherited autosomal domina
High risk of colorectal, endometrial and ovarian tumours
40-60% endometrial cancer lifetime risk
