Gynae-oncology Flashcards
Symptoms of ovarian cancer?
Often vague symptoms, misdiagnosed as IBS
75% present at stage III
Bloating Abdominal or pelvic pain Vaginal bleeding Palpable mass Urinary symptoms - frequency or urgency Change in bowel habit
Unexplained weight loss, loss of appetite, early satiety
Fatigue
Hip or groin pain (obturator nerve)
Investigations for ovarian cancer
FBC, U&E, LFTS
CA125 (raised in 80% of epithelial cancers) normal = <35
TVS
CXR
CT TAP
Ascites or pleural effusion can be sampled and sent to cytology
Worrying finding on USS
Cysts
- large, bilateral, appear “complex” (both have solid and cystic areas)
What is risk of malignancy index?
RMI = U x M x CA125 - High risk = >200
U (0-3) point for multilocular cysts, solid areas, metastases, ascites, bilateral lesions
M - 1=pre-menopausal 3=OST menopausal
CA125
Types of ovarian cancer
High grade serous (85%)
Endometrioid (15%)
Low grade, clear cell, mucinous (<1%)
When is chemo given?
Recommended for everyone following surgery, unless low grade or stage 1a or 1b
Platinum agents used - carboplatin with paclitaxel
Types of cervical cancer
80% squamous cell carcinoma
Adenocarcinoma next most common
(Small cell carcinoma)
What cancers is HPV associated with?
Primarily cervical
Also:
anal, vulval, vaginal, penis, mouth and throat
Which strains of HPV are asociated with cervical cancer?
Type 16 and 18
Responsible for 70% of cervical cancer
(6 and 11 cause genital warts)
How does HPV cause cervical cancer?
Inhibits tumour suppressor genes
E6 inhibits P53
E7 inhibits pRb
What are the RF for cervical cancers
Increased risk of catching HPV
Later detection of precancerous and cancerous changes (non-engagement with screening) - missing smears
Increased risk of catching HPV (4)
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
Other risk factors for cervical cancer excluding HPV and screening?
Smoking
HIV (patients with HIV are offered yearly smear tests)
Combined contraceptive pill use for more than five years
Increased number of full-term pregnancies
Exposure to diethylstilbestrol during fetal development
How does cervical cancer present?
Cervical cancer may be detected during cervical smears in otherwise asymptomatic women
Bleeding (intermenstrual, postcoital or post-menopausal bleeding)
Discharge
Pelvic pain
Dyspareunia (pain or discomfort with sex)
Ulceration
Inflammation
Visible tumour
Cervical Intraepithelial Neoplasia
grading system for level of dysplasia
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer,
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ
Who is involved in the cervical screening programmes?
25 – 49 Every 3 years
50 – 64 Every 5 years
HIV - screened annually
65+ may request a smear if they have not had one since aged 50
Previous CIN may require additional tests (e.g. test of cure after treatment)
Immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
Pregnant women should wait until 12 weeks post-partum
What is colposcopy?
Insertion of a speculum and using equipment (a colposcope) to magnify the cervix
Acetic acid causes abnormal cells to appear white
Schiller’s iodine test - turns healthy cells brown
Management of cervical cancer
Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A: Chemotherapy and radiotherapy
Stage 4B: Combination of surgery, radiotherapy, chemotherapy and palliative care
Types of endometrial cancer
80% adenocarcinoma
Risk factors for endometrial cancer
Based on exposure to UNOPPOSED OESTROGEN:
Increased age Earlier onset of menstruation Late menopause Oestrogen only hormone replacement therapy No or fewer pregnancies Obesity Polycystic ovarian syndrome Tamoxifen
What do women with PCOS need to take for endometrial protection?
Should have one of:
The combined contraceptive pill
An intrauterine system (e.g. Mirena coil)
Cyclical progestogens to induce a withdrawal bleed
Why is obesity a crucial risk factor in endometrial cancer?
Adipose tissue produces aromatase
Aromatase converts androgens into oestrogen
Risk factors in endometrial cancer not relating to unopposed oestrogen
T2DM - increased prod. of insulin increases risk of hyperplasia
HNPCC (Lynch syndrome)
What are protective factors for endometrial cancer?
Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking
