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Obs & Gynae > Gynae Oncology, Screening and Surgery > Flashcards

Gynae Oncology, Screening and Surgery Flashcards

1
Q

Endometrial cancer (most common gynae cancer) has highest prevalence ~___yrs

  • name 4 RFs, one is Lynch Syndrome type II
  • NB: COCP and pregnancy are protective
A
  • ~60yrs
  • RF: exposure to endogenous/exogenous oestrogens therefore:
  • obesity
  • diabetes (probably due to higher BMI)
  • early menarche
  • nulliparity
  • late onset menopause
  • older age
  • unopposed oestrogen
  • use of tamoxifen (E2 antagonist in breast, but E2 agonist in uterus)
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2
Q

Endometrial cancer is split into type 1 (more common) and type 2.
Give 2 features of each:

A
  • type 1: low-grade, E2-sensitive, associated w obesity, less aggressive, usually has atypia as precursor
  • type 2: high grade endometriod, clear cell, serous or carcinosarcoma, more aggressive, not E2 sensitive, not related to obesity
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3
Q

Suggest 2 ways endometrial cancer may present?

A
  • postmenopausal bleeding (PMB)

- if premenopausal, bleeding may be irregular or have IMB (intermenstrual bleeding), menorrhagia

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4
Q

Unless the pt is unfit or has metastasised endometrial cancer, what is the surgery of choice?

A

-a total laparoscopic hysterectomy and BSO (bilateral salpingo-oophorectomy)

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5
Q

Uterine sarcomas are v rare. What type aka malignant fibroids present with rapid, painful uterine enlargeement?
NB: rx is hysterectomy +/- chemoradiotherapy, prognosis is poor

A

-Leiomyosarcomas

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6
Q

Endometrial stromal tumours involve a range of histological types from benign nodules to stromal malignant sarcomas.
They are most common in women at what reproductive stage of life?

A

Peri-menopausal

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7
Q

What epithelium lines the endocervix? And the ectocervix which is continuous with the vagina is lined with ____ epithelium, hence where the 2 types meet is referred to as what?

A
  • columnar glandular epithelium (endocervix)
  • squamous epithelium (ectocervix)
  • squamocolumnar junction
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8
Q

What are cervical ectropions?
NB: normal finding in pregnant women or those taking the pill
NB: usually asymptomatic but can cause post-coital bleeding or discharge

A

-when the columnar epithelium of endocervix is visible as a red area around the os, due to eversion

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9
Q

Ectropions can be treated with cryotherapy, but what investigations must be done first to rule out____

A

-a smear and colposcopy done to exclude carcinoma

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10
Q

Define cervical intraepithelial neoplasia (CIN) aka cervical dysplasia

A
  • -presence of atypical cells within the squamous epithelium
  • these cells are dyskaryotic: larger nuclei and undergo frequent mitoses
  • CIN is graded from I to III based on extent of dysplasia hence is a histological diagnosis
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11
Q

If atypical cells are found in the lower third of the epithelium only, what grade of CIN is this?

A

-Grade 1

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12
Q

What is Grade II CIN:

A

-atypical cells in the lower 2/3rds of the epithelium

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13
Q

What is grade III CIN:

-what is different between this and malignancy?

A

-atypical cells occupy full thickness of epithelium, = carcinoma in situ (cells as like malignancy but no invasion through basement membrane)

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14
Q

Roughly what age group is most affected by CIN?

A

-90% those under 45yrs, most common in 25-30yrs

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15
Q

CIN is almost never seen in virgins, what is the most important RF for the development of CIN?
NB: COCP and smoking increase risk slightly too

A
  • HPV, number of sexual contacts

- types 16, 18, 31 and 33 most associated with malignancy

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16
Q

Cervical Smear Screening:
25-49yrs how often are smears?
-50-64yrs?
-65+ if normal, no screening

A

-25-49yrs: repeated every 3 years

50-64yrs: repeated every 5 years

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17
Q

If at screening, HR-HPV is detected, the cells are sent for cytology.

  • if cytology is normal when is the next screening
  • if cytology is abnormal what happens next?
A
  • normal cytology, repeat in 1 year

- abnormal, refer for colposcopy

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18
Q

If at screening, HR-HPV is detected, the cells are sent for cytology. if cytology is normal the next screening is in 12 months. If at 12 months, they are HR-HPV negative, when is the next screening?

A

-return to normal recall so every 3yrs if 25-49 or every 5yrs if 50-65yrs

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19
Q

If at screening, HR-HPV is detected, the cells are sent for cytology. if cytology is normal the next screening is in 12 months. If at 12 months, they remain HR-HPV positive, when is the next screening?

A

Repeat in 1 year

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20
Q

What happens if:

  • at screening, HR-HPV is detected, the cells are sent for cytology. if cytology is normal the next screening is in 12 months.
  • If at 12 months, they remain HR-HPV positive, so the screening is repeated in 12 months
  • they remain HR-HPV positive with normal cytology
  • _________
A

-referral to colposcopy (strike III -> refer)

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21
Q

What acidic is used at colposcopy to stain the cervix and visualise CIN

A

-acetic acid 5%

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22
Q

The treatment for cervical cancer is LLETZ (large loop excision of transformation zone), what is a pregnancy-related complication of this procedure?
NB: the risk increases in proportion to the depth of excision

A

-risk of preterm delivery

NB: a cervical suture can be inserted to help prevent this in some cases

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23
Q

90% of cervical malignancies are carcinomas of which epithelium?

A

-squamous cell carcinoma

24
Q

Suggest 2 features in a history that may suggest cervical cancer?

A
  • post-coital bleeding
  • offensive vaginal discharge
  • IMB or post-menopaausal bleeding
25
Q

Suggest 3 ix to stage cervical cancer
-clue: consider how the size of lesion may be assessed, rectal invasion, bladder involvement, tumour size/spread and LN involvement

A
  • vaginal and rectal examination
  • examination under anaesthesia (EUA - unless lesion is v small)
  • cystoscopy
  • MRI
26
Q

Lesions of cervical cancer confined to the cervix (stage 1a(i) can be treated with ____ biopsy

A

-cone biopsy

27
Q

In other stages of cervical cancer, suggest 2 treatment options:

A
  • surgery: radical hysterectomy, radical trachelectomy removing 80% cervix + upper vagina
  • chemo-radiotherapy
  • if stage 3 or worse need radiotherapy + chemotherapy
28
Q

Death in cervical cancer is commonly from u____ due to ______ ob______

A

-uraemia due to ureteric obstruction

29
Q

What type of carcinoma is the most common malignant ovarian neoplasm?

A

-Adenocarcinoma

30
Q

What is the general prognosis of clear cell carcinoma ovarian malignancy?

A

-Poor

31
Q

Sex cord tumours
-Granulosa cell tumours = malignant but slow growing, rare, usually affect what age? They secrete high levels of oestrogens and _____, stimulation of the endometrium can cause what sx?
Serum ““___ levels are used a tumour marker to monitor for recurrence

A
  • post-menopausal women
  • inhibin
  • sx: bleeding, endometrial hyperplasia, endometrial malignancy (young girls –> precocious puberty)
  • serum inhibin
32
Q

Fibromas are rare and benign, they can cause Meig’s syndrome where ascites +/- a right benign ___ ____ is found in conjunction with the small ovarian mass, resolves on removal of mass

A

-pleural effusion

33
Q

Ovary is a common site for metastases esp. from breast and ___ (if from here are called ‘Krukenberg” tumours”)

  • a few contain ‘signet ring’ cells
  • prognosis = poor
A

gut

34
Q

What effect does COCP have on the development of ovarian cancer?

A

-reduces risk of ovarian cancer

35
Q

RFs for ovarian cancer relate to the # of ovulations, more = increased risk.
Therefore give 2 RFs
and 2 protective factors:

A
  • RFs: early menarche, late menopause, nulliparity

- protective: pregnancy, lactation, use of COCP

36
Q

Suggest 2 different gene mutations that may have a role in familial ovarian carcinoma?

A
  • BRCA 1 and BRCA 2

- HPNCC mutations (Lynch syndrome)

37
Q

Why is ovarian cancer prognosis poor?

A

-asymptomatic mostly until late stages
-so presents late
(70% present with stage 3-4 disease - LN affected or mets)

38
Q

suggest 2 sx that may be warning signs of ovarian cancer:

A
  • persistent bloating
  • felling full early (satiety)
  • loss of appetite
  • -pelvic/abdo pain
  • increased urinary urgency/frequency
39
Q

What disease may ovarian cancer presenting sx mimic? However as it is uncommon to present for the first time in older women, ovarian cancer should be excluded before diagnosing it

A

-IBS

40
Q

Ovarian adenocarcinoma spreads by transcoelomic spread, what does this mean?

A

-spreads directly within the pelvis and abdo

41
Q

In an older women presenting with sx suspicious of ovarian cancer

  • what blood test is done
  • if these results show level raised >35 IU, what is the next ix carried out?
  • if this shows ascites/abdo mass, urgent referral to 2dry care
A
  • CA 125 levels

- US of abdo/pelvis

42
Q

In women <40yrs, as well as CA 125, what other serum levels are measured to identify women with germ cell tumours rather than epithelial ovarian tumours:

A
  • alpha fetoprotein (AFP)

- hCG

43
Q

RMI = Risk Malignancy Index for ovarian cancer is calculated from:
U - _____
M - ______
CA 125 level

U x M x CA 125
if >250 referred to MDT

A 
U = ultrasound scan score (0-3 pts)
M = menopausal status (1 if pre, 3 if post)
44
Q

Suggest 2 things involved in the ultrasound scan for ovarian cancer, in the RMI each finding is 1 point

A
  • multilocular cysts
  • solid areas
  • metastases
  • ascites
  • bilateral lesions
45
Q

What surgery is done for ovarian cancer

A
  • midline laparotomy for thorough abdo/pelvis assessment
  • total hysterectomy, BSO and partial omentectomy
    • biopsies of any peritoneal deposits and random biopsies of the peritoneum and LNs
  • ultraradical surgery may include bowel resection, splenectomy and peritoneal stripping
46
Q

Chemotherapy for ovarian cancer:

Stage 2-4 ovarian cancer Ci___ alone or in combo with pacl____ is used

A

-cisplatin +/- paclitaxel

47
Q

Death from ovarian cancer is usually due to bowel _____ or _____

A

-obstruction or perforation

48
Q

<40yrs: most common ovarian cysts are: f_____ cyst, d____ cyst and e____ioma
>40yrs: most common are epithelial cysts known as c______

A

<40yrs: functional cyst, dermoid cyst, endometrioma

>40yrs: cystadenomas

49
Q

Bearing in mind, most common cyst in >40yrs: is cystadenomas, although malignancy uncommon, but if present most likely form will be: ______

A

cystadenocarcinoma

50
Q

Name a worrying symptoms in a post-menopausal woman that would raise the suspicion of ovarian cancer:

A

-persistent bloating/swelling (>3weeeks at a time)
-change in bowel habit
(so 2 week wait referral to rule out cancer)

51
Q

Most common cysts:
<40yrs: functional cyst, dermoid cyst, endometrioma
How to differentiate?

A

-TVUS
functional cyst: anechoic, thin lining, fluid filled
-dermoid cyst: obvious findings of abnormal contents, acoustic shadowing
-endometrioma: uniform ground glass appearance, chocolate cyst

52
Q

Ovarian cyst accidents (sudden onset pain), you should take a menstrual cycle history and ask re: contraception and chance of pregnancy.
At what time in the cycle do ovarian cyst accidents most commonly occur?

A

luteal phase

53
Q

What 3 ovarian cyst accidents can happen?

A
  • Rupture (luteal phase)
  • Haemorrhage into cyst (luteal phase)
  • Torsion of Cyst (sudden onset, no obvious cyclical pattern)
54
Q

How will a haemorrhage into an ovarian cyst appear on US?

A
  • still intact cyst

- spiderweb pattern of fresh blood in the cyst

55
Q

How will a ruptured cyst appear on US?

A
  • absent (as cyst has ruptured)
  • hemoperitoneum
  • tender, bleeding in abdomen irritates but is self-limiting
56
Q

Ovarian cyst torsion presentation:

A
  • nausea and vomiting (ischaemic pain)
  • look unwell
  • most common is torsion of a dermoid cyst
  • need surgery, de-torsion and remove cyst

Obs & Gynae (9 decks)

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