Gynae Oncology, Screening and Surgery Flashcards
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
- ~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)
Endometrial cancer is split into type 1 (more common) and type 2.
Give 2 features of each:
- 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
Suggest 2 ways endometrial cancer may present?
- postmenopausal bleeding (PMB)
- if premenopausal, bleeding may be irregular or have IMB (intermenstrual bleeding), menorrhagia
Unless the pt is unfit or has metastasised endometrial cancer, what is the surgery of choice?
-a total laparoscopic hysterectomy and BSO (bilateral salpingo-oophorectomy)
Uterine sarcomas are v rare. What type aka malignant fibroids present with rapid, painful uterine enlargeement?
NB: rx is hysterectomy +/- chemoradiotherapy, prognosis is poor
-Leiomyosarcomas
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?
Peri-menopausal
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?
- columnar glandular epithelium (endocervix)
- squamous epithelium (ectocervix)
- squamocolumnar junction
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
-when the columnar epithelium of endocervix is visible as a red area around the os, due to eversion
Ectropions can be treated with cryotherapy, but what investigations must be done first to rule out____
-a smear and colposcopy done to exclude carcinoma
Define cervical intraepithelial neoplasia (CIN) aka cervical dysplasia
- -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
If atypical cells are found in the lower third of the epithelium only, what grade of CIN is this?
-Grade 1
What is Grade II CIN:
-atypical cells in the lower 2/3rds of the epithelium
What is grade III CIN:
-what is different between this and malignancy?
-atypical cells occupy full thickness of epithelium, = carcinoma in situ (cells as like malignancy but no invasion through basement membrane)
Roughly what age group is most affected by CIN?
-90% those under 45yrs, most common in 25-30yrs
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
- HPV, number of sexual contacts
- types 16, 18, 31 and 33 most associated with malignancy
Cervical Smear Screening:
25-49yrs how often are smears?
-50-64yrs?
-65+ if normal, no screening
-25-49yrs: repeated every 3 years
50-64yrs: repeated every 5 years
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?
- normal cytology, repeat in 1 year
- abnormal, refer for colposcopy
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?
-return to normal recall so every 3yrs if 25-49 or every 5yrs if 50-65yrs
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?
Repeat in 1 year
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
- _________
-referral to colposcopy (strike III -> refer)
What acidic is used at colposcopy to stain the cervix and visualise CIN
-acetic acid 5%
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
-risk of preterm delivery
NB: a cervical suture can be inserted to help prevent this in some cases
90% of cervical malignancies are carcinomas of which epithelium?
-squamous cell carcinoma
Suggest 2 features in a history that may suggest cervical cancer?
- post-coital bleeding
- offensive vaginal discharge
- IMB or post-menopaausal bleeding
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
- vaginal and rectal examination
- examination under anaesthesia (EUA - unless lesion is v small)
- cystoscopy
- MRI
Lesions of cervical cancer confined to the cervix (stage 1a(i) can be treated with ____ biopsy
-cone biopsy
In other stages of cervical cancer, suggest 2 treatment options:
- surgery: radical hysterectomy, radical trachelectomy removing 80% cervix + upper vagina
- chemo-radiotherapy
- if stage 3 or worse need radiotherapy + chemotherapy
Death in cervical cancer is commonly from u____ due to ______ ob______
-uraemia due to ureteric obstruction
What type of carcinoma is the most common malignant ovarian neoplasm?
-Adenocarcinoma
What is the general prognosis of clear cell carcinoma ovarian malignancy?
-Poor
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
- post-menopausal women
- inhibin
- sx: bleeding, endometrial hyperplasia, endometrial malignancy (young girls –> precocious puberty)
- serum inhibin
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
-pleural effusion
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
gut
What effect does COCP have on the development of ovarian cancer?
-reduces risk of ovarian cancer
RFs for ovarian cancer relate to the # of ovulations, more = increased risk.
Therefore give 2 RFs
and 2 protective factors:
- RFs: early menarche, late menopause, nulliparity
- protective: pregnancy, lactation, use of COCP
Suggest 2 different gene mutations that may have a role in familial ovarian carcinoma?
- BRCA 1 and BRCA 2
- HPNCC mutations (Lynch syndrome)
Why is ovarian cancer prognosis poor?
-asymptomatic mostly until late stages
-so presents late
(70% present with stage 3-4 disease - LN affected or mets)
suggest 2 sx that may be warning signs of ovarian cancer:
- persistent bloating
- felling full early (satiety)
- loss of appetite
- -pelvic/abdo pain
- increased urinary urgency/frequency
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
-IBS
Ovarian adenocarcinoma spreads by transcoelomic spread, what does this mean?
-spreads directly within the pelvis and abdo
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
- CA 125 levels
- US of abdo/pelvis
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:
- alpha fetoprotein (AFP)
- hCG
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
U = ultrasound scan score (0-3 pts) M = menopausal status (1 if pre, 3 if post)
Suggest 2 things involved in the ultrasound scan for ovarian cancer, in the RMI each finding is 1 point
- multilocular cysts
- solid areas
- metastases
- ascites
- bilateral lesions
What surgery is done for ovarian cancer
- 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
Chemotherapy for ovarian cancer:
Stage 2-4 ovarian cancer Ci___ alone or in combo with pacl____ is used
-cisplatin +/- paclitaxel
Death from ovarian cancer is usually due to bowel _____ or _____
-obstruction or perforation
<40yrs: most common ovarian cysts are: f_____ cyst, d____ cyst and e____ioma
>40yrs: most common are epithelial cysts known as c______
<40yrs: functional cyst, dermoid cyst, endometrioma
>40yrs: cystadenomas
Bearing in mind, most common cyst in >40yrs: is cystadenomas, although malignancy uncommon, but if present most likely form will be: ______
cystadenocarcinoma
Name a worrying symptoms in a post-menopausal woman that would raise the suspicion of ovarian cancer:
-persistent bloating/swelling (>3weeeks at a time)
-change in bowel habit
(so 2 week wait referral to rule out cancer)
Most common cysts:
<40yrs: functional cyst, dermoid cyst, endometrioma
How to differentiate?
-TVUS
functional cyst: anechoic, thin lining, fluid filled
-dermoid cyst: obvious findings of abnormal contents, acoustic shadowing
-endometrioma: uniform ground glass appearance, chocolate cyst
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?
luteal phase
What 3 ovarian cyst accidents can happen?
- Rupture (luteal phase)
- Haemorrhage into cyst (luteal phase)
- Torsion of Cyst (sudden onset, no obvious cyclical pattern)
How will a haemorrhage into an ovarian cyst appear on US?
- still intact cyst
- spiderweb pattern of fresh blood in the cyst
How will a ruptured cyst appear on US?
- absent (as cyst has ruptured)
- hemoperitoneum
- tender, bleeding in abdomen irritates but is self-limiting
Ovarian cyst torsion presentation:
- nausea and vomiting (ischaemic pain)
- look unwell
- most common is torsion of a dermoid cyst
- need surgery, de-torsion and remove cyst
