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Obstetrics and Gynaecology > Gynaecological Cancer > Flashcards

Gynaecological Cancer Flashcards

1
Q

What cancers may present with abnormal vaginal bleeding or discharge?

A

Cervical
Ovarian

Uterine
Vaginal

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2
Q

What cancers may present with abnormal vaginal bleeding or discharge?

A

Cervical
Ovarian

Uterine
Vaginal

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3
Q

What cancers may present with pelvic pain or pressure?

A

Ovarian
Uterine

Vulvar

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4
Q

What cancers present with abdominal pain and bloating?

A

Ovarian

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5
Q

What cancers present with change in bowel habits?

A

Ovarian

Vaginal

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6
Q

What cancers present with itching or burning of the vulva?

A

Vulvar

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7
Q

What cancers present with changes in vulva colour or skin?

A

Vulvar

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8
Q

When does cervical cancer most commonly affect women?

A

25-34yo

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9
Q

Histologically, what type of cancer can cervical cancer be?

A

70% squamous
15% adenocarcinoma

15% mixed

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10
Q

What is squamous cell cervical cancer commonly associated with?

A

99.7% contain HPV DNA

HPV 16 and 18

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11
Q

How do HPV16 and 18 cause cervical cancer?

A

HPV 16 produce E6 oncogene - inhibit p53 (tumour suppressor)

HPV 18 produce E7 oncogene - inhibit RB (tumour suppressor)

Uncontrolled cervical epithelium division

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12
Q

What is CIN?

A

Cervical intraepithelial neoplasia - dysplasia of the cervical epithelium

Can progress to cancer over 10-20 years

Most cases don’t progresses and spontaneously regress

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13
Q

What risk factors are associated with cervical cancer?

A

Persistent HPV infection
Smoking

Other STD’s
>8 years COCP use
Immunodeficiency
Early first intercourse

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14
Q

How does cervical cancer present?

A

Majority asymptomatic - picked up on screening

!!Abnormal vaginal bleeding
!!Discharge

Dyspareunia
Pelvic pain
Weight loss
Symptoms of invasion - loin pain, haematuria, oedema, rectal bleeding, radiculopathy

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15
Q

How would you investigate suspected cervical cancer in a woman pre-menopause?

A

Chlamydia screen

Positive - treat
Negative - colposcopy and biopsy

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16
Q

How would you investigate suspected cervical cancer in a woman post-menopause?

A

Urgent colposcopy and biopsy

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17
Q

How is cervical cancer staged?

A

I - Only in cervical tissue
II - Spread to upper 2/3 vagina or other tissue next to cervix

III - Spread tor issues on side of pelvic and/or lower 1/3 vagina
IV - Spread to bladder or rectum or beyond pelvis

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18
Q

Where does cervical cancer metastasise to?

A

Lung
Liver

Bone
Bowel

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19
Q

Briefly, how is cervical cancer managed surgically?

A

Preserve fertility - radical trachelectomy

Stage 1: Laparoscopic hysterectomy + cervical lymphadenectomy
Stage 2: radical hysterectomy
Stage 4: pelvic exenteration

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20
Q

What is a trachelectomy?

A

Removal of the uterine cervix

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21
Q

What other management options are there for cervical cancer?

A

Radiotherapy - external beam or brachytherapy

Chemotherapy - chemoradiation gold standard for stage Ib to III

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22
Q

What is a Lletz biopsy and what are the complications?

A

Transformation zone is removed with diathermy

Scarring and stenosis
Pyometra (uterus infection)
Cervical incompetence = PROM

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23
Q

When are women screened for cervical cancer?

What happens to screening if a women becomes pregnant?

A

25-49 yo = 3 yearly screening

50-64 yo = 5 yearly screening

Delay in pregnancy until 3 months post partum

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24
Q

How is cervical cancer screened?

When in the cycle is it best to do this?

A

Smear - brush rotated at squamo-columnar junction

Liquid based cytology to analyse fluid collected

Best to take mid cycle

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25
Q

What is a smear poor at picking up?

A

Adenocarcinomas

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26
Q

How are smear results categorised?

A

Borderline or mild dyskaryosis
Moderate dyskaryosis - CIN II

Severe dyskaryosis - CIN III
Suspected invasive cancer
Glandular neoplasia
Inadequate

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27
Q

What is done if a smear comes back as HPV negative?

A

Return to normal recall

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28
Q

What is done if a smear comes back as HPV positive?

A

Cytology is done on the sample:
abnormal (including borderline dyskaryosis)

= 2wk colposcopy

normal
= yearly smear

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29
Q

A women returns a year later for a smear as she is HPV positive… what now?

A women returns for the third year in a row due to being HPV positive… what now?

A

HPV -ve = return to normal 3 yearly
HPV +ve but cytology still normal = yearly

HPV -ve = return to normal 3 yearly
HPV +ve but cytology still normal = colposcopy

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30
Q

What should be done if a smear is inadequate?

A

Repeat smear

If persistent (3 inadequate samples) - colposcopy assessment

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31
Q

What can the risk factors of cervical cancer be categorised into?

A

Those that increase the risk of catching HPV
Later detection of precancerous and cancerous changes - not engaging in screening
Other risk factors

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32
Q

How can CIN be diagnosed?

A

With colposcopy not with cervical screening

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33
Q

How can CIN be diagnosed?

A

With colposcopy not with cervical screening

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34
Q

What cancers may present with pelvic pain or pressure?

A

Ovarian
Uterine

Vulvar

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35
Q

What cancers present with abdominal pain and bloating?

A

Ovarian

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36
Q

What cancers present with change in bowel habits?

A

Ovarian

Vaginal

How well did you know this?
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37
Q

What cancers present with itching or burning of the vulva?

A

Vulvar

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38
Q

What cancers present with changes in vulva colour or skin?

A

Vulvar

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39
Q

When does cervical cancer most commonly affect women?

A

25-34yo

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40
Q

Histologically, what type of cancer can cervical cancer be?

A

70% squamous
15% adenocarcinoma

15% mixed

How well did you know this?
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Not at all
2
3
4
5
Perfectly
41
Q

What is squamous cell cervical cancer commonly associated with?

A

99.7% contain HPV DNA

HPV 16 and 18

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

How do HPV16 and 18 cause cervical cancer?

A

HPV 16 produce E6 oncogene - inhibit p53 (tumour suppressor)

HPV 18 produce E7 oncogene - inhibit RB (tumour suppressor)

Uncontrolled cervical epithelium division

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What is CIN?

A

Cervical intraepithelial neoplasia - dysplasia of the cervical epithelium

Can progress to cancer over 10-20 years

Most cases don’t progresses and spontaneously regress

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

What risk factors are associated with cervical cancer?

A

Persistent HPV infection
Smoking

Other STD’s
>8 years COCP use
Immunodeficiency
Early first intercourse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

How does cervical cancer present?

A

Majority asymptomatic - picked up on screening

!!Abnormal vaginal bleeding
!!Discharge

Dyspareunia
Pelvic pain
Weight loss
Symptoms of invasion - loin pain, haematuria, oedema, rectal bleeding, radiculopathy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

How would you investigate suspected cervical cancer in a woman pre-menopause?

A

Chlamydia screen

Positive - treat
Negative - colposcopy and biopsy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

How would you investigate suspected cervical cancer in a woman post-menopause?

A

Urgent colposcopy and biopsy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

How is cervical cancer staged?

A

I - Only in cervical tissue
II - Spread to upper 2/3 vagina or other tissue next to cervix

III - Spread tor issues on side of pelvic and/or lower 1/3 vagina
IV - Spread to bladder or rectum or beyond pelvis

How well did you know this?
1
Not at all
2
3
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49
Q

Where does cervical cancer metastasise to?

A

Lung
Liver

Bone
Bowel

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Briefly, how is cervical cancer managed surgically?

A

Preserve fertility - radical trachelectomy

Stage 1: Laparoscopic hysterectomy + cervical lymphadenectomy
Stage 2: radical hysterectomy
Stage 4: pelvic exenteration

How well did you know this?
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51
Q

What is a trachelectomy?

A

Removal of the uterine cervix

How well did you know this?
1
Not at all
2
3
4
5
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52
Q

What other management options are there for cervical cancer?

A

Radiotherapy - external beam or brachytherapy

Chemotherapy - chemoradiation gold standard for stage Ib to III

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

What is a Lletz biopsy and what are the complications?

A

Transformation zone is removed with diathermy

Scarring and stenosis
Pyometra (uterus infection)
Cervical incompetence = PROM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

When are women screened for cervical cancer?

What happens to screening if a women becomes pregnant?

A

25-49 yo = 3 yearly screening

50-64 yo = 5 yearly screening

Delay in pregnancy until 3 months post partum

55
Q

How is cervical cancer screened?

When in the cycle is it best to do this?

A

Smear - brush rotated at squamo-columnar junction

Liquid based cytology to analyse fluid collected

Best to take mid cycle

56
Q

How is stage 2 endometrial cancer managed?

A

Radical hysterectomy + pelvic lymphadenectomy + radiotherapy

57
Q

How are smear results categorised?

A

Borderline or mild dyskaryosis
Moderate dyskaryosis - CIN II

Severe dyskaryosis - CIN III
Suspected invasive cancer
Glandular neoplasia
Inadequate

58
Q

What is done if a smear comes back as HPV negative?

A

Return to normal recall

59
Q

What is done if a smear comes back as HPV positive?

A

Cytology is done on the sample:
abnormal (including borderline dyskaryosis)

= 2wk colposcopy

normal
= yearly smear

60
Q

A women returns a year later for a smear as she is HPV positive… what now?

A women returns for the third year in a row due to being HPV positive… what now?

A

HPV -ve = return to normal 3 yearly
HPV +ve but cytology still normal = yearly

HPV -ve = return to normal 3 yearly
HPV +ve but cytology still normal = colposcopy

61
Q

What should be done if a smear is inadequate?

A

Repeat smear

If persistent (3 inadequate samples) - colposcopy assessment

62
Q

What can the risk factors of cervical cancer be categorised into?

A

Those that increase the risk of catching HPV
Later detection of precancerous and cancerous changes - not engaging in screening
Other risk factors

63
Q

What appearances on colposcopy may suggest cervical cancer?

A

Ulceration
Inflammation
Bleeding
Visible tumour

64
Q

How can CIN be diagnosed?

A

With colposcopy not with cervical screening

65
Q

What are the stages of CIN?

A

CIN 1 - mild dysplasia, affecting 1/3 thickness of epithelial layer
CIN 2 - moderate, affecting 2/3, likely to progress to cancer if untreated
CIN 3 - severe, very likely to become cancer if untreated

66
Q

What is dyskaryosis?

A

Found on smear results - cells examined under microscope for precancerous changes

67
Q

How are smears tested?

A

Initially tested for high risk HPV, if HPV test negative then the cells are not examined and smear considered negative.

68
Q

What are notable exceptions to the smear program?

A

Women with HIV screened annually
Women over 65 can request one if not had one since 50
Women with previous CIN may require additional testing
Immunocompromised additional
Pregnancy women should wait 12 weeks post partum

69
Q

What are the outcomes of smear cytology results?

A 
Inadequate
Normal
Borderline changes
Low grade dyskaryosis
High grade dyskaryosis
Possible invasive squamous cell carcinoma
Possible glandular neoplasia
70
Q

When should smears be repeated based on results?

A

Inadequate sample - repeat after at least three months
HPV negative - continue routine screening
HPV positive with normal cytology - repeat HPV test after 12 months
HPV positive with abnormal cytology - refer for colposcopy

71
Q

What tests can be performed on colposcopy?

A

Acetic acid causes abnormal cells to appear white, if there are cells with an increased nuclear to cytoplasmic ratio

Abnormal cells will not stain with Schiller’s iodine test

Punch biopsy or loop excision can be performed

72
Q

What is LLETZ?

A

Large loop excision of the transformation zone

Removes abnormal tissue on the cervix
Procedure can increase risk of preterm labour

73
Q

What is a cone biopsy?

A

Treatment for CIN and very early stage cervical cancer

Done under GA, cone shaped piece of cervix removed using scalpel

74
Q

What are the main risks of cone biopsy?

A

Pain
Bleeding
Infection
Scar formation with stenosis of the cervix
Increased risk of miscarriage and premature labour

75
Q

What is the management of cervical cancer?

A

CIN and early stage 1A - LLETZ or cone biopsy
1B - 2A radical hysterectomy and removal of local lymph nodes with chemo and radio
2B - 4A chemotherapy and radiotherapy
4B - combination of surgery, radiotherapy, chemo, palliative care

76
Q

What investigation is done in secondary care for patients referred with a raised CA125 and abnormal USS?

A

CT abdo-pelvis to look at extent of disease
Laparotomy for histology
Paracentesis can be used to test ascitic fluid for cancer cells

77
Q

What are the risk factors for ovarian cancer?

A

Increased ovulation - null parity, early menarche, late menopause
Increasing age

Oestrogen only HRT
Obesity
Genetics - BRCA 1/2, Lynch syndrome

78
Q

What are the protective factors against ovarian cancer?

A

Reduced ovulations
- multiparity

  • breastfeeding
  • COCP
79
Q

When is the HPV vaccine given?

A

Boys and girls, ideally before they become sexually active

80
Q

What is the peak age of endometrial cancer?

A

65-75 years old

81
Q

What is the most common type of endometrial cancer?

A

Adenocarcinoma

82
Q

What is happening to the incidence of endometrial cancer?

A

Rising - possibly due to obesity

83
Q

What is the pathophysiology of endometrial cancer?

A

Most due to unopposed oestrogen stimulating endometrium

No protective effects of progesterone

84
Q

What risk factors are associated with endometrial cancer?

A

OESTROGEN

Anovulation
- Early menarche and late menopause
- Low parity
- PCOS
- HRT - oestrogen alone
- Tamoxifen
Increasing age
Obesity
HNPCC - Lynch syndrome
85
Q

How does endometrial cancer present?

A

Post-menopausal bleeding
Clear/white vaginal discharge

Pre-menopausal - abnormal bleeding, pelvic pain and dyspareunia

86
Q

Describe the staging of endometrial cancer

A

1 - confined to uterine body
2 - extend to cervix but not beyond uterus

3 - extend beyond uterus but confined to pelvis
4 - Involved bladder or bowel or metastasis

87
Q

What is the presentation of ovarian cancer?

A 
Non specific symptoms
Have a low threshold 
Abdominal bloating
Early satiety
Loss of appetite
Pelvic pain
Urinary symptoms
Weight loss
Abdominal or pelvic mass
Ascites

Ovarian mass may press on obturator nerve causing referred hip or groin pain

88
Q

How is stage 2 endometrial cancer managed?

A

Radical hysterectomy + pelvic lymphadenectomy + radiotherapy

89
Q

How are stage 3/4 endometrial cancer managed?

A

Maximal debulking + chemo + radio

May palliate

90
Q

What is the difference between a total and radical hysterectomy?

A

Total: uterus + cervix removed

Radical: uterus + cervix + parametrium + top part of vagina removed

91
Q

What can be protective against endometrial cancer?

A

COCP
Smoking
Mirena coil
Increased pregnancies

92
Q

What is endometrial hyperplasia?

A

Thickening of uterine cavity due to too much oestrogen with too little progesterone

93
Q

How is endometrial hyperplasia managed?

A

Hyperplasia without atypia - progesterone (Mirena coil) + surveillance biopsies

Intrauterine system e.g. Mirena, or continuous oral progestogens e.g. levonorgestrel

Atypical hyperplasia - as stage 1 - total hysterectomy + bilateral salpingo-oophorectomy + peritoneal washing
High risk of becoming malignant

94
Q

Why is smoking protective against endometrial cancer in postmenopausal women?

A

Not protective against other oestrogen dependent cancers

Anti oestrogenic in endometrial cancer - oestrogen may be metabolised differently by smokers, smokers tend to be leaner meaning less adipose tissue and aromatase, smoking destroys oocytes resulting in earlier menopause

95
Q

What is the referral criteria for endometrial cancer?

A

Postmenopausal bleeding - red flag symptom - 2WW

Also recommends TVUSS in women over 55 years with unexplained vaginal discharge, or visible haematuria plus raised platelets, anaemia or elevated glucose levels

96
Q

What are the investigations for endometrial cancer?

A

TVUSS for endometrial thickness, less than 4mm in postmenopause
Pipelle biopsy highly sensitive
Hysteroscopy with biopsy

97
Q

What are the stages of endometrial cancer?

A

1 - confined to the uterus
2 - invades the cervix
3 - invades ovaries, fallopian tubes, vagina or lymph nodes
4 - invades bladder, rectum or beyond pelvis

98
Q

What is the management of endometrial cancer?

A

Treatment for stage 1 or 2 is total abdominal hysterectomy with bilateral salpingo-oophorectomy TAHBSO - uterus, cervix and adnexa

Radical hysterectomy also removing pelvic lymph nodes, surrounding tissues and top of vagina
Radiotherapy, chemotherapy
Progesterone to slow progression

99
Q

What is the peak age women get ovarian cancer?

A

60 years old

100
Q

How can ovarian cancer be classified?

A

Epithelial - 90%
Germ cell

Sex cord stromal

101
Q

What are the types of epithelial ovarian cancers?

A

Serous, mucinous, endometriod etc.

Arise from surface epithelium due to irritation during ovulation

102
Q

What are germ cell ovarian tumour? How do they present?

A

Tumours arising from embryonic germ cells of gonad

Present in younger patients as rapidly enlarging abdominal mass

103
Q

What do sex-cord stroll ovarian cancers arise from?

A

Connective tissue cells

104
Q

How do ovarian cancers present?

A

Vague - 58% present in stage 3 or 4

Persistent bloating
Early satiety/loss of appetite
Pelvic or abdominal pain
Urinary frequency or urgency
Vaginal bleeding
105
Q

What must be done in women >50yo with a new onset of IBS?

A

Ovarian cancer testing - can present similarly

106
Q

How is ovarian cancer investigated in primary care?

A

CA125 >35 = USS
USS abdo/pelvis abnormal = secondary care

USS abdo/pelvis normal = safety netting

CA125 <35 = safety netting

107
Q

What other tests can be done in <40yo in primary care for suspected ovarian cancer? Why?

A

AFP
Beta HCG

Raised levels suggest alternate tumours

108
Q

What investigation is done in secondary care for patients referred with a raised CA125 and abnormal USS?

A

CT abdo-pelvis to look at extent of disease

Laparotomy for histology

109
Q

What are the risk factors for ovarian cancer?

A

Increased ovulation - null parity, early menarche, late menopause
Increasing age

Oestrogen only HRT
Obesity
Genetics - BRCA 1/2, Lynch syndrome

110
Q

What are the protective factors against ovarian cancer?

A

Reduced ovulations
- multiparity

  • breastfeeding
  • COCP
111
Q

What is important to know about CA125?

A

Reduced specificity in premenopausal women

Also raised due to:

  • Endometriosis, benign ovarian cysts, menstruation, pregnancy
  • Diverticulitis, cirrhosis
  • Other malignancies (bladder, breast, liver, lung)
112
Q

What is RMI (ovarian cancer)?

How is it calculated?

A

Score to calculate risk of malignancy in those with suspected ovarian cancer

M x U x CA125

Menopause: pre = 1, post = 3
USS score: 1 feature = 1 , >1 feature = 3

If score >250: specialist MDT

113
Q

What features on USS of ovaries cause concern?

A

Multilocular cyst
Solid areas

Metastasis
Ascites
Bilateral lesions

114
Q

Describe the staging of ovarian cancer

A

FIGO system
I - one or both ovaries only

II - spread to other pelvic organs
III - spread to peritoneum or lymph nodes
IV - spread to distant organs - lung/liver

115
Q

What is the management for ovarian cancer?

A

Combination of surgery and chemo

Laparotomy - tumour debunking
Hysterectomy, salpingo-oophorectomy and infra colic omentectomy

116
Q

How is ovarian cancer followed up?

A

5 year CA125 monitoring

117
Q

What is a Krukenberg tumour?

A

A metastasis in the ovary, usually from a gastrointestinal tract cancer. Signet ring on histology

118
Q

What are protective factors in ovarian cancer?

A

Factors which stop ovulation or reduce the number of lifetime ovulations e.g.
Combined contraceptive pill
Breastfeeding
Pregnancy

119
Q

When should 2WW be referred for ovarian cancer?

A

If feels ascites, pelvic mass (unless due to fibroids) or abdominal mass on examination

Carry out further investigations before referral e.g. CA125

120
Q

What is the staging of ovarian cancer?

A

1 - confined to ovary
2 - spread past ovary but inside pelvis
3 - spread past pelvis but inside abdomen
4 - spread outside abdomen - distant mets

121
Q

What is the epidemiology of vulval cancer?

A

Very rare cancer
90% squamous

Mostly >75yo

Less commonly they can be malignant melanomas

122
Q

How do vulval cancers present?

A

May be an incidental finding e.g. catheterisation in a patient with dementia

Lump
Ulceration + bleeding

Pruritus
Pain
Lymphadenopathy in the groin

Vulval cancer most frequently affects the lavia majora - giving it an appearance of
irregular mass, fungating lesion, ulceration, bleeding

123
Q

When would you refer someone to gynae under 2 week wait for suspected vulval cancer?

A

Lump

Ulceration + bleeding

124
Q

Where do vulval cancers affect?

A

Labia majora - 50%
Labia minora - 20%

Clitoris and bartholin’s glands - infrequent

125
Q

What are the risk factors for vulval cancer?

A

VIN
HPV

Lichen sclerosus

126
Q

How is vulval cancer diagnosed?

A

Examination and biopsy

127
Q

Where do vulval cancers spread?

A

Inguinal and femoral lymph nodes

128
Q

How are vulval cancers managed?

A

Surgical - radical or wide local resection
Senitel lymph node biopsy +- groin node dissection

Reconstructive surgery often performed

Biopsy of the lesion, sentinel lymph node biopsy, further imaging for staging e.g. CT abdomen and pelvis

129
Q

What is VIN?

A

Premalignant state that occurs spontaneously or due to pre-existing vulval disorder such as lichen sclerosis

Affects the squamous epithelium of the skin that can precede vulval cancer

High grade squamous intraepithelial lesion is a type of VIN associated with HPV
Typically occurs between 35-50

Differentiated VIN is associated with lichen sclerosus, 50-60 years of age

130
Q

How does VIN present?

A

Itching

Plaque like white patches

131
Q

How is VIN diagnosed?

A

Biopsy - confirm not invasive cancer

132
Q

How is VIN managed?

A

Laser therapy

Wide local excision

133
Q

What are some complications of a Lletz biopsy (for suspected cervical cancer)

A

Scarring = cervical stenosis
Cervical incompetence
Infection and pyometra

Obstetrics and Gynaecology (11 decks)

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