Gynaecological Cancer Flashcards
What cancers may present with abnormal vaginal bleeding or discharge?
Cervical
Ovarian
Uterine
Vaginal
What cancers may present with abnormal vaginal bleeding or discharge?
Cervical
Ovarian
Uterine
Vaginal
What cancers may present with pelvic pain or pressure?
Ovarian
Uterine
Vulvar
What cancers present with abdominal pain and bloating?
Ovarian
What cancers present with change in bowel habits?
Ovarian
Vaginal
What cancers present with itching or burning of the vulva?
Vulvar
What cancers present with changes in vulva colour or skin?
Vulvar
When does cervical cancer most commonly affect women?
25-34yo
Histologically, what type of cancer can cervical cancer be?
70% squamous
15% adenocarcinoma
15% mixed
What is squamous cell cervical cancer commonly associated with?
99.7% contain HPV DNA
HPV 16 and 18
How do HPV16 and 18 cause cervical cancer?
HPV 16 produce E6 oncogene - inhibit p53 (tumour suppressor)
HPV 18 produce E7 oncogene - inhibit RB (tumour suppressor)
Uncontrolled cervical epithelium division
What is CIN?
Cervical intraepithelial neoplasia - dysplasia of the cervical epithelium
Can progress to cancer over 10-20 years
Most cases don’t progresses and spontaneously regress
What risk factors are associated with cervical cancer?
Persistent HPV infection
Smoking
Other STD’s
>8 years COCP use
Immunodeficiency
Early first intercourse
How does cervical cancer present?
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 would you investigate suspected cervical cancer in a woman pre-menopause?
Chlamydia screen
Positive - treat
Negative - colposcopy and biopsy
How would you investigate suspected cervical cancer in a woman post-menopause?
Urgent colposcopy and biopsy
How is cervical cancer staged?
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
Where does cervical cancer metastasise to?
Lung
Liver
Bone
Bowel
Briefly, how is cervical cancer managed surgically?
Preserve fertility - radical trachelectomy
Stage 1: Laparoscopic hysterectomy + cervical lymphadenectomy
Stage 2: radical hysterectomy
Stage 4: pelvic exenteration
What is a trachelectomy?
Removal of the uterine cervix
What other management options are there for cervical cancer?
Radiotherapy - external beam or brachytherapy
Chemotherapy - chemoradiation gold standard for stage Ib to III
What is a Lletz biopsy and what are the complications?
Transformation zone is removed with diathermy
Scarring and stenosis
Pyometra (uterus infection)
Cervical incompetence = PROM
When are women screened for cervical cancer?
What happens to screening if a women becomes pregnant?
25-49 yo = 3 yearly screening
50-64 yo = 5 yearly screening
Delay in pregnancy until 3 months post partum
How is cervical cancer screened?
When in the cycle is it best to do this?
Smear - brush rotated at squamo-columnar junction
Liquid based cytology to analyse fluid collected
Best to take mid cycle
What is a smear poor at picking up?
Adenocarcinomas
How are smear results categorised?
Borderline or mild dyskaryosis
Moderate dyskaryosis - CIN II
Severe dyskaryosis - CIN III
Suspected invasive cancer
Glandular neoplasia
Inadequate
What is done if a smear comes back as HPV negative?
Return to normal recall
What is done if a smear comes back as HPV positive?
Cytology is done on the sample:
abnormal (including borderline dyskaryosis)
= 2wk colposcopy
normal
= yearly smear
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?
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
What should be done if a smear is inadequate?
Repeat smear
If persistent (3 inadequate samples) - colposcopy assessment
What can the risk factors of cervical cancer be categorised into?
Those that increase the risk of catching HPV
Later detection of precancerous and cancerous changes - not engaging in screening
Other risk factors
How can CIN be diagnosed?
With colposcopy not with cervical screening
How can CIN be diagnosed?
With colposcopy not with cervical screening
What cancers may present with pelvic pain or pressure?
Ovarian
Uterine
Vulvar
What cancers present with abdominal pain and bloating?
Ovarian
What cancers present with change in bowel habits?
Ovarian
Vaginal
What cancers present with itching or burning of the vulva?
Vulvar
What cancers present with changes in vulva colour or skin?
Vulvar
When does cervical cancer most commonly affect women?
25-34yo
Histologically, what type of cancer can cervical cancer be?
70% squamous
15% adenocarcinoma
15% mixed
What is squamous cell cervical cancer commonly associated with?
99.7% contain HPV DNA
HPV 16 and 18
How do HPV16 and 18 cause cervical cancer?
HPV 16 produce E6 oncogene - inhibit p53 (tumour suppressor)
HPV 18 produce E7 oncogene - inhibit RB (tumour suppressor)
Uncontrolled cervical epithelium division
What is CIN?
Cervical intraepithelial neoplasia - dysplasia of the cervical epithelium
Can progress to cancer over 10-20 years
Most cases don’t progresses and spontaneously regress
What risk factors are associated with cervical cancer?
Persistent HPV infection
Smoking
Other STD’s
>8 years COCP use
Immunodeficiency
Early first intercourse
How does cervical cancer present?
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 would you investigate suspected cervical cancer in a woman pre-menopause?
Chlamydia screen
Positive - treat
Negative - colposcopy and biopsy
How would you investigate suspected cervical cancer in a woman post-menopause?
Urgent colposcopy and biopsy
How is cervical cancer staged?
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
Where does cervical cancer metastasise to?
Lung
Liver
Bone
Bowel
Briefly, how is cervical cancer managed surgically?
Preserve fertility - radical trachelectomy
Stage 1: Laparoscopic hysterectomy + cervical lymphadenectomy
Stage 2: radical hysterectomy
Stage 4: pelvic exenteration
What is a trachelectomy?
Removal of the uterine cervix
What other management options are there for cervical cancer?
Radiotherapy - external beam or brachytherapy
Chemotherapy - chemoradiation gold standard for stage Ib to III
What is a Lletz biopsy and what are the complications?
Transformation zone is removed with diathermy
Scarring and stenosis
Pyometra (uterus infection)
Cervical incompetence = PROM
When are women screened for cervical cancer?
What happens to screening if a women becomes pregnant?
25-49 yo = 3 yearly screening
50-64 yo = 5 yearly screening
Delay in pregnancy until 3 months post partum
How is cervical cancer screened?
When in the cycle is it best to do this?
Smear - brush rotated at squamo-columnar junction
Liquid based cytology to analyse fluid collected
Best to take mid cycle
How is stage 2 endometrial cancer managed?
Radical hysterectomy + pelvic lymphadenectomy + radiotherapy
How are smear results categorised?
Borderline or mild dyskaryosis
Moderate dyskaryosis - CIN II
Severe dyskaryosis - CIN III
Suspected invasive cancer
Glandular neoplasia
Inadequate
What is done if a smear comes back as HPV negative?
Return to normal recall
What is done if a smear comes back as HPV positive?
Cytology is done on the sample:
abnormal (including borderline dyskaryosis)
= 2wk colposcopy
normal
= yearly smear
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?
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
What should be done if a smear is inadequate?
Repeat smear
If persistent (3 inadequate samples) - colposcopy assessment
What can the risk factors of cervical cancer be categorised into?
Those that increase the risk of catching HPV
Later detection of precancerous and cancerous changes - not engaging in screening
Other risk factors
What appearances on colposcopy may suggest cervical cancer?
Ulceration
Inflammation
Bleeding
Visible tumour
How can CIN be diagnosed?
With colposcopy not with cervical screening
What are the stages of CIN?
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
What is dyskaryosis?
Found on smear results - cells examined under microscope for precancerous changes
How are smears tested?
Initially tested for high risk HPV, if HPV test negative then the cells are not examined and smear considered negative.
What are notable exceptions to the smear program?
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
What are the outcomes of smear cytology results?
Inadequate Normal Borderline changes Low grade dyskaryosis High grade dyskaryosis Possible invasive squamous cell carcinoma Possible glandular neoplasia
When should smears be repeated based on results?
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
What tests can be performed on colposcopy?
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
What is LLETZ?
Large loop excision of the transformation zone
Removes abnormal tissue on the cervix
Procedure can increase risk of preterm labour
What is a cone biopsy?
Treatment for CIN and very early stage cervical cancer
Done under GA, cone shaped piece of cervix removed using scalpel
What are the main risks of cone biopsy?
Pain
Bleeding
Infection
Scar formation with stenosis of the cervix
Increased risk of miscarriage and premature labour
What is the management of cervical cancer?
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
What investigation is done in secondary care for patients referred with a raised CA125 and abnormal USS?
CT abdo-pelvis to look at extent of disease
Laparotomy for histology
Paracentesis can be used to test ascitic fluid for cancer cells
What are the risk factors for ovarian cancer?
Increased ovulation - null parity, early menarche, late menopause
Increasing age
Oestrogen only HRT
Obesity
Genetics - BRCA 1/2, Lynch syndrome
What are the protective factors against ovarian cancer?
Reduced ovulations
- multiparity
- breastfeeding
- COCP
When is the HPV vaccine given?
Boys and girls, ideally before they become sexually active
What is the peak age of endometrial cancer?
65-75 years old
What is the most common type of endometrial cancer?
Adenocarcinoma
What is happening to the incidence of endometrial cancer?
Rising - possibly due to obesity
What is the pathophysiology of endometrial cancer?
Most due to unopposed oestrogen stimulating endometrium
No protective effects of progesterone
What risk factors are associated with endometrial cancer?
OESTROGEN
Anovulation - Early menarche and late menopause - Low parity - PCOS - HRT - oestrogen alone - Tamoxifen Increasing age Obesity HNPCC - Lynch syndrome
How does endometrial cancer present?
Post-menopausal bleeding
Clear/white vaginal discharge
Pre-menopausal - abnormal bleeding, pelvic pain and dyspareunia
Describe the staging of endometrial cancer
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
What is the presentation of ovarian cancer?
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
How is stage 2 endometrial cancer managed?
Radical hysterectomy + pelvic lymphadenectomy + radiotherapy
How are stage 3/4 endometrial cancer managed?
Maximal debulking + chemo + radio
May palliate
What is the difference between a total and radical hysterectomy?
Total: uterus + cervix removed
Radical: uterus + cervix + parametrium + top part of vagina removed
What can be protective against endometrial cancer?
COCP
Smoking
Mirena coil
Increased pregnancies
What is endometrial hyperplasia?
Thickening of uterine cavity due to too much oestrogen with too little progesterone
How is endometrial hyperplasia managed?
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
Why is smoking protective against endometrial cancer in postmenopausal women?
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
What is the referral criteria for endometrial cancer?
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
What are the investigations for endometrial cancer?
TVUSS for endometrial thickness, less than 4mm in postmenopause
Pipelle biopsy highly sensitive
Hysteroscopy with biopsy
What are the stages of endometrial cancer?
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
What is the management of endometrial cancer?
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
What is the peak age women get ovarian cancer?
60 years old
How can ovarian cancer be classified?
Epithelial - 90%
Germ cell
Sex cord stromal
What are the types of epithelial ovarian cancers?
Serous, mucinous, endometriod etc.
Arise from surface epithelium due to irritation during ovulation
What are germ cell ovarian tumour? How do they present?
Tumours arising from embryonic germ cells of gonad
Present in younger patients as rapidly enlarging abdominal mass
What do sex-cord stroll ovarian cancers arise from?
Connective tissue cells
How do ovarian cancers present?
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
What must be done in women >50yo with a new onset of IBS?
Ovarian cancer testing - can present similarly
How is ovarian cancer investigated in primary care?
CA125 >35 = USS
USS abdo/pelvis abnormal = secondary care
USS abdo/pelvis normal = safety netting
CA125 <35 = safety netting
What other tests can be done in <40yo in primary care for suspected ovarian cancer? Why?
AFP
Beta HCG
Raised levels suggest alternate tumours
What investigation is done in secondary care for patients referred with a raised CA125 and abnormal USS?
CT abdo-pelvis to look at extent of disease
Laparotomy for histology
What are the risk factors for ovarian cancer?
Increased ovulation - null parity, early menarche, late menopause
Increasing age
Oestrogen only HRT
Obesity
Genetics - BRCA 1/2, Lynch syndrome
What are the protective factors against ovarian cancer?
Reduced ovulations
- multiparity
- breastfeeding
- COCP
What is important to know about CA125?
Reduced specificity in premenopausal women
Also raised due to:
- Endometriosis, benign ovarian cysts, menstruation, pregnancy
- Diverticulitis, cirrhosis
- Other malignancies (bladder, breast, liver, lung)
What is RMI (ovarian cancer)?
How is it calculated?
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
What features on USS of ovaries cause concern?
Multilocular cyst
Solid areas
Metastasis
Ascites
Bilateral lesions
Describe the staging of ovarian cancer
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
What is the management for ovarian cancer?
Combination of surgery and chemo
Laparotomy - tumour debunking
Hysterectomy, salpingo-oophorectomy and infra colic omentectomy
How is ovarian cancer followed up?
5 year CA125 monitoring
What is a Krukenberg tumour?
A metastasis in the ovary, usually from a gastrointestinal tract cancer. Signet ring on histology
What are protective factors in ovarian cancer?
Factors which stop ovulation or reduce the number of lifetime ovulations e.g.
Combined contraceptive pill
Breastfeeding
Pregnancy
When should 2WW be referred for ovarian cancer?
If feels ascites, pelvic mass (unless due to fibroids) or abdominal mass on examination
Carry out further investigations before referral e.g. CA125
What is the staging of ovarian cancer?
1 - confined to ovary
2 - spread past ovary but inside pelvis
3 - spread past pelvis but inside abdomen
4 - spread outside abdomen - distant mets
What is the epidemiology of vulval cancer?
Very rare cancer
90% squamous
Mostly >75yo
Less commonly they can be malignant melanomas
How do vulval cancers present?
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
When would you refer someone to gynae under 2 week wait for suspected vulval cancer?
Lump
Ulceration + bleeding
Where do vulval cancers affect?
Labia majora - 50%
Labia minora - 20%
Clitoris and bartholin’s glands - infrequent
What are the risk factors for vulval cancer?
VIN
HPV
Lichen sclerosus
How is vulval cancer diagnosed?
Examination and biopsy
Where do vulval cancers spread?
Inguinal and femoral lymph nodes
How are vulval cancers managed?
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
What is VIN?
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
How does VIN present?
Itching
Plaque like white patches
How is VIN diagnosed?
Biopsy - confirm not invasive cancer
How is VIN managed?
Laser therapy
Wide local excision
What are some complications of a Lletz biopsy (for suspected cervical cancer)
Scarring = cervical stenosis
Cervical incompetence
Infection and pyometra
