Gynaecological Cancer Flashcards
What are the 3 histological sub-types of ovarian cancer?
- Epithelial (derived from cells of fallopian tubes or ovary) - 70% cases
- Germ cell (derived from cells that produce eggs)
- Cord-stromal cell (derived from connective tissue in ovaries)
What is the clinical presentation of ovarian cancer?
- Silent presentation (vague and non-specific symptoms)
- Abdominal distension/bloating
- Shifting dullness
- Vaginal bleeding or discharge that are not normal for individual
- Pelvic or abdominal pain or pressure
- Abdominal mass
- Back pain
- Feeling full quickly when eating
- Urinary frequency
- Constipation
- Diarrhoea
- SOB
- Weight loss
- Persistent fatigue
How is suspected ovarian cancer investigated?
- Tumour markers - CA-125
- USS abdomen/transvaginal (may pick up ascites)
- CT abdomen/pelvis
- Needle biopsy
- Laparoscopy
What CT findings may be seen in ovarian cancer?
- Peritoneal thickening
- Ascites
What is the surgical management of ovarian cancer?
Total abdominal hysterectomy, bilateral salpingo-oopherectomy and omentectomy.
What is the optimal treatment regime in ovarian cancer?
Surgical debulking with adjuvant chemotherapy (paclitaxel/carboplatin)
What are the signs and symptoms of endometrial cancer?
Premenopausal: irregular menstrual bleeding, spotting, and bleeding between menstrual periods.
Postmenopausal: any bleeding is abnormal.
Symptoms of advanced endometrial cancer include abdominal or pelvic pain, bloating, feeling full quickly when eating, and changes in bowel or bladder habits.
What investigations are employed in suspected endometrial cancer?
- Transvaginal USS
- Endometrial biopsy
- MRI pelvis
What are the risk factors for endometrial cancer?
- Age (post-menopausal women)
- Oestrogen exposure - HRT, nulliparity, peri-menopause, obesity, PCOS
- Lynch syndrome (HNPCC)
How is endometrial cancer managed?
- Surgery - hysterectomy usually curative
- Total hysterectomy (removing cervix and uterus) + bilateral salpingo-oopherectomy
- Adjuvant radiotherapy and chemotherapy depending on stage and grade of
tumour
What is the commonest histological sub-type of cervical cancer?
- SCC (70%)
- Adenocarcinoma (15%)
- Mixed type (15%)
Explain the pathophysiology of cervical cancer?
Cervical cancer usually develops as a progression from cervical intraepithelial neoplasia (CIN). This occurs over the course of 10-20 years, although not all cases of CIN progress to cancer (and most spontaneously regress).
Invasive cervical cancer occurs when the basement membrane of the epithelium has been breached. The most common sites of metastasis are the lung, liver, bone and bowel.
Discuss the role of HPV (notably types 16+18) in cervical cancer pathogenesis
- 99.7% of cervical SCCs have HPV DNA
- HPV is a sexually transmitted virus (skin/mucous membranes)
- Some infections persist and can cause dysplastic changes such as CIN and in turn, malignant changes i.e. cervical cancer
- HPV 6/11 are low-risk serotypes which cause genital warts
- HPV 16/18 serotypes are common and high risk which produce proteins which inhibit TSG p53 in cervical epithelial cells
Describe the role of screening in cervical cancer and recall the screening programme ages and intervals
Screening programme: • 3 yearly 25-49 year old • 5 yearly 50-64 year old • Cytology, HPV testing • Reduces the incidence and mortality of cervical cancer = Cancers detected earlier
Discuss the signs and symptoms of cervical cancer
- Most common = abnormal vaginal bleeding (e.g post-coital, intermenstrual or post-menopausal).
- Other clinical features include vaginal discharge (blood-stained, foul-smelling), dyspareunia, pelvic pain and weight loss.
- Often asymptomatic – particularly in the early stages of disease – and many cases are detected through routine screening.
In advanced disease, the patient may experience oedema, loin pain, rectal bleeding, radiculopathy and haematuria. These often occur as a result of the cancer invading into nearby structures.
What should your clinical examination involve in suspected cervical cancer?
Speculum examination – assess for evidence of bleeding, discharge and ulceration.
Bimanual examination – assess for pelvic masses.
GI examination – assess for hydronephrosis, hepatomegaly, rectal bleeding, mass on PR.
What is the differential diagnosis of abnormal vaginal bleeding?
- Cervical carcinoma
- STI
- Cervical ectropion
- Polyp
- Fibroids
- Pregnancy-related
- Post-menopausal women - endometrial carcinoma
After symptoms suggestive of cervical cancer, which investigations should you order?
Pre-menopausal – test for chlamydia trachomatis infection
If positive; treat for chlamydia infection. If symptoms persist after treatment, refer for colposcopy and biopsy.
If negative; a colposcopy and biopsy is usually performed.
Post-menopausal – urgent colposcopy and biopsy.
A colposcopy is where a colposcope is used to produce a magnified view of the cervix. Acetic acid is used to stain dysplastic areas, and a biopsy is taken.
If the diagnosis of cervical cancer is confirmed, further investigations are required:
Basic blood tests – such as full blood count, liver function tests and urea & electrolytes CT Chest-Abdomen-Pelvis – looking for metastases. Further staging scans – e.g. MRI pelvis, PET. \+/- examination under anaesthesia with further biopsies.
How is cervical cancer managed?
Very early stage disease - treated with:
- trachelectomy (if fertility is to be preserved) or
- Simple hysterectomy
• Patients with more advanced disease (i.e. Stage >2B) →
chemoradiotherapy
