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Year 3- placement > Gynaecological cancer > Flashcards

Gynaecological cancer Flashcards

1
Q

Pelvic inflammatory disease (PID)

A

Inflammation of the upper female reproductive tract

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2
Q

PID- presentation

A
  • Bilateral lower abdominal pain
  • Deep dyspareunia
  • Purulent discharge
  • Abnormal uterine bleeding
  • Nausea and Vomiting
  • Urinary symptoms
  • Fever > 38 C but can be afebrile
  • Cervical excitation
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3
Q

PID- signs on examination

A
  • CERVICAL EXCITATION (MOTION TENDERNESS) – Key finding
  • Mucopurulent cervicitis on speculum examination
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4
Q

PID- causes and risk factors

A

Causes
- Untreated chlamydial or gonorrhoeal infection can progress to PID
- Neisseria Gonorrhoea or Chlamydia trachomatis

Risk Factors
- Increased risk in women with multiple sexual partners
- <20s
- Termination of pregnancy can introduce bacterial infection to the upper reproductive tract
- Iatrogenic due to invasive gynaecological procedures

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5
Q

PID- Investigation

A
  • Endocervical Swabs for Chlamydia and Gonorrhoea with nucleic acid amplification tests
  • Urine dipstick and culture – Rule out UTI
  • Pregnancy Test- rule out ectopic which can also present with cervical excitation
  • Pelvic USS – Rule out other pathology
  • Gold Standard: Laparoscopic visualisation. Invasive procedure only to be performed if clinical uncertainty
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6
Q

PID- management

A

If patient is severely unwell, consider admission for IV antibiotics:
o Fever >38 C
o Severe nausea or vomiting
o Ectopic pregnancy cannot be ruled out
o Patient is haemodynamically unstable

  • Start empirical antibiotics as soon as diagnosis is confirmed
  • Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
  • Removal of IUD should be considered
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7
Q

PID- complications

A
  • Subfertility caused by scarring and inflammation of the reproductive tract
  • Chronic Pelvic Pain
  • Reiter’s syndrome
  • Increased likelihood of future ectopic pregnancy
  • Increased risk of preterm delivery
  • Increased foetal and maternal morbidity in future pregnancies
  • Perihepatitis (Fitz-Hugh Curtis syndrome)- in 10% of cases, RUQ pain
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8
Q

Fibroids

A

Benign smooth muscle tumours of the uterus. More common in afro-caribbean women, rare before puberty, develop in response to oestrogen

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9
Q

Fibroids- symptoms

A
  • May be asymptomatic
  • Menorrhagia-may result in iron-deficiency anaemia
  • Bulk-related symptoms- lower abdominal pain: cramping pains, often during menstruation, bloating, urinary symptoms, e.g. frequency, may occur with larger fibroids
  • Subfertility
  • Rare features: polycythaemia secondary to autonomous production of erythropoietin
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10
Q

Fibroids- diagnosis and management of asymptomatic fibroids

A

Diagnosis: transvaginal ultrasound

Management of asymptomatic fibroids: no treatment is needed other than periodic review to monitor size and growth

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11
Q

Management of menorrhagia secondary to fibroids

A
  • Levonorgestrel intrauterine system (LNG-IUS): useful if the woman also requires contraception, cannot be used if there is distortion of the uterine cavity
  • NSAIDs e.g. mefenamic acid
  • Tranexamic acid
  • Combined oral contraceptive pill
  • Oral progestogen
  • Injectable progestogen
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12
Q

Treatment to shrink/remove fibroids

A
  • Medical: GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
  • Surgical: myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically. hysteroscopic endometrial ablation. Hysterectomy. uterine artery embolization
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13
Q

Fibroids- prognosis and complications

A
  • Fibroids generally regress after the menopause
  • Complications: subfertility and iron deficient anaemia
  • Red degeneration: haemorrhage into tumour, commonly occurs during pregnancy
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14
Q

Endometrial cancer

A

Classically seen in post menopausal women, but 25% occur before the menopause. Good prognosis due to early detection

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15
Q

Risk factors for endometrial cancer

A
  • obesity
  • nulliparity
  • early menarche, late menopause
  • unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
  • diabetes mellitus
  • tamoxifen
  • polycystic ovarian syndrome
  • hereditary non-polyposis colorectal carcinoma
  • COCP and smoking are protective
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16
Q

Features of endometrial cancer

A
  • Postmenopausal bleeding- slight and intermittent before becoming more heavy
  • Premenopausal women may have a change in intermenstrual bleeding
  • Pain is not common and signifies extensive disease
  • Vaginal discharge is unusual
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17
Q

Endometrial cancer- Investigations

A
  • Women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
  • First-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
  • Hysteroscopy with endometrial biopsy
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18
Q

Endometrial cancer- management

A
  • localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have postoperative radiotherapy
  • progestogen therapy is sometimes used in frail elderly women not considered suitable for surgery
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19
Q

Red flags for ovarian cancer

A
  • persistent bloating (intermittent bloating is very common)
  • persistent abdominal or pelvic pain
  • difficulty eating, feeling full quickly, persistent nausea
  • change in your bowels
  • Abdominal or pelvic mass
  • Urinary urgency/frequency
  • Unexplained weight loss
  • Unexplained fatigue
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20
Q

Red flags for endometrial/uterine/womb cancer

A
  • bleeding in between periods, after sex or after the menopause
  • heavier periods
  • abnormal vaginal discharge
  • Thrombocytosis with visible haematuria or vaginal discharge in 55 or older
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21
Q

Cervical cancer red flags

A
  • bleeding in between periods or after sex
  • pain during sex
  • abnormal vaginal discharge
22
Q

Vaginal cancer red flags

A
  • bleeding in between periods, after sex or after the menopause
  • pain during sex
  • abnormal vaginal discharge
  • a vaginal lump
  • persistent vaginal itching
23
Q

Vulval cancer red flags

A
  • vulval pain or soreness
  • persistent vulval itching
  • a vulval lump or ulceration
  • thickened, raised patches which can be red, white or dark
  • Unexplained vulval bleeding
24
Q

Cervical cancer

A

Highest rates in people aged 25-29. Divided into squamous cell carcinoma (80%) and adenocarcinoma (20%)

25
Q

Features of cervical cancer

A
  • May be detected during routine cervical cancer screening
  • Abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
  • Vaginal discharge
26
Q

Risk factors for cervical cancer

A
  • HPV serotypes 16,18, 33
  • Smoking
  • HIV
  • Early first intercourse, many sexual partners
  • High parity (lots of pregnancies)
  • Lower socioeconomic status
  • COCP
27
Q

Cervical cancer screening: when it happens

A
  • 25-49 years: 3-yearly screening
  • 50-64 years: 5-yearly screening
  • cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self-refer once past screening age)
  • In pregnancy its usually delayed till 3 months post partum
  • Women who have never been sexually active can opt out of screening
28
Q

Treatment of CIN and cervical cancer staging

A

Treatment of CIN (cervical intra-epithelial neoplasia): large loop excision of transformation zone. Alternatively cryotherapy.

Cervical cancer staging: FIGO staging

29
Q

Management of cervical cancer

A
  • Gold standard is hystercetomy +/- lymph node clearance
  • For patients wanting to maintain fertility a cone biopsy with negative margins can be performed.
  • For advanced cancers offer chemotherapy and radiotherpy, if stage 4 should be palliative
  • If hydronephrosis, nephrostomy should be considered
30
Q

Four main types of ovafian tumours

A
  • Surface derived tumours
  • Germ cell tumours
  • Sex cord stromal tumours
  • Metastasis
31
Q

Surface derived tumours- 65% of ovarian tumours

A
  • Serous cystadenoma: most common benign ovarian tumour, often bilateral. Cyst lined by ciliated cells
  • Serous cystadenocarcinoma: malignant, often bilateral. Psammoma bodies seen (collection of calcium)
  • Mucinous cystadenoma: benign, cyst lined by mucus secreting epithelium
32
Q

Ovarian tumour- Germ cell tumours

A
  • Most common in adolescent girls and account for 15-20% of tumours
  • Teratoma- the mature teratoma (dermoid cyst) is the most common and is benign. Immature teratoma is malignant. Account for 90% of germ cell tumours, contain a combination of ectodermal i.e. hair, mesodermal i.e. bone and endodermal tissue
  • Dysgerminoma- most common malignant germ cell tumour. Histological appearance similar to a testicular seminoma. Associated with turners syndrome. Typically secretes hCG and LDH
33
Q

Ovarian cancer- Sex cord stromal tumour

A
  • Around 3-5% of ovarian tumours, often produce hormones
  • Granulosa cell tumour: malignant, produces oestrogen, leading to precocious puberty if in children or endometrial hyperplasia in adults. Contains Call-Exner bodies (small eosinophilic fluid filled spaces between granulosa cells)
34
Q

Sex cord stromal tumours= Sertoli-Leydig cell tumour and Fibroma

A
  • Sertoli-Leydig cell tumour: benign, produces androgens causing a masculinizing effect. Associated with Peutz-Jegher syndrome
  • Fibroma- benign. Associated with Meigs syndrome (ascites, pleural effusion). Solid tumour consisting of bundles of spindle shaped fibroblasts. Typically occur around the menopause, classically causing a pulling sensation in the pelvis.
35
Q

Ovarian tumour- metastatic

A
  • 5% of ovarian tumours
  • Krukenberg tumour- malignant, metastases from a gastrointestinal tumour resulting in a mucin secreting signet ring cell adenocarcinoma
36
Q

Germ cell tumour- yolk sac tumour and choriocarcinoma

A
  • Yolk sac tumour: typically secretes AFP, schiller-duval bodies on histology
  • Choriocarcinoma- malignant. Rare tumour that is part of the spectrum of gestational trophoblastic disease. Typically, have increased hCG levels. Characterised by early haematogenous spread to the lungs
37
Q

Surface derived tumours- brenner tumour and mucinous cystadenocarcinoma

A
  • Mucinous cystadenocarcinoma: malignant. May be associated with pseudomyxoma peritonei
  • Brenner tumour: benign, Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have ‘coffee bean’ nuclei.
38
Q

Ovarian tumours- symptoms

A
  • Bloating or indigestion
  • Gradually increasing abdominal distension
  • Chronic abdominal, pelvic or back pain, urinary frequency/urgency, constipation/altered bowel habit/bowel obstruction, leg swelling and DVT/PE
  • Abnormal vaginal bleeding
  • Symptoms of metastatic disease i.e. pleural effusion, ascites, weight loss and fatigue
  • Sudden torsion or rupture can present with acute abdominal or pelvic pain
39
Q

Ovarian cancer- clinicals signs

A
  • general examination – cachexia, lymphadenopathy, signs of pleural effusion
  • abdominal examination – distension, ascites, palpable pelvic mass, “omental cake” metastasis
  • Cusco speculum examination – usually normal
  • bimanual palpation – palpable adnexal/pelvic mass which may be fixed and immobile
40
Q

Ovarian cancer- investigations

A
  • Pregnancy test
  • CA-125: is present in most cases of advanced ovarian cancer
  • Other tumour markers: CA19-9, beta-hcg, placental ALP, AFP, Inhibin and LDH
  • Transabdominal +/- transvaginal ultrasound
41
Q

Ovarian cancer- Imaging

A
  • Imaging- CXR to check for pleural effusion or lung metastases, CT +/- MRI abdomen and pelvis to assess mass, pelvic nodes and any metastases; a PET scan may be required in advanced disease
  • Invasive tests – pleural or ascitic tap may be required if effusion/ascites present
  • Laparoscopy and biopsy is indicated for large cystic lesions or adnexal masses to inform further management
42
Q

Ovarian cancer risk factors

A
  • Age (peaks age 60)
  • BRCA1 and BRCA2 genes (consider the family history)
  • Increased number of ovulations
  • Obesity
  • Smoking
  • Recurrent use of clomifene
  • Increased number of ovulations: early onset periods, late menopause, no pregnancies
43
Q

Ovarian cancer- RMI

A

The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:

  • Menopausal status
  • Ultrasound findings
  • CA125 level
44
Q

Ovarian cancer0 further investigations in secondary care include

A
  • CT scan to establish the diagnosis and stage the cancer
  • Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
  • Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells
45
Q

Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:

A
  • Alpha-fetoprotein (α-FP)
  • Human chorionic gonadotropin (HCG)
46
Q

Staging of ovarian cancer

A
  • Stage 1: Confined to the ovary
  • Stage 2: Spread past the ovary but inside the pelvis
  • Stage 3: Spread past the pelvis but inside the abdomen
  • Stage 4: Spread outside the abdomen (distant metastasis)
47
Q

Vulval cancer

A

Around 80% of vulval cancers are squamous cell carcinomas. Most cases occur in women over the age of 65 years. Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.

48
Q

Risk factors for vulval cancer

A
  • Human papilloma virus (HPV) infection
  • Vulval intraepithelial neoplasia (VIN)
  • Immunosuppression
  • Age
49
Q

Features of vulval cancer

A
  • lump or ulcer on the labia majora
  • inguinal lymphadenopathy
  • may be associated with itching, irritation
50
Q

Treatment for vulval cancer

A
  • Watch and wait with close follow up
  • Wide local excision (surgery) to remove the lesion
  • Imiquimod cream
  • Laser ablation
51
Q

Investigations for vulval cancer

A
  • Biopsy of the lesion
  • Sentinel node biopsy to demonstrate lymph node spread
  • Further imaging for staging (e.g. CT abdomen and pelvis)

Year 3- placement (34 decks)

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