Gynaecological Cancer Flashcards
A 31-year-old woman attends the GP with post-coital bleeding for 3 months. She also reports some pink discharge. Her last smear test was 6 years ago. She has been needle-phobic since childhood. A NAAT swab is negative for chlamydia and gonorrhoea. On cervical examination, the cervix is inflamed and bleeding. Which of the following is the most appropriate next investigation?
A. Hysteroscopy
B. Colposcopy
C. Cervical smear test
D. TVUSS
E. Abdo USS
B. Colposcopy
The most appropriate next investigation for a 31-year-old woman with post-coital bleeding and inflamed, bleeding cervix would be a colposcopy.
What are the dyes used for colposcopy?
- Acetic acid causes abnormal cells to appear white. This appearance is described as acetowhite. This occurs in cells with an increased nuclear to cytoplasmic ratio (more nuclear material), such as cervical intraepithelial neoplasia and cervical cancer cells.
- Schiller’s iodine test involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain (appear yellow under microscopy).
A 24 year old woman attends concerned about her risk of cancer. Her mother was recently diagnosed with breast cancer at age 48, and her maternal grandmother died of ovarian cancer aged 70. She has attended for genetic counselling and has been found to have a mutation in the BRCA1 gene.
What is the most appropriate management for this patient to reduce her risk of ovarian cancer?
A. Ovarian biopsy
B. Bilateral oophorectomy
C. Hysterectomy, bilateral salpingoophorectomy and omentectomy
D. Hysterectomy and bilateral salpingoophorectomy
E. Bilateral salpingooophorectomy
E. Bilateral salpingooophorectomy
Women with BRCA1 mutations have a 65-85% risk of developing breast cancer, and a 40% risk of developing ovarian cancer.
Bilateral salpingooophorectomy is recommended as prophylactic surgery. There is evidence that some tumours arise from the fallopian, so it is important to remove as much of the tubes as possible
A 53-year-old lady is referred urgently to the gynaecology clinic after presenting to her General Practitioner (GP) with unexplained vaginal bleeding. Her last period was 18 months ago.
Which of the following aspects of her history is a risk factor for the development of endometrial cancer?
A. multiparity
B. 40 pack year smoking history
C. PCOS
D. Use of COCP
5. late menarche
C. PCOS
In PCOS increased levels of androgens in the ovaries leads to anovulation. As a result, the corpus luteum does not develop and hence progesterone is not produced. Progesterone mediates the shedding of the endometrial lining each month and its absence increases the risk of endometrial hyperplasia. This, in turn, is a risk factor for endometrial cancer
The COCP reduces the risk of endometrial cancer. This is thought to be due to it causing suppression of endometrial cell proliferation. The COCP also reduces the risk of ovarian cancer. However, it increases the risk of breast and cervical cancer
A 29-year-old woman attends for her cervical screen. She reports feeling well and denies any gynaecological symptoms. She has no significant past medical history and currently has four children. On insertion of the speculum, the GP notes four lumps around the cervical os, which contain amber mucous. They are approximately 4 mm in size each. What is the most likely diagnosis?
A. Bartholin cysts
B. Cervical polyps
C. cervical cancer
D. Cervical ectropion
E. nabothian cysts
E. Nabothian cysts are cysts on the cervix that occur when the squamous-cell epithelium of the cervix slightly covers the columnar epithelium. As the columnar epithelium secretes mucous, the mucous becomes trapped, and cysts form. The cysts contain yellow/amber mucous and are usually located around the os where the epitheliums transition. They are a normal finding, particularly in women who have had children. The cervical smear should still be taken.
When should cervical screening be done for immunocompromised individuals (eg with HIV)?
annually
what CA-125 level is associated with malignant?
> 35units per ml
when should urgent referral to secondary care be warranted if suspecting ovarian cancer (before ca-125)?
on examination: ascites or pelvic/abdominal mass
A 56-year-old woman presents at the GP with spotting. She had her last menstrual period 6 years ago. Bimanual vaginal exam is normal. Which of the following is the most appropriate investigation?
A. FSH
B. Pipelle biopsy
C. Hysteroscopy
D. TVUSS
E. FSH
D. TVUSS
According to NICE guidance, any woman over 55 with postmenopausal bleeding (defined as unexplained vaginal bleeding 12 months after the last menstrual period) should be referred under a 2-week wait pathway for endometrial cancer. The first-line investigation for endometrial cancer is a TVS to assess endometrial thickness.
staging vs grading:
Staging means how big the cancer is and whether it has spread. Grading means how abnormal the cancer cells look under a microscope.
what staging system is used for endometrial and ovarian cancer?
FIGO staging
what are 3 investigations for diagnosing/excluding endometrial cancer?
- Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
- Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
- Hysteroscopy with endometrial biopsy
what is the normal endometrial thickness:
A) pre-menopausal
B) post-menopausal
A) <10mm pre-menopausal
B)<4mm post-menopausal
what is the premalignant stage of endometrial cancer known as?
Endometrial intraepithelial neoplasia (EIN), formally known as complex atypical hyperplasia (CAH),
what are the 2 types of endometrial cancer? Differences?
Type 1 = oestrogen dependent
* Associated with unopposed oestrogen exposure, obesity, subfertility, PCO
* Well-differentiated
* Endometrioid carcinomas (90%; most common=type 1)
- Type 2 = non-oestrogen dependent
- Serous, clear-cell
- Associated with advanced age
- Poorer prognosis
what is leiomyosarcoma
Very rare cancer; smooth muscle cancer of the uterus
Associated with Gardner’s syndrome (sub-type of FAP with extra-colonic polyps)
when should hysteroscopy only be carried out?
-if outpatient endometrial
biopsy is not feasible
-for women with ultrasound irregularities and at
high risk of endometrial cancer (eg tamoxifen use)
what are the different FIGO stages for endometrial cancer?
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
what are the two types of endometrial hyperplasia to be aware of:
- Hyperplasia without atypia
- Atypical hyperplasia
how is endometrial hyperplasia treated?
Using progestogens
1. Intrauterine system (e.g. Mirena coil)
2. Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
what type of cancer is majority of cervical cancer?
SQUAMOUS CELL CARCINOMAS (>90%)
what are the 3 grades of CIN?
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated
what are the 4 FIGO stages of cervical cancer?
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
what is the management for:
Cervical intraepithelial neoplasia and early-stage 1A
: LLETZ or cone biopsy
what is the management for: Stage 1B – 2A:
(radical hysterectomy or radical trachelectomy if
willing to preserve fertility)
* If nodes negative opt for surgery
* If nodes positive opt to chemo-radiotherapy
what is the management for: Stage 2B – 4A:
Chemotherapy and radiotherapy
what is the management for: Stage 4B:
Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
what is the most common type of ovarian cancer? Of that what is the most common?
Epithelial cell tumour
-serous tumour
What forms the risk of malignancy index (RMI)
estimates the risk of an ovarian mass being malignant, taking account of three things:
1. Menopausal status
2. Ultrasound findings
3. CA125 level
what are markers of a germ cell tumour?
- Alpha-fetoprotein (α-FP)
- Human chorionic gonadotropin (HCG)
- Lactate dehydrogenase (LDH)
what are the 4 FIGO stages of ovarian cancer?
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)
how is ovarian cancer managed?
managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.
what are the main types of ovarian cancer?
- Epithelial Cell Tumours
- Serous tumours (the most common)
- Endometrioid carcinomas
- Clear cell tumours
- Mucinous tumours
- Undifferentiated tumours
- Dermoid Cysts / Germ Cell Tumours
- They are teratomas, meaning they come from the germ cells.
- They are particularly associated with ovarian torsion.
-Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG) & lactate dehydrogenase
- Sex Cord-Stromal Tumours
These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles).
-There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.
- Metastasis
- A Krukenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach.
-Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.
what scan is preferred for ovarian cancer (after TVUSS) ?
CT CAP > MRI
where does vulval cancer drain to?
inguinal lymph nodes
where does cervical cancer metastasise to?
iliac lymph nodes
where does endometrial cancer metastasise to?
para aortic LNs
what scan is preferred for cervical cancer?
MRI > CT-CAP
management of ovarian cancer;
Conservative
Medical:
* Chemotherapy first-line usually paclitaxel
+ platinum-based e.g.
cisplatin/carboplatin
* Bevacizumab (Avastin) only for advanced
Surgical:
* Usually ultra-radical surgery
* Primary or interval debulking
most common type of vulval carcinoma?
SCC
what type of vaginal cancer is in teenagers, rare, associated with DES
(diethyltilbestrol)
clear cell adenocarcinoma
what are 2 types of vulval cancer & risk factors?
o Usual type (warty/basaloid SCC) VIN (HPV type 16), immunosuppression, smoking
o Differentiated type (keratinised SCC) lichen sclerosis
VIn treatments:
-Watch and wait with close followup
-Wide local excision (surgery) to remove the lesion
-Imiquimod cream
-Laser ablation
After LLETZ procedure (histology CIN 1 &2) what is the next step in management?
HPV test of cure in 6 months, if negative recall in 3 years (irrespective of age)
76 yr old woman presents with 2cm unilateral, invasive vulvar carcinoma with no evidence of lymph node involvement. Recommended management?
Simple vulvectomy & bilateral inguinal lymphadenopathy
(lymphatic drainage of vulva=inguinal nodes)
what management option for vulvar tumour that is localised (eg T1 staging)
wide local excision (radial local excision)
neoadjuvant vs adjuvant treatment:
Neoadjuvant therapies are delivered before the main treatment, to help reduce the size of a tumor or kill cancer cells that have spread.
Adjuvant therapies are delivered after the primary treatment, to destroy remaining cancer cells.
when would radiotherapy be considered in vulval cancer?
for T2 or greater lesions when combined with surgery (role of radiation is often to shrink tumours to make a surgical excision more likely to succeed ie neoadjuvant therapy or increase the chance of remission ie adjuvant therapy)
when would chemotherapy be considered for vulval cancer?
neoadjuvant or adjuvant therapy. Particularly useful for tumours that extend within 1cm of structures that wouldn’t be surgically removed ef urethra, clitoris and anus.
-It can also be used when surgery in positive margins may not be feasible
If smear test is HPV positive, when should routine colposcopy be performed?
within 6 weeks
