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)
