Gynaecological Cancer

Question 1

What does LH cause production of?

Answer 1

Progesterone

Question 2

What does FSH cause production of?

Answer 2

Oestrogen

Question 3

What is mittelschmerz pain?

Answer 3

Pelvic and lower abdo pain that some women experience during ovulation

Question 4

What are the symptoms/signs of ovarian cancer?

Answer 4

OFTEN SILENT

• Abdominal distension
• Indigestion
• Urinary frequency
• Ascites
• Early satiety
• Abdominal pain (rupture, haemorrhage, torsion)
• Incidental findings on USS (cyst >5cm in perimenopausal, or any cyst at all in postmenopausal)

Question 5

How are primary ovarian tumours categorised?

Answer 5

Primary (3 main groups):

• Epithelial (serous or mucinous cystadenomas, endometroid, clear cell, Brenner) MOST COMMON
• Germ cell (teratoma/dermoid cyst, dysgerminoma)
• Sex cord (granulosa, thecomas, fibromas)

Question 6

In what age group are teratomas common?

Answer 6

Young women

Question 7

How are secondary ovarian tumours categorised?

Answer 7

Krukenburg tumours - contain signet ring cells, very poor prognosis, classically metastasised from the GI tract

Question 8

What are some tumour-like conditions?

Answer 8

Endometriotic (chocolate) cysts - NB this gives a high Ca125 so can be confused with an ovarian malignancy
Functional cysts

Question 9

Who is more at risk of ovarian carcinoma?

Answer 9

• BRCA 1/2 gene
• Incessant ovulation theory (more cycles)
• Early menarche, late menopause, nulliparity
• Fertility treatment
• HRT

Question 10

What are protective factors for ovarian carcinoma?

Answer 10

• Multiparity
• Lactation
• COCP
• Hysterectomy

Question 11

What investigations should be done for suspected ovarian cancer?

Answer 11

Bloods: FBC, U&E, LFT, Ca125, CEA (aFP, bHCG and LDH in younger women)
Imaging: USS (first line), CXR, explorative laparotomy, preoperative endometrial sampling
Special tests: Barium enema

Question 12

How does ovarian cancer spread?

Answer 12

Directly, Lymphatic, Blood borne

Question 13

What is the staging of ovarian cancer?

Answer 13

Stage 1 - confined to ovary
Stage 2 - confined to pelvis
Stage 3 - confined to abdomen
Stage 4 - growth beyond abdomen

Question 14

How is the risk of malignancy index assessed?

Answer 14

Take into account risk factors (menopausal status, Ca125, USS score) and multiply them together to create score

Question 15

How is ovarian cancer managed?

Answer 15

SURGICAL: Total abdo hysterectomy, bilateral salpingo-oophorectomy with removal of omentum
CHEMOTHERAPY: in all stages except 1a (cisplatin, carboplatin, taxol)
RADIOTHERAPY
LAPAROSCOPY

Treatment is often unsuccessful and requires palliative care

Question 16

How can ovarian cancer be screened for?

Answer 16

Ca125 or transvaginal USS/colour flow doppler - this is poor because there is no clearly defined premalignant stage in ovarian cancer

Question 17

What is the prognosis for endometrial cancer?

Answer 17

VERY GOOD - develops very slowly and symptoms tend to occur early so it is easily detectable

Question 18

What is the pre-cancerous condition of the endometrium?

Answer 18

Endometrial hyperplasia - if atypical, is more likely to progress to cancer

Question 19

What are the risk factors for endometrial cancer?

Answer 19

Higher oestrogen production:

• Age
• Obesity
• Family history
• Early menarche, late menopause
• Nulliparous
• PCOS

NB - HRT is not an indication because it has progesterone as well as the oestrogen and this is PROTECTIVE

Question 20

What are the symptoms of endometrial cancer?

Answer 20

• Intermenstrual/postmenopausal bleeding
• Vaginal discharge
• Pelvic pain

Question 21

How is endometrial cancer investigated?

Answer 21

Transvaginal USS to investigate the endometrial thickness (then do biopsy if >5mm)

Question 22

What is the most common cause of PMB?

Answer 22

Vaginal atrophy (due to lack of oestrogen) - this is a common DD for endometrial cancer

Question 23

Where in the cervix is prone to carcinoma?

Answer 23

Transformation zone - this is where columnar cells have undergone partial eversion and metaplasia into squamous cells

Question 24

What is the premalignant stage of cervical carcinoma?

Answer 24

Cervical intraepithelial neoplasia:
CINI - lower third
CINII - lower two thirds
CINIII - full thickness

Question 25

If CIN is suspected, what should happen?

Answer 25

Coloscopy and punch biopsy to confirm diagnosis

Question 26

How should CINII+ be treated?

Answer 26

LLETZ - large loop excision of transformation zone, using a wire with an electric current running through it.

Question 27

How often should cervical screening occur?

Answer 27

25-49 - every 3 years
50 - 64 - every 5 years
65+ - only if abnormal results

Question 28

What are the risk factors of CIN?

Answer 28

HPV (16,18,31,33), smoking, immunosuppression (HIV), HRT, COPC

Question 29

What are the symptoms of cervical cancer?

Answer 29

Postcoital bleeding, IMB, PMB, offensive discharge

Question 30

What is the 2WW criteria for cervical cancer?

Answer 30

> 35 yo, 4 week history of postcoital bleeding

Question 31

Describe the staging of cervical cancer?

Answer 31

0 - in situ
1 - confined to cervix
2 - beyond cervix but not to pelvic wall or lower 1/3 vagina
3 - disease to pelvic wall or lower 1/3 vagina
4 - bladder, rectum, metastasis

Question 32

How is cervical cancer treated?

Answer 32

If mild - biopsy, trachelectomy
If moderate - (wertheims radical) hysterectomy
If severe/LN involvement - chemo-radiotherapy (brachytherapy)

Question 33

What is Wertheim’s hysterectomy ?

Answer 33

Stage 1a - 2a: Removal of pelvic nodes, uterus, parametric and upper third of vagina - this has many complications, including haemorrhage

Question 34

What is the usual pathology of cervical carcinoma?

Answer 34

90% squamous cell carcinoma, 10% adenocarcinoma

Question 35

What is the role of MRI in cancer screening?

Answer 35

It is beneficial for detecting tumour size, spread and lymph node involvement

Question 36

Why is HPV a risk factor for cervical cancer?

Answer 36

It invades the host and uses its DNA to replicate. It contains proteins E6 and E7. The E6 protein inhibits the tumour suppressor p53 and the E7 protein inhibits pRb, enabling uncontrolled cell division.