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Gynaecological cancers Flashcards

1
Q

peak incidence of cervical cancer

A

25-29

80s second peak

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2
Q

cervical cancer type

A

70% SCC
15% adenocarcinoma
15% mixed

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3
Q

how long for CIN->cancer

A

10-20 years

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4
Q

human papilloma virus types that cause cancer

A

16 and 18

p53, pRB inhibition

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5
Q

risk factors for cervical cancer

A

smoking
other STIs
long-term COCP use (>8 years)
immunodeficiency (HIV)

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6
Q

3rd commonest gynae cancer

A

cervical

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7
Q

risk factors for HPV

A

Early sexual activity

Increased number of sexual partners

Sexual partners who have had more partners

Not using condoms

Smoking

HIV (patients with HIV are offered yearly smear tests)

Combined contraceptive pill use for more than five years

Increased number of full-term pregnancies

Family history

Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)

Young age at first intercourse

Multiple sex partners

Exposure (no barrier contraception)

Immunosuppression/ HIV

Non-compliance with cervical screening

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8
Q

symptoms of cervical cancer

A 
abnormal vaginal bleeding
vaginal discharge
dyspareunia
pelvic pain and weight loss
asymptomatic in early stages
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9
Q

advanced disease of cervical cancer

A 
lower limb oedema
loin pain
rectal bleeding
radiculopathy
haematuria
fistulae
renal failure
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10
Q

examination in cervical cancer

A

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.

no smear test needed

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11
Q

grades of CIN

A

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

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12
Q

DD cervical cancer:

abnormal vaginal bleeding

A 
STI
cervical ectropion
polyp
fibroids
pregnancy-related bleeding
endometrial carcinoma if post-menopausal
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13
Q

pre-menopausal investigation in cervical cancer

A

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.

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14
Q

post-menopausal investigation in cervical cancer

A

urgent colposcopy and biopsy.

A colposcopy is where a colposcope (modified microscope) 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:

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15
Q

investigations in cervical cancer

A 
chylamydia
colposcopy and biopsy
basic blood tests: FBC, LFT, U&E
CT CAP
further staging scans- MRI pelvis, PET
\+/- examination under anaesthesia
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16
Q

principles of screening WHO

A

Condition should be an important health problem

Should be a treatment for the condition

Facilities for diagnosis and treatment should be available

Should be a latent stage of the disease

Should be a test or examination for the condition

Test should be acceptable to the population

Natural history of the disease should be adequately understood

Should be an agreed policy on who to treat

Total cost of finding a case should be economically balanced in relation to medical expenditure as a whole

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17
Q

exceptions to screening programme

A

Women with HIV are screened annually

Women over 65 may request a smear if they have not had one since aged 50

Women with previous CIN may require additional tests (e.g. test of cure after treatment)

Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)

Pregnant women due a routine smear should wait until 12 weeks post-partum

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18
Q

smear result guidlines

A

Inadequate sample – repeat the smear after at least three months

HPV negative – continue routine screening

HPV positive with normal cytology – repeat the HPV test after 12 months

HPV positive with abnormal cytology – refer for colposcopy

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19
Q

stage 1 cervical cancer

A

Stage 1: Confined to the cervix:

A microinvasive

B clinical lesion

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20
Q

stage 2 cervical cancer

A

Stage 2: Invades the uterus or upper 2/3 of the vagina:

A upper 1/3 vagina

B parametrium

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21
Q

stage 3 cervical cancer

A

Stage 3: Invades the pelvic wall or lower 1/3 of the vagina:

Lower 1/3 vagina, hydronephrosis

B extends to pelvic side wall, hydronephrosis

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22
Q

stage 4 cervical cancer

A

Stage 4: Invades the bladder, rectum or beyond the pelvis:

A invades adjacent organs (bladder/ bowel)

B distant sites

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23
Q

surgical options for cervical cancer stage 1a

A

Radical trachelectomy if fertility-preservation is a priority. (remove cervix and upper part of vagina)

Otherwise, a laparoscopic hysterectomy with pelvic lymphadenectomy is offered.

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24
Q

surgical options for cervical cancer stage 1b/2a

A

Radical (Wertheim’s) hysterectomy as a curative treatment modality.

Involves removal of the uterus, vagina and parametrial tissues up to the pelvic sidewall, plus lymphadenectomy.

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25
surgical options for cervical cancer stage 4a or recurrent disease
Anterior/posterior/total pelvic extenteration. Removal of all pelvic adnexae plus bladder (anterior)/rectum (posterior or both (total).
26
radiotherapy for stage 1b to 3 cervical cancer
Offered in conjunction with chemotherapy over a 5-8 week course. Evidence suggests additional hysterectomy offers no benefits in terms of survival for these stages. Therefore chemoradiation therapy is the gold standard.
27
chemotherapy for cervical cancer
Chemotherapy in cervical cancer is often cisplatin-based. It can be given before treatment by surgery or radiotherapy (known as neoadjuvant chemotherapy), or after treatment (adjuvant chemotherapy). It is also the mainstay of treatment in the palliative setting.
28
follow-up cervical cancer
Patients should be reviewed by a gynaecologist every 4 months after treatment has been completed for the first 2 years, and every 6-12 months for the subsequent 3 years. All follow-ups should involve a physical examination of the vagina and cervix (if they haven’t been removed).
29
complications of surgery for cervical cancer
Infection VTE Haemorrhage Vesicovaginal fistula Bladder dysfunction Lymphocyst formation Short vagina
30
complications of radiotherapy
Vaginal dryness Vaginal stenosis Radiation cystitis Radiation proctitis Loss of ovarian function
31
HPV vaccine
The current NHS vaccine is Gardasil, which protects against strains 6, 11, 16 and 18: Strains 6 and 11 cause genital warts Strains 16 and 18 cause cervical cancer Cervarix protects against 16 and 18 3 injections over 6 months Ideally prior to SI 5 years protection Still need smears
32
what is the fourth most common cancer affecting women in the UK?
endometrial cancer
33
peak incidence of endometrial cancer
65-75 years
34
most common form of endometrial cancer
adenocarcinoma
35
pathophysiology of endometrial cancer
stimulation of endometrium by unopposed oestrogen progesterone is produced by CL after ovulation endometrial hyperplasia
36
risk factors for endometrial cancer
``` anovulation age: 65-75, <45 obesity: aromatisation of androgens to oestrogen hereditary factors: HNPCC diabetes parkinsons endometrial polyps ```
37
anovulation factors
``` early menarche, late menopause low parity PCOS HRT, oestrogen only tamoxifen ```
38
symptoms of endometrial cancer
PMB!!! white vaginal discharge, abnormal cervical smears IMB, irregular bleeding abdo pain, weight loss
39
endometrial hyperplasia types
hyperplasia without atypia | atypical hyperplasia
40
management of endometrial hyperplasia
IUS (Mirena) | continuous oral progestogens (medroxyprogesterone or levonorgestrel)
41
endometrial protection in women with PCOS
The combined contraceptive pill An intrauterine system (e.g. Mirena coil) Cyclical progestogens to induce a withdrawal bleed.
42
protective factors against endometrial cancer
COCP Mirena coil increased pregnancies cigarette smoking continuous combined HRT physical activity coffee/ tea
43
examination of endometrial cancer
abdominal examination for masses speculum: atropy or cervical lesions bimanual examination: size and axis of uterus prior to endometrial sampling
44
transvaginal USS criteria in >55
Unexplained vaginal discharge Visible haematuria plus raised platelets, anaemia or elevated glucose levels
45
referral criteria for endometrial cancer 2WW
PMB >12 months after LMP
46
investigations for endometrial cancer
transvaginal USS FBC, UE, LFT CT CAP MRI pelvis
47
endometrial thickness >5mm on transvaginal USS
then Pipelle biopsy | hysteroscopy with biopsy is gynaecologist deems the case high risk
48
endometrial thickness <4mm | on transvaginal USS
risk of cancer low
49
FIGO staging 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
50
management of endometrial hyperplasia without atypia
Mirena IUS or continuous oral progestogens surveillance biopsies
51
management of endometrial hyperplasia with atypia
total abdominal hysterectomy + bilateral salpingo-oopherectomy
52
stage 1 endometrial carcinoma management
total hysterectomy and bilateral salpingo-oophorectomy
53
stage 2 endometrial carcinoma management
radical hysterectomy and lymphadenectomy
54
stage 3 endometrial carcinoma management
maximal debulking surgery
55
epithelial types of ovarian carcinoma
Serous cystadenocarcinoma – characterised by Psammoma bodies. Mucinous cystadenocarcinoma – characterised by mucin vacuoles. endometrioid clear cell
56
germ cell ovarian tumours
teratoma dysgerminoma yolk sac choriocarcinoma
57
stroma/ sex cord ovarian tumours
granulosa cell theca cell sertoli-leydig
58
risk factors for ovarian cancer
``` 60 years BRCA 1/2 increased ovulations obesity smoking clomifene nulliparity early menarche, late menopause unopposed oestrogen, oestrogen HRT FH endometriosis HNPCC ```
59
protective factors for ovarian cancer
``` multiparity combined contraceptive methods breastfeeding hysterectomy oopherectomy sterilisation pregnancy ```
60
risk of malignancy index ovarian cancer
menopausal status USS: multilocular cyst, solid areas, mets, ascites, bilateral lesions CA125
61
Symptoms
Abdominal bloating Early satiety (feeling full after eating) Loss of appetite Pelvic pain Urinary symptoms (frequency / urgency) vaginal bleeding Weight loss Abdominal or pelvic mass Ascites referred hip/ groin pain from obturator nerve compression
62
chronic pain ovarian tumour
may develop secondary to pressure on the bladder or bowel also causing frequency or constipation. It may also manifest as dyspareunia or cyclical pain in those patients with endometriosis who have developed chocolate cysts.
63
2WW ovarian cancer
Ascites Pelvic mass (unless clearly due to fibroids) Abdominal mass
64
investigations ovarian cancer
Pelvic examination USS FBC, U&E, LFT CA125 CSR CT to assess peritoneal, omental and retroperitoneal disease Cytology of ascitic tap Surgical exploration Histopathology
65
tumour markers for germ cell tumour
aFP | HCG
66
causes of raised CA125 | non-malignant
Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy
67
management of epithelial ovarian cancer
Surgery and chemotherapy Staging laparotomy, TAH PLUS BSO and debulking Platinum (cisplatin, carboplatin) and taxane (paclitaxel) In women of reproductive age, where the tumour is confined to one ovary, oophorectomy only may be considered
68
vulval cancer type
SCC | less common malignant melanomas
69
risk factors
Advanced age (particularly over 75 years) Immunosuppression Human papillomavirus (HPV) infection Lichen sclerosus Chronic vulvar irritation HSV T2 Smoking
70
mx of VIN
Watch and wait with close followup Wide local excision (surgery) to remove the lesion Imiquimod cream Laser ablation conservative: antihisramine

Gynaecology (10 decks)

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