Gynaecological cancers Flashcards
peak incidence of cervical cancer
25-29
80s second peak
cervical cancer type
70% SCC
15% adenocarcinoma
15% mixed
how long for CIN->cancer
10-20 years
human papilloma virus types that cause cancer
16 and 18
p53, pRB inhibition
risk factors for cervical cancer
smoking
other STIs
long-term COCP use (>8 years)
immunodeficiency (HIV)
3rd commonest gynae cancer
cervical
risk factors for HPV
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
symptoms of cervical cancer
abnormal vaginal bleeding vaginal discharge dyspareunia pelvic pain and weight loss asymptomatic in early stages
advanced disease of cervical cancer
lower limb oedema loin pain rectal bleeding radiculopathy haematuria fistulae renal failure
examination in cervical cancer
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
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
DD cervical cancer:
abnormal vaginal bleeding
STI cervical ectropion polyp fibroids pregnancy-related bleeding endometrial carcinoma if post-menopausal
pre-menopausal investigation in cervical cancer
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.
post-menopausal investigation in cervical cancer
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:
investigations in cervical cancer
chylamydia colposcopy and biopsy basic blood tests: FBC, LFT, U&E CT CAP further staging scans- MRI pelvis, PET \+/- examination under anaesthesia
principles of screening WHO
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
exceptions to screening programme
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
smear result guidlines
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
stage 1 cervical cancer
Stage 1: Confined to the cervix:
A microinvasive
B clinical lesion
stage 2 cervical cancer
Stage 2: Invades the uterus or upper 2/3 of the vagina:
A upper 1/3 vagina
B parametrium
stage 3 cervical cancer
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
stage 4 cervical cancer
Stage 4: Invades the bladder, rectum or beyond the pelvis:
A invades adjacent organs (bladder/ bowel)
B distant sites
surgical options for cervical cancer stage 1a
Radical trachelectomy if fertility-preservation is a priority. (remove cervix and upper part of vagina)
Otherwise, a laparoscopic hysterectomy with pelvic lymphadenectomy is offered.
surgical options for cervical cancer stage 1b/2a
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.
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).
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.
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.
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).
complications of surgery for cervical cancer
Infection
VTE
Haemorrhage
Vesicovaginal fistula
Bladder dysfunction
Lymphocyst formation
Short vagina
complications of radiotherapy
Vaginal dryness
Vaginal stenosis
Radiation cystitis
Radiation proctitis
Loss of ovarian function
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
what is the fourth most common cancer affecting women in the UK?
endometrial cancer
peak incidence of endometrial cancer
65-75 years
most common form of endometrial cancer
adenocarcinoma
pathophysiology of endometrial cancer
stimulation of endometrium by unopposed oestrogen
progesterone is produced by CL after ovulation
endometrial hyperplasia
risk factors for endometrial cancer
anovulation age: 65-75, <45 obesity: aromatisation of androgens to oestrogen hereditary factors: HNPCC diabetes parkinsons endometrial polyps
anovulation factors
early menarche, late menopause low parity PCOS HRT, oestrogen only tamoxifen
symptoms of endometrial cancer
PMB!!!
white vaginal discharge, abnormal cervical smears
IMB, irregular bleeding
abdo pain, weight loss
endometrial hyperplasia types
hyperplasia without atypia
atypical hyperplasia
management of endometrial hyperplasia
IUS (Mirena)
continuous oral progestogens (medroxyprogesterone or levonorgestrel)
endometrial protection in women with PCOS
The combined contraceptive pill
An intrauterine system (e.g. Mirena coil)
Cyclical progestogens to induce a withdrawal bleed.
protective factors against endometrial cancer
COCP
Mirena coil
increased pregnancies
cigarette smoking
continuous combined HRT
physical activity
coffee/ tea
examination of endometrial cancer
abdominal examination for masses
speculum: atropy or cervical lesions
bimanual examination: size and axis of uterus prior to endometrial sampling
transvaginal USS criteria in >55
Unexplained vaginal discharge
Visible haematuria plus raised platelets, anaemia or elevated glucose levels
referral criteria for endometrial cancer 2WW
PMB >12 months after LMP
investigations for endometrial cancer
transvaginal USS
FBC, UE, LFT
CT CAP
MRI pelvis
endometrial thickness >5mm on transvaginal USS
then Pipelle biopsy
hysteroscopy with biopsy is gynaecologist deems the case high risk
endometrial thickness <4mm
on transvaginal USS
risk of cancer low
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
management of endometrial hyperplasia without atypia
Mirena IUS
or continuous oral progestogens
surveillance biopsies
management of endometrial hyperplasia with atypia
total abdominal hysterectomy + bilateral salpingo-oopherectomy
stage 1 endometrial carcinoma management
total hysterectomy and bilateral salpingo-oophorectomy
stage 2 endometrial carcinoma management
radical hysterectomy and lymphadenectomy
stage 3 endometrial carcinoma management
maximal debulking surgery
epithelial types of ovarian carcinoma
Serous cystadenocarcinoma – characterised by Psammoma bodies.
Mucinous cystadenocarcinoma – characterised by mucin vacuoles.
endometrioid
clear cell
germ cell ovarian tumours
teratoma
dysgerminoma
yolk sac
choriocarcinoma
stroma/ sex cord ovarian tumours
granulosa cell
theca cell
sertoli-leydig
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
protective factors for ovarian cancer
multiparity combined contraceptive methods breastfeeding hysterectomy oopherectomy sterilisation pregnancy
risk of malignancy index ovarian cancer
menopausal status
USS: multilocular cyst, solid areas, mets, ascites, bilateral lesions
CA125
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
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.
2WW ovarian cancer
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
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
tumour markers for germ cell tumour
aFP
HCG
causes of raised CA125
non-malignant
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
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
vulval cancer type
SCC
less common malignant melanomas
risk factors
Advanced age (particularly over 75 years)
Immunosuppression
Human papillomavirus (HPV) infection
Lichen sclerosus
Chronic vulvar irritation
HSV T2
Smoking
mx of VIN
Watch and wait with close followup
Wide local excision (surgery) to remove the lesion
Imiquimod cream
Laser ablation
conservative: antihisramine
