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Medicine > Gynaecological cancers > Flashcards

Gynaecological cancers Flashcards

1
Q

Incidence of gynaecological cancers

A
  1. Uterine (endo,myo)
  2. Ovarian
  3. Cervical (commonest worldwide)
  4. Vulval
  5. Vaginal
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2
Q

Endometrial cancer histology

A

Around 80% of cases are adenocarcinoma

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3
Q

Risk factors for endometrial cancer

A

unopposed oestrogen stimulates the endometrial cells and increases the risk of endometrial hyperplasia and cance
T - tamoxifen (oestrogenic effect on the endometrium.)
A - age (increased)
M - menopause(late) , menarche (early)
P - PCOS ( leads to increased exposure to unopposed oestrogen due to a lack of ovulation)
O- obesity (adipose tissue (fat) is a source of oestrogen)
N - no/few pregnancies (during pregnancy, there is shifts towards progesterone, which is protective )

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4
Q

Protective factors against endometrial cancer

A

Combined contraceptive pill
Mirena coil
Increased pregnancies ( reduced ovulations, reduced estrogen)
Cigarette smoking ( anti-oestrogenic.)

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5
Q

Mx endometrial intraepithelial neoplasia

A

Reversible risk factors such as obesity and the use of hormone replacement therapy (HRT) should be identified and addressed
Progestogen treatment is indicated in women who fail to regress following observation alone and in symptomatic women with abnormal uterine bleeding.
1. Intrauterine system (e.g. Mirena coil)
2. Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
Hysterectomy is indicated in women not wanting to preserve their fertility

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6
Q

Risk factors for endometrial cancer not related to unopposed oestrogen

A

Type 2 diabetes
Hereditary nonpolyposis colorectal cancer (HNPCC)/Lynch syndrome

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7
Q

Clinical presenation endometrial cancer

A

postmenopausal bleeding
Postcoital bleeding
Intermenstrual bleeding ( metrorrhagia)
Unusually heavy menstrual bleeding
Abnormal increased vaginal discharge
Anaemia
Raised platelet count
pyometra (a collection of pus in the uterine cavity)
symptoms of advanced disease: pelvic pain, pelvic mass, leg swelling, haematuria, PR bleeding
symptoms of metastatic disease :cough, shortness of breath or haemoptysis, abdominal pain and jaundice, bone pain, hypercalcaemia and pathological fractures

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8
Q

2 ww endometrial cancer

A

55 and over with postmenopausal bleeding (more than 12 months after the last menstrual period)

Consider 2ww if <55y with post menopausal bleed

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9
Q

Transvaginal US for endometrial cancer if women 55y and over with

A

Unexplained vaginal discharge +- thrombocytosis, haematuria
Visible haematuria + low Hb or thrombocytosis or high glucose levels

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10
Q

Ix endometrial cancer

A

Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
If thickness is >4: Pipelle biopsy or Hysteroscopy with endometrial biopsy

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11
Q

FIGO staging for endometrial cancer

A

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

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12
Q

Mx endometrial cancer

A

Stage 1 &2- total abdominal hysterectomy with bilateral salpingo-oophorectomy

Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer
hormonal therapies such as tamoxifen and progestogens can be used in advanced or recurrent diseas/palliative

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13
Q

Types of ovarian cancer

A

Epithelial cell tumours
Dermoid cysts/germ cell tumours
Sex Cord-Stromal Tumours

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14
Q

Krukenberg tumour

A

metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach
“signet-ring” cells on histology

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15
Q

Ovarian cancer risk factors

A

Age
BRCA1&2
Increased oovulations
Smoking
Recurrent use of clomifene
Diabetes
endometrial cancer and ovarian cysts

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16
Q

Factors that increase the number of ovulations, increase the risk of ovarian cancer. These include:

A

Early-onset of periods
Late menopause
No pregnancies

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17
Q

Factors that stop ovulation or reduce the number of lifetime ovulations, reduce the ovarian cancer risk:

A

Combined contraceptive pill >10 years
Breastfeeding
Pregnancy (have about half the risk of ovarian cancer of women without children) > 3 pregnancies
Hysterectomy, tubal ligation
Exercise
Aspirin

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18
Q

Clinical presenation ovarian cancer

A

Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
Post menopausal bleeding
Bowel symptoms

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19
Q

2ww ovarian cancer

A

if a physical examination reveals:
Ascites
Pelvic mass or Abdominal mass (unless clearly due to fibroids)

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20
Q

Carry out tests in primary care for ovarian cancer if

A

a woman (especially if 50 years or over) reports

Persistent abdominal distension.
Feeling full (early satiety) and/or loss of appetite.
Pelvic or abdominal pain.
Increased urinary urgency and/or frequency.
If CA125 is 35 IU/mL or higher, you should arrange an urgent US scan of her abdomen and pelvis

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21
Q

non-malignant causes of a raised CA125:

A

Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy

22
Q

risk of malignancy index (RMI)

A

estimates the risk of an ovarian mass being malignant, taking account of three things:
Ultrasound findings
Menopausal status
CA125 level

23
Q

FIGO
staging of ovarian cancer
Stage 1 –>
Stage 2 –>
Stage 3 –>
Stage 4 –>

A

Stage 1 –> Tumour confined to ovary
Stage 2 –> Tumour outside ovary but within pelvis
Stage 3 –> Tumour outside pelvic but within abdomen
Stage 4 –> Distant metastasis

24
Q

Mx ovarian cancer

A

Combination of surgery and chemotherapy
the tumours tend to be very radioresistant
Biological immunotherapy is emerging as an option
If ascites were present then an ultrasound guided aspiration of ascities may have been useful both for diagnosis and to ease discomfort

25
Ovarian cancer differentials
Irritable bowel syndrome Ovarian cysts Urinary tract infection Gastric problems Menopausal problems
26
Cervical cancer histology
Ectoocervix is lined by stratified squamous epithelium Endocervix is lined by columnar mucinous epithelium The skin-like cells of the ectocervix can become cancerous, leading to a squamous cell cervical cancer. This is the most common type of cervical cancer. The glandular cells of the endocervix can also become cancerous, leading to an adenocarcinoma of the cervix.
27
Aetiology of cervical cancer
human papillomavirus 16 and 18
28
HPV is also associated with
anal, vulval, vaginal, penis, mouth and throat cancers
29
Risk factors for cervical cancer
Early sexual activity: increased partners , not using condoms Non engagement with cervical screening Other: smoking, HIV, OCP use>5y, fhx, immunisuprresion, increase no. full term pregnancies
30
Clinical presenation cerivcal cancer
Abnormal vaginal bleeding (intermenstrual, postcoital (after intercourse) or post-menopausal bleeding) Vaginal discharge Pelvic pain and/or back pain Dyspareunia (pain or discomfort with sex) Vaginal discomfort Urinary or bowel habit change (can also be associated with bleeding) Suprapubic pain
31
Appearabces that may be suggestive of cervical cancer
Ulceration Inflammation Bleeding Visible tumour Abnormal white/red patches on the cervix. Pelvic bulkiness on PV examination
32
Cervical Intraepithelial Neoplasia
grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy
33
CIN I
mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
34
CIN II
moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
35
CIN III
severe dysplasia, very likely to progress to cancer if untreated. sometimes called cervical carcinoma in situ.
36
Cervical screening
aims to pick up precancerous changes in the epithelial cells of the cervix samples are initially tested for high-risk HPV , if the HPV test is negative the cells are not examined, the smear is considered negative, and the woman is returned to the routine screening program, if HPV positive with abnormal cytology – refer for colposcopy
37
Cervical screening program ages
Every three years aged 25 – 49 Every five years aged 50 – 64
38
Large Loop Excision of the Transformation Zone (LLETZ)/loop biopsy
performed with a local anaesthetic during a colposcopy procedure. It involves using a loop of wire with electrical current (diathermy) to remove abnormal epithelial tissue on the cervix
39
Cone Biopsy
treatment for cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer.
40
FIGO 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
41
Mx cervical cancer
Stage 1B – 2A: Radical(Wertheim's) hysterectomy Stage 2B – 4A: Chemotherapy and radiotherapy Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care,Bevacizumab (Avastin)
42
HPV vaccine
protects against strains 6, 11, 16 and 18
43
Vulval cancer Risk Factors
Advanced age (particularly over 75 years) Immunosuppression Persistent HPV infection Vulval intra-epithelial neoplasia VIN is a precursor Lichen sclerosus (autoimmune disease) Pagets disease (rare, predisposes to adenocarcinoma) Smoking Women who have had melanoma or dysplastic nevi (atypical moles) in other places have an increased risk of developing a melanoma on the vulva
44
HSIL= High grade squamous intraepithelial lesion
type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years.
45
dVIN=Differentiated VIN
alternative type of VIN associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years). A lso associated with erosive lichen sclerosis (not with HPV) . Less common than HSIL. Up to 85% of dVIN will progress to SCC if untreated.
46
Clinical presentation VIN
persistent itch, soreness, burn, tingle, painful sex, areas of red/white skin, raised areas of skin
47
Mx VIN
Wait and watch Wide local excision vulvectomy Imiquimod cream (leads to inflammatory cell infiltration within the field of drug application followed by apoptosis of diseased tissue) Laser ablation Photodynamic therapy steroid cream to ease any inflammation or itch. local anaesthetic ointment to ease soreness.
48
Clinical presentation vulval cancer
Vulval lump Ulceration Bleeding Pain/soreness Itching Lymphadenopathy in the groin Dysuria Vaginal discharge/bleeding Labia majora might have Irregular mass/ Fungating lesion/ Ulceration/ Bleeding
49
2ww vulval cancer
in women with an unexplained vulval lump, ulceration, or bleeding.
50
Ix Vulval cancer
Biopsy of the lesion Sentinel node biopsy to demonstrate lymph node spread Further imaging for staging (e.g. CT abdomen and pelvis)
51
Mx vulval cancer
Wide local excision to remove the cancer Groin lymph node dissection Chemotherapy Radiotherapy Total vulvectomy Plastic surgeons can help create flap to replace excision
52
Vaginal cancer
Rare Predominantly squamous cell carcinoma and commonly HPV related

Medicine (72 decks)

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