Gynaecological cancers Flashcards
What are the risk factors for Endometrial cancer? (give 4)
Increased oestrogen exposure = Tamoxifen; Nulliparity; Early menarche-late menopause; PCOS
BRCA 1/2 mutations [Strong FHx breast cancer]
Increasing age
Endometrial polyps
Obesity; Diabetes
Parkinsons disease
Which factors lower the risk for Endometrial cancer? (give 4)
Continuous combined HRT.
COCP.
Smoking.
Physical activity.
Coffee & Tea.
What are the pre- and post-menopausal presentations for Endometrial cancer
o Premenopausal = Prolonged, frequent vaginal bleeding. Intermenstrual bleeding.
o Postmenopausal = POSTMENOPAUSAL BLEEDING. Less commonly blood stained, watery or purulent vaginal discharge.
What is the pre-malignant condition for Endometrial cancer?
Endometrial hyperplasia (with or without atypia)
Treatment = Progestagens / Surgery
What is the classification system for Endometrial cancer?
FIGO staging:
o Stage 1 = Limited to Myometrium
o Stage 2 = Cervical spread
o Stage 3 = Uterine serosa. Ovaries/Tubes/Vagina. Pelvic / para-aortic lymph nodes.
o Stage 4 = Bladder / Bowel involvement. Distant metastases.
What are the diagnostic tests for Endometrial cancer (for post-menopausal bleeding)?
o Transvaginal ultrasound = useful for investigation of Post-Menopausal Bleeding (if Endometrial thickness >5mm then Hysteroscopy + Endometrial biopsy)
o Endometrial sampling by Pipelle biopsy or (less commonly) Dilation & Curettage.
o Hysteroscopy (+endometrial biopsy) = Gold standard to access uterine cavity.
o Other investigations: Metastases are RARE in Type 1 cancers but Metastases can occur in the Intraperitoneal, Lung, Bone and Brain.
FBC, U&E, LFT. CT chest, abdo, pelvis. MRI pelvis if needed.
What is the treatment for Endometrial cancer?
o Surgery = Total hysterectomy PLUS Bilateral Salpingo-oophorectomy, Peritoneal washings (Laparoscopic/Open).
o Non-surgical alternatives = Progestagens. Primary Radiotherapy.
o Adjuvant Radiotherapy (if high risk of recurrence) – external beam or brachytherapy
o Advanced disease / Inoperable disease / Unfit for surgery = Chemotherapy. Radiotherapy. Hormones. Palliative care.
What are the steps / investigations in the One-Stop postmenopausal bleeding clinic?
One-Stop Postmenopausal bleeding clinic:
History & Examination.
FBC.
Transvaginal ultrasound.
Hysteroscopy & Endometrial biopsy.
What are the histological subtypes of Ovarian Cancer?
o Surface epithelium (all usually malignant) = Serous (50%). Mucinous (10-15%). Endometrioid (10-15%). Clear cell (5%). Brenner Tumours.
o Germ cell = Teratoma (common, rarely malignant). Choriocarcinoma. Yolk sac. Dysgerminoma.
o Stroma/Sex cord = Granulosa cell. Theca cell. Sertoli-Leydig cell. Fibroma.
o Miscellaneous & Metastatic = Primary lymphoma. Metastases. Krukenberg tumour.
What are the risk factors for Ovarian cancer? (give 4)
o Obesity
o Increased oestrogen exposure > Nulliparity. Early menarche/Late menopause. HRT.
o Family history
o BRCA 1 or 2 or Lynch syndrome (HNPCC)
o Endometriosis
What are the factors that lower the risk of Ovarian cancer? (give 4)
COCP.
Pregnancy.
Breastfeeding.
Hysterectomy.
Oophorectomy.
Sterilisation.
Give 4 factors of Ovarian cancer presentation
o Abdominal swelling (50-65%)
o Pain (50-65%)
o Anorexia (20%)
o N&V (20%)
o Weight loss (15%)
o Vaginal bleeding (15%)
o Bowel symptoms (5%)
What does the workup for Ovarian cancer include? (give 5)
o Pelvic Examination
o Ultrasound
o FBC, U&E, LFT
o CEA125
o (CXR)
o CT – assess peritoneal, omental and retroperitoneal disease
o Cytology of ascitic tap
o Surgical exploration + Histopathological diagnosis
What is the staging system for Ovarian cancer?
o Stage 1 = Limited to ovary / ovaries
o Stage 2 = Spread to pelvic organs
o Stage 3 = Spread to rest of peritoneal cavity. Omentum. Positive lymph nodes.
o Stage 4 = Distant metastases. Liver parenchyma. Lung.
What is the treatment for Ovarian cancer?
Epithelial cancer:
o Surgery + Chemotherapy
o Staging laparotomy, TAH PLUS BSO and debulking
o Platinum (Cisplatin, Carboplatin) and Taxane (Paclitaxel)
Non-epithelial tumours: often occur in young women and can be extremely chemo-sensitive (eg Germ cell). Often treated with combination of “conservative” surgery and chemo
Recurrent disease: Palliative chemotherapy
What is the most common histological subtype of Cervical carcinoma?
2/3 = Squamous cell carcinoma
15% = Adenocarcinoma
Give 4 risk factors for Cervical carcinoma
o HPV (esp 16, 18)
o Young age at first intercourse. Multiple sexual partners. Exposure (no barrier contraception).
o Smoking.
o Long term use of COCP.
o Immunosuppression/HIV.
o Non-compliance with Cervical screening.
Give 3 presenting features of Cervical carcinoma
o Post-coital bleeding
o Post-menopausal bleeding
o Intermenstrual bleeding
o Blood stained vaginal discharge
o Very advanced disease = Fistulae. Renal failure. Nerve root pain. Lower limb oedema.
How is Cervical carcinoma staged clinically?
Stage 1 = Confined to Cervix (A = Microinvasive; B = Clinical lesion)
Stage 2 = Beyond cervix but not pelvic side wall or lower 1/3 of vagina
(A = Upper 1/3 Vagina, B = Parametrium)
Stage 3 = Pelvic spread, reaches side wall or lower 1/3 of vagina
(A = Lower 1/3 Vagina, B = Extends to pelvic side wall)
Stage 4 = Distant spread (A = Adjacent organs; B = Distant sites)
Outline the treatment options for Cervical carcinoma
Cervical cancer Treatment (Basically Cone biopsy, Hysterectomy, or Chemoradiotherapy)
o Microinvasive carcinoma = More conservative.
If fertility is an issue, then Cone biopsy can be used.
Once family complete = Hysterectomy is appropriate
o Clinical Lesions (1b-2a) = Wertheim’s radical hysterectomy or Chemoradiotherapy (same survival)
o Clinical lesions beyond stage 2a = Chemoradiotherapy
o Post-operative radiotherapy for Lymph node involvement
o Recurrent disease = Radiotherapy, Chemotherapy, Exenteration, Palliative care
Outline the frequency of Cervical smears
Cervical screening:
* First invite = 25 years
o 3 yearly from 25-50 years
o 5 yearly from 50-65
o After 65 = Selected patients only
How are Cervical smears analysed?
The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
How are the Cervical smear results managed?
Negative hrHPV = Return to normal recall
Positive hrHPV = Cells studied cytologically
o Abnormal cytology = Colposcopy
o Normal cytology = Re-test in 12 months
o At 12 months retest > if HPV -ve = Return to normal testing
o At 12 months retest > if still HPV +ve and cytology normal = Retest in 12 months
o At 24 months retest > if HPV -ve = Return to normal testing
o At 24 months retest > if HPV +ve and cytology normal = Colposcopy
If sample is inadequate = repeat the sample within 3 months
o If 2 samples inadequate = Colposcopy
What is the follow-up for previously treated Cervical intraepithelial neoplasm (CIN)?
Individuals who’ve been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
What is the treatment for Cervical intraepithelial neoplasm (CIN)?
Large loop excision of transformation zone (LLETZ)
Name a HPV vaccine and what subtypes it covers?
Gardasil = 6, 11, 16, 18
Cervarix = 16 & 18
Name 3 risk factors for Vulval cancers?
o HPV
o Herpes simplex virus – type 2
o Smoking
o Immunosuppression
o Chronic vulvar irritation
o Conditions such as Lichen Sclerosus
What is the treatment for Vulval cancers?
Surgery (anatomical considerations)
Radiotherapy / Chemotherapy
