Gynaecological cancers

Question 1

What are the risk factors for Endometrial cancer? (give 4)

Answer 1

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

Question 2

Which factors lower the risk for Endometrial cancer? (give 4)

Answer 2

Continuous combined HRT.
COCP.
Smoking.
Physical activity.
Coffee & Tea.

Question 3

What are the pre- and post-menopausal presentations for Endometrial cancer

Answer 3

o Premenopausal = Prolonged, frequent vaginal bleeding. Intermenstrual bleeding.

o Postmenopausal = POSTMENOPAUSAL BLEEDING. Less commonly blood stained, watery or purulent vaginal discharge.

Question 4

What is the pre-malignant condition for Endometrial cancer?

Answer 4

Endometrial hyperplasia (with or without atypia)
Treatment = Progestagens / Surgery

Question 5

What is the classification system for Endometrial cancer?

Answer 5

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.

Question 6

What are the diagnostic tests for Endometrial cancer (for post-menopausal bleeding)?

Answer 6

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.

Question 7

What is the treatment for Endometrial cancer?

Answer 7

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.

Question 8

What are the steps / investigations in the One-Stop postmenopausal bleeding clinic?

Answer 8

One-Stop Postmenopausal bleeding clinic:
History & Examination.
FBC.
Transvaginal ultrasound.
Hysteroscopy & Endometrial biopsy.

Question 9

What are the histological subtypes of Ovarian Cancer?

Answer 9

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.

Question 10

What are the risk factors for Ovarian cancer? (give 4)

Answer 10

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

Question 11

What are the factors that lower the risk of Ovarian cancer? (give 4)

Answer 11

COCP.
Pregnancy.
Breastfeeding.
Hysterectomy.
Oophorectomy.
Sterilisation.

Question 12

Give 4 factors of Ovarian cancer presentation

Answer 12

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%)

Question 13

What does the workup for Ovarian cancer include? (give 5)

Answer 13

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

Question 14

What is the staging system for Ovarian cancer?

Answer 14

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.

Question 15

What is the treatment for Ovarian cancer?

Answer 15

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

Question 16

What is the most common histological subtype of Cervical carcinoma?

Answer 16

2/3 = Squamous cell carcinoma
15% = Adenocarcinoma

Question 17

Give 4 risk factors for Cervical carcinoma

Answer 17

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.

Question 18

Give 3 presenting features of Cervical carcinoma

Answer 18

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.

Question 19

How is Cervical carcinoma staged clinically?

Answer 19

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)

Question 20

Outline the treatment options for Cervical carcinoma

Answer 20

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

Question 21

Outline the frequency of Cervical smears

Answer 21

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

Question 22

How are Cervical smears analysed?

Answer 22

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.

Question 23

How are the Cervical smear results managed?

Answer 23

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

Question 24

What is the follow-up for previously treated Cervical intraepithelial neoplasm (CIN)?

Answer 24

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

Question 25

What is the treatment for Cervical intraepithelial neoplasm (CIN)?

Answer 25

Large loop excision of transformation zone (LLETZ)

Question 26

Name a HPV vaccine and what subtypes it covers?

Answer 26

Gardasil = 6, 11, 16, 18

Cervarix = 16 & 18

Question 27

Name 3 risk factors for Vulval cancers?

Answer 27

o HPV
o Herpes simplex virus – type 2
o Smoking
o Immunosuppression
o Chronic vulvar irritation
o Conditions such as Lichen Sclerosus

Question 28

What is the treatment for Vulval cancers?

Answer 28

Surgery (anatomical considerations)
Radiotherapy / Chemotherapy