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Obstetrics & Gynaecology > Gynaecological Cancers > Flashcards

Gynaecological Cancers Flashcards

1
Q

HPV strains associated with cervical cancer

A

16 and 18

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2
Q

HPV strains associated with genital warts

A

6 and 11

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3
Q

HPV vaccines available

A

Gardisil: introduced in 2006, quadrivalent coverins strains 6, 11, 16, 18
Bivalent vaccine: strains 16,18 available too

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4
Q

Clearance of HPV infection

A

Most women clear the infection spontaneously in 8-14 months

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5
Q

Typical pre-invasive period of cervical cancer

A

10+ years

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6
Q

Causes of false negative pap smear for high grade lesion

A

Chronic cervicitis
Blood
Inflammation

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7
Q

Current Australian guidelines for pap smears:

A

All sexually active women to have a pap smear every 2 years from the age of 18-70

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8
Q

Natural history of LSIL on pap smear

A

80% regress by 12 months

under 4% progress to high-grade lesions in 12 months

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9
Q

Management of woman with LSIL on Pap smear

A

Under 30y: conservative f/up with repeat smear in 12 months
Over 30y: consider referring for colposcopy
IF 2 LSIL results within 12 months: refer for colposcopy

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10
Q

Management of HSIL on pap smear

A

Refer for LLETZ procedure
Follow up repeat pap smear and colposcopy at 6 months + Pap smear and HPV testing at 12 months - repeat 12 monthly until both HPV and cytology are normal, then Pap smear every 2 years

Women with adenocarcinoma in situ at ongoing risk for developing further invasive disease, advise to have total hysterectomy once complete childbearing

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11
Q

Recurrence and prognosis of cervical cancer

A

Majority of recurrent in first 2 years after treatment, largely dependent on stage of disease

40-50% 5 year survival rate

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12
Q

Epidemiology of ovarian cancer

A

Highest mortality rate of gynaecological cancers (late presentation)
Epithelial tumours most common
Average age 50y
Family history of ovarian, breast of colorectal cancer associated with increased risk

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13
Q

Typical triad of symptoms of ovarian cancer

A

abdominal discomfort + weight loss + abnormal uterine bleeding

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14
Q

Abdominal discomfort + weight loss + abnormal uterine bleeding
triad for…

A

Ovarian carcinoma

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15
Q

Presentation of ovarian cancer

A 
Usually asymptomatic until metastatic
Non-specific symptoms:
- abnormal uterine bleeding
- weight loss
- abdo discomfort
- low appetite/anorexia
- nausea and vomiting
- abdominal swelling (mass or ascites)
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16
Q

Investigations if suspect ovarian cancer

A

Serum CA 125 (common to all ovarian malignancies)
Pelvic USS
HCG (raised in germ cell tumours)

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17
Q

Malignancy associated with raised Serum CA 125

A

Ovarian cancers (all forms)

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18
Q

Most common primary sources of secondary metastasis to ovary

A 
Endometrium
Breast
Colon
Stomach
Cervix
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19
Q

Most common kinds of uterine cancer

A 
Endometrioid adenocarcinoma (Type 1)
Serious papillary carcinoma (type 2)
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20
Q

Risk factors for endometrial cancer

A

Exogenous oestrogen or oestrogen agnosits (unopposed oestrogen HRT, tmoxifen post-BCa, phytoestrogens)
Endogenous oestrogen (chronic anovulation, obesity, early menarche/late menopause, oestrogen-secreting tumours e.g. granulosa cell ovarian tumours)
Age-postmenopausal
Family history (Lynch syndrome, BRCA)
Nulliparity and infertility

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21
Q

Clinical features of endometrial cancer

A 
Abnormal vaginal bleeding (post-menopausal, intermenstrual, blood-stained discharge, menorrhagia)
Lower abdo pain
Dyspareunia
Advanced disease (fistula, bony mets, liver dysfn, resp symptoms)
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22
Q

Examination findings in endometrial cancer

A

Enlarged uterus on bimanual examination

blood arising from cervix on speculum examination

23
Q

Investigations for endometrial cancer

A

b-hcg to exclude pregnancy as cause
USS (ideally transvaginal)
- endometrial cancer unlikely if endometrial thickness

24
Q

Staging of Endometrial cancer

A

CA-125 predicts extrauterine spread
MRI better than CT or PET
FIGO staging:
1: confined to uterine body
2: Invading cervical stroma
3. Local and/or regional spread of tumour
4. Tumour invades bladder +/- bowel +/- distant metastases

25
Q

Management of endometrial cancer

A

generally total hysterectopy + bilateral salpingectomy for stage 1
Later than stage 1: radical hysterectomy with pelvic lymph node dissection
3+ or papillary serious: pelvic and para-aortic node dissection (30% risk of involvement)
Postop RTx does not influence survival
CTx: if metastatic disease

26
Q

Prognosis of endometrial cancer

A

80% 5 year survival overall

27
Q

Adverse prognostic indicators in endometrial cancer:

A 
older than 70y
High BMI
grade 3 tumours
Papillary serous or clear cell histology
Lymphovascular involvement
Nodal mets
Distant mets
28
Q

What are pure uterine sarcomas

A

Endometrial stromal sarcomas and leiomyosarcoams

29
Q

leiomyosarcomas

A

tumour of myometrium
Present with rapidly growing pelvic mass and pain
May be able to diagnose with MRI - necrosis within fibroid
Pre-op diagnosis is difficult
Enlarged soft uterus on palpation
Tx: surgery +/- adjuvant treatment if mitotic count is high

30
Q

Mixed epithelial uterine sarcomas

A

AKA carcinosarcomas
Contain both carcinoma(glandular) and sarcoma (endometrial or stromal usually)
Present after menopause with bleeding, fleshy mass protruding from cervix + enlarged soft uterus
previous history of pelvic radiation
Surgery + post-op RTx

31
Q

Heterologous uterine sarcomas

A

Sarcomatous tissue not usually found in uterus (e.g. striated muscle, bone, cartilage)
Most commonly rhabdomyosarcoma - may present in children as grape-like mass protruding from cervix with watery discharge

32
Q

Pathophysiology of vulval cancers

A

Most are squamous cell cancers of the skin
Melanoma can rarely develop
HPV-associated (predominantly younger women)
Non-HPV associated (e.g. lichen sclerosis) predominantly older/postmenopausal women`

33
Q

Clinical presentation incl. examination of vulval cancer

A

Lump noticed when washing
Vulval pain
Post-menopausal bleeding
EXAMINATION:
Clinically obvious cauliflower-type growth of the vulva (may be ulcerated or have thickening of skin)
Inspect cervix and palpate for groin lymph nodes

34
Q

Most common sites of vulval cancer

A

Labia majora or clitoris

35
Q

Vulval intraepithelial neoplasia clinical features

A

Variable: usually pain and/or pruritus

Indurated pigmented lesions OR eroded red areas on the labia on examination

36
Q

Management options for Vulval Intraepithelial Neoplasia

A

Surgical excision (high recurrence rate, may be disfiguring)
Laser treatment
Immunomodulating cream e.g. imiquimod (avoids disfiguration, response rate only 60%, can cause significant skin burning)
Observational Follow up

37
Q

Causes of vulval intraepithelial neoplasia

A 
HPV (pre-menopausal women)
Lichen sclerosis (older, generally post-menopausal women)
38
Q

Definition of lichen sclerosis

A

An autoimmune destructive inflammatory skin condition which affects mainly the anogenital area of women

39
Q

Prevalence of lichen sclerosis

A

1/300

40
Q

Associations with lichen sclerosis

A

Other autoimmune diseases (thyroid, pernicious anaemia)
15% have lichen sclerosis elsewhere on body
Associated with vulval cancer (but not the cause)

41
Q

Pathophysiology of lichen sclerosis

A

Autoimmune inflammatory reaction in subdermal layers of skin of vulva - hyalinisation of skin - fragility and parchment paper appearance + loss of vulval anatomy

42
Q

Symptoms of lichen sclerosis

A

Vulval itching and soreness secondary to scratching

Splitting of the skin, often at posterior fourchette causing superficial dyspareunia

43
Q

Examination findings in lichen sclerosis

A

Whitening, fissuring and loss of normal anatomy of the vulva (fusion of prepuce, loss of distinction between labia majora and minora)
White atrophic papules that may coalesce into plaques
Appearance may be subtle in early stages

44
Q

Management of Lichen sclerosis

A

Good skin care + strong topical steroids

45
Q

Definition of Bartholin cyst

A

The most common benign cyst of the vulva, developing in the region of the Bartholin gland due to obstruction of the duct orifice and accumulation of mucus

46
Q

Cause of bartholin cyst

A

obstruction of bartholin duct, often caused by local or diffuse vulvar oedema

47
Q

Clinical presentation of Bartholin duct cyst (symptoms and signs)

A

Usually unilateral and asymptomatic (1-3cm)
larger size may cause discomfort during sex, sitting or ambulating
Clinical diagnosis based on: soft, painless mass in area of Bartholin gland (medial labia majora or lower vestibular area)

48
Q

Clinical presentation of bartholin abscess

A

Severe pain and swelling (unable to walk, sit or have sex)
Warm, tender, soft/fluctuant mass in lower medial labia majora area
may be surrounded by erythema and oedema
Pus may break through skin and drain spontaneously if abscess close to surface

49
Q

Management of bartholin duct cyst

A

No intervention if asymptomatic
Drainage if symptomatic
Biopsy if any findings suggestive of malignancy

50
Q

Bartholin duct abscess management

A

Incision and drainage of pus provides immediate pain relief
Culture pus (?MRSA)
No benefit of antibiotic therapy unless recurrent, complicated (pregnancy, ISS, cellulitis, MRSA, systemic infection) or known or suspected gonorrhoea or chlamydia
Antibiotic of choice is augmentin duo forte + clindamycin

51
Q

Skene glands AKA

A

Paraurethral cysts

52
Q

diagnosis of Skene gland cyst

A

Palpable cyst/abscess adjacent to distal urethra
Most are under 1cm and asymptomatic
Larger cysts may be symptomatic (dyspareunia, urinary outflow obstruction, UTIs)
Abscess: painful, swollen, tender, erythematous

53
Q

Management of Skene gland cyst/abscess

A

Symptomatic cyst: surgical excision

Abscesses: treat with broad spectrum antibiotics (e.g. cephalexin) and then excised or marsupialised

Obstetrics & Gynaecology (22 decks)

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