Gynaecological Cancers Flashcards
HPV strains associated with cervical cancer
16 and 18
HPV strains associated with genital warts
6 and 11
HPV vaccines available
Gardisil: introduced in 2006, quadrivalent coverins strains 6, 11, 16, 18
Bivalent vaccine: strains 16,18 available too
Clearance of HPV infection
Most women clear the infection spontaneously in 8-14 months
Typical pre-invasive period of cervical cancer
10+ years
Causes of false negative pap smear for high grade lesion
Chronic cervicitis
Blood
Inflammation
Current Australian guidelines for pap smears:
All sexually active women to have a pap smear every 2 years from the age of 18-70
Natural history of LSIL on pap smear
80% regress by 12 months
under 4% progress to high-grade lesions in 12 months
Management of woman with LSIL on Pap smear
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
Management of HSIL on pap smear
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
Recurrence and prognosis of cervical cancer
Majority of recurrent in first 2 years after treatment, largely dependent on stage of disease
40-50% 5 year survival rate
Epidemiology of ovarian cancer
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
Typical triad of symptoms of ovarian cancer
abdominal discomfort + weight loss + abnormal uterine bleeding
Abdominal discomfort + weight loss + abnormal uterine bleeding
triad for…
Ovarian carcinoma
Presentation of ovarian cancer
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)
Investigations if suspect ovarian cancer
Serum CA 125 (common to all ovarian malignancies)
Pelvic USS
HCG (raised in germ cell tumours)
Malignancy associated with raised Serum CA 125
Ovarian cancers (all forms)
Most common primary sources of secondary metastasis to ovary
Endometrium Breast Colon Stomach Cervix
Most common kinds of uterine cancer
Endometrioid adenocarcinoma (Type 1) Serious papillary carcinoma (type 2)
Risk factors for endometrial cancer
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
Clinical features of endometrial cancer
Abnormal vaginal bleeding (post-menopausal, intermenstrual, blood-stained discharge, menorrhagia) Lower abdo pain Dyspareunia Advanced disease (fistula, bony mets, liver dysfn, resp symptoms)
Examination findings in endometrial cancer
Enlarged uterus on bimanual examination
blood arising from cervix on speculum examination
Investigations for endometrial cancer
b-hcg to exclude pregnancy as cause
USS (ideally transvaginal)
- endometrial cancer unlikely if endometrial thickness
Staging of Endometrial cancer
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
Management of endometrial cancer
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
Prognosis of endometrial cancer
80% 5 year survival overall
Adverse prognostic indicators in endometrial cancer:
older than 70y High BMI grade 3 tumours Papillary serous or clear cell histology Lymphovascular involvement Nodal mets Distant mets
What are pure uterine sarcomas
Endometrial stromal sarcomas and leiomyosarcoams
leiomyosarcomas
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
Mixed epithelial uterine sarcomas
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
Heterologous uterine sarcomas
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
Pathophysiology of vulval cancers
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`
Clinical presentation incl. examination of vulval cancer
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
Most common sites of vulval cancer
Labia majora or clitoris
Vulval intraepithelial neoplasia clinical features
Variable: usually pain and/or pruritus
Indurated pigmented lesions OR eroded red areas on the labia on examination
Management options for Vulval Intraepithelial Neoplasia
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
Causes of vulval intraepithelial neoplasia
HPV (pre-menopausal women) Lichen sclerosis (older, generally post-menopausal women)
Definition of lichen sclerosis
An autoimmune destructive inflammatory skin condition which affects mainly the anogenital area of women
Prevalence of lichen sclerosis
1/300
Associations with lichen sclerosis
Other autoimmune diseases (thyroid, pernicious anaemia)
15% have lichen sclerosis elsewhere on body
Associated with vulval cancer (but not the cause)
Pathophysiology of lichen sclerosis
Autoimmune inflammatory reaction in subdermal layers of skin of vulva - hyalinisation of skin - fragility and parchment paper appearance + loss of vulval anatomy
Symptoms of lichen sclerosis
Vulval itching and soreness secondary to scratching
Splitting of the skin, often at posterior fourchette causing superficial dyspareunia
Examination findings in lichen sclerosis
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
Management of Lichen sclerosis
Good skin care + strong topical steroids
Definition of Bartholin cyst
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
Cause of bartholin cyst
obstruction of bartholin duct, often caused by local or diffuse vulvar oedema
Clinical presentation of Bartholin duct cyst (symptoms and signs)
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)
Clinical presentation of bartholin abscess
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
Management of bartholin duct cyst
No intervention if asymptomatic
Drainage if symptomatic
Biopsy if any findings suggestive of malignancy
Bartholin duct abscess management
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
Skene glands AKA
Paraurethral cysts
diagnosis of Skene gland cyst
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
Management of Skene gland cyst/abscess
Symptomatic cyst: surgical excision
Abscesses: treat with broad spectrum antibiotics (e.g. cephalexin) and then excised or marsupialised
