GYNAECOLOGICAL CANCERS Flashcards
How common is ovarian cancer?
Fairly common. It is the 5th most common cancer in women behind breast, bowel, lung and uterine.
What is the peak age of incidence of ovarian cancer?
60-64
What are the risk factors for developing ovarian cancer?
Age over 50 Nulliparity Late age of first conception Early menarche Late menopause Smoking Obesity Family history White caucasian Blood group A HRT Genetic syndromes such as HNPCC
What are the mutations known to increase ones chances of developing ovarian cancer?
BRCA1 (chromosome 17)
BRCA2 (chromosome 13)
What are the protective factors against developing ovarian cancer?
Pregnancy Breast feeding Exercise Treatment with the combined oral contraceptive pill Black/Asia Blood group O
What are the signs and symptoms associated with ovarian cancer?
Ovarian cancer is often called the ‘silent killer’ as there are very often no symptoms. Therefore there should be a high index of suspicion for older women presenting with even very vague symptoms such as:
Bloating Abdominal pain Distension Abdominal mass Urinary frequency Post-menopausal bleeding Ascites
What investigations should women with signs and symptoms that may indicate ovarian cancer be sent for?
Pelvic ultrasound is first line - this can be either trans-abdominal or trans-vaginal
Blood tests - tumour marker CA-125
Those suspected of having ovarian cancer will have a CT
A 58 year old women presents to her GP with abdominal bloating and the GP wants to rule out ovarian cancer. Having had an ultrasound scan, how does he work out whether or not to refer the patient for specialist care?
Risk of Malignancy Index (RMI), which takes into account the ultrasound results, menopausal status and the serum CA125 level.
RMI = ultrasound score x menopausal score x CA125 level
Ovarian cysts are very common, especially in pre-menopausal women therefore, differentiating benign from malignant can be hard. Hence the use of the index.
When working out the Risk of Malignancy Index (RMI), what features would score a point when working out the ultrasound score?
Multilocular cysts Solid areas Metastases Ascites Bilateral lesions
0-1 of the features scores 1 in the ultrasound score of the RMI
2-5 scores 3
What is the cut off score for referral in the Risk of Malignancy Index (RMI) for someone with features that may indicate ovarian cancer?
A score above 250 should prompt referral to a specialist
How do we manage ovarian cancer?
MDT
Surgery with adjuvant chemotherapy depending on stage (not recommended in stage 1)
Rarely is surgery limited to affected ovary. Even with stage 1 cancers, a total abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy is usually performed. Perineal washing is also performed for cytology.
What is the 5 year survival rate for someone with ovarian cancer?
This is stage dependent
Stage 1 - 80%
Stage 2 - 60%
Stage 3 - 25%
Stage 4 (distant metastases) - 5-10%
What is the most common gynaecological cancer?
Endometrial cancer
What are the risk factors for developing endometrial cancer?
Age above 50 Obesity (threefold increase) PCOS Nulliparity Unopposed oestrogen use Tamoxifen use Genetic syndromes such as HNPCC
What is endometrial hyperplasia?
A premalignant condition often resulting from high levels of oestrogen such as those seen in PCOS, obesity, oestrogen producing tumours and hormone replacement therapy
How can we treat endometrial hyperplasia?
Progesterone will encourage regression. However, due to the high level of progression to endometrial cancer, hysterectomy should be discussed.
What type of cancer is endometrial cancer?
Adenocarcinoma
What are the subtypes of endometrial cancer?
Endometrioid - most common Serous Clear cell Mixed Small cell
What are the most common symptoms associated with endometrial cancer?
Post-menopausal or perimenopausal bleeding
What investigations should be done for someone in whom with want to rule out endometrial cancer?
Pelvic ultrasound
Pipelle biopsy (small sampling size, means often not worth it)
Hysteroscopy and endometrial biopsy (gold standard)
MRI (once diagnosis has been confirmed from tissue sample)
What thickness should the endometrium of a post-menopausal women be?
Less than 5mm
How do we manage endometrial cancer?
MDT
Surgery - Peritoneal washing for cytology, total abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy is usually performed.
What is the overall 5-year survival rate for all stages of endometrial carcinoma?
83-86%
What is the 5-year survival rate for those in whom endometrial cancer is confined to the uterus?
95-97%
What are the uterine sarcomas?
Stromal sarcoma Myometrial sarcoma (leiomyosarcoma)
What are the two age peaks in terms of incidence of cervical cancer?
Mid 30s
Mid 80s
What is the most common type of cervical cancer?
Squamous cell carcinomas (more than 90%)
What are the risk factors associated with cervical cancer?
Early age of first intercourse Higher number of sexual partners HPV (human papilloma virus) infection Smoking Lower SEC Partner with prostatic or penile cancer
Which HPVs have been particularly associated with cervical cancer?
16 and 18
6 and 11 to a lesser degree
What is the format of the national cervical screening programme?
Women are invited for cervical smears every 3 years between the age of 25-49 and every 5 years between the age of 50 and 65
Patients with abnormal smears will be offered a colposcopy.
At what age are people invited for vaccination against HPV? Do they still need smear screening?
12-13 year olds.
Yes, they will still be invited for cervical screening.
What is cervical intraepithelial neoplasia?
The precancerous state of the cervix epithelium.
How can we treat cervical intraepithelial neoplasia before it progresses to cervical cancer?
Excising or destroying the transformation zone.
Excising techniques include large loop excision of transformation zone (LLETZ), needle excision of transformation zone (NETZ) and cone biopsy. The sample is then checked for margins, ensuring complete excision.
Destructive techniques include cold coagulation, diathermy and laser.
What is the success rate of treating cervical intraepithelial neoplasia?
95%
What are the signs and symptoms of cervical cancer?
Often asymptomatic or picked up on screening
Post-coital bleeding
Intermenstrual bleeding
Persistent vaginal discharge (often blood stained)
Post-menopausal bleeding
How is cervical cancer treated?
MDT
Depending on staging, cone biopsy or large loop excision of transformation zone may be sufficient.
Surgery, chemotherapy and radiotherapy are all offered depending on patient’s circumstances.
What are the risk factors for vulval cancer?
History of vulval intraepithelial neoplasia
Immunosuppression
Lichen sclerosus
What is lichen sclerosus?
Benign/precancerous condition (only in 4%) skin condition, characterised by white plaques and atrophy in a figure of 8 pattern around the vulva and anus. Extragenital plaques on trunk and back might be seen. Associated with vitiligo.
What type of cancer are most vulva cancers?
Squamous cell carcinomas
What are the common presenting symptoms of vulva cancer?
Pruritus Lump/ulcer Bleeding Pain Discharge
What investigations should be done to diagnose vulval cancer?
Biopsy
CT or MRI for identifying positive nodes once diagnosis has been made
How do we manage vulval cancers?
MDT
Surgery and radiotherapy (if there is nodal involvement)
Chemotherapy is not indicated.
