gynaecological cancers DONE Flashcards
what is endometrial hyperplasia
thickening of the inner lining of the womb (uterus)
excess of the hormone oestrogen not balanced by progestrone hormone
what are the two types of endometrial hyperplasia
hyperplasia without atypia. In this type, the lining of the womb is thicker, as more cells have been produced. The cells are all normal, however, and are very unlikely to ever change to cancer. Over time, the overgrowth of cells may stop on its own, or may need treatment to do so.
Atypical hyperplasia. In this type, the cells are not normal (they are said to be atypical). This type of hyperplasia is more likely to become cancerous over time if not treated.
Sx of endometrial hyperplasia
red flags above 55 vaginal bleeding which is different to your usual pattern. PMB vaginal discharge
inbetween their periods
heavier or irregular
HRT you may get bleeding
causes of endometrial hyperplasia
overweight diabetic HRT no children PCOS tumour of the ovary tamoxifen
tests for endometrial hyperplasia
US scan - exclude other causes such as polyps or cysts
after menopause lining is thin usually
endometrial biopsy
hysteroscopy
Mx for endometrial hyperplasia without atypia
nothing and repeat biopsy
IUS is the best treatment releases progestorn which thins the lining of the women.
stays in at least for 6 months but for upo 5 years
repeat sampling in 3-4 months
when may hysterectomy endometrial hyperplasia without atypia be required
The hormone treatments are not working after 6-12 months.
The condition comes back after treatment.
You go on to develop atypical hyperplasia.
You prefer to have an operation than to take regular medication or have an IUS
Mx for atypical endometrial hyperplasia
total hysterectomy with bilateral salpingo-oophorectomy
menopause - removal of ovaries and fallopian tubes may be suggested
most common gynaecological cancer
endometrial
Rare before the age of 35
Peak age group 64 – 74
Declines after 80
Commoner in western world
high risk factors for endometrial cancer
Obesity Early menarche-late menopause Nulliparity PCOS Unopposed oestrogen Tamoxifen Previous breast or ovarian cancer BRCA 1/2 Endometrial polyps Diabetes Parkinson’s
all result in excess oestrogen
risk factors that reduce endometrial cancer
Continuous combined HRT Combined oral contraceptive pill Smoking Physical activity Coffee Tea
presentation of endometrial cancer
Pre-menopausal (1% risk)
Prolonged, frequent vaginal bleeding
Intermenstrual bleeding
Postmenopausal Postmenopausal Bleeding (PMB) (10% risk) Less commonly blood stained, watery or purulent vaginal discharge
pathology of endometrial hyperplasia
Pre-malignant condition
Classification simple, complex, atypical
With atypical, malignancy co-exists in 25-50% of cases, and 20% will develop Ca within 10 years.
Treatment with progestagens/ surgery
classification of endometrial adenocarcinoma
TYPE 1 (80%): Endometrial Adenocarcinoma
TYPE 2 (20%):
Papillary Serous
Clear cell Carcinosarcoma
endometrial FIGO staging
1A - confined to cervix - <7mm wide
1B - confined to cervix - >7mm
2 - Cervical spread NOT TO PELVIC WALL
3 - Uterine serosa
Ovaries / Tubes Vagina
Pelvic / Para-aortic Lymph Nodes to pelvic wall
4 - Bladder / bowel involvement
Distant metastases
diagnostic tests for endometrial cancer
Endometrial sampling by Pipelle or (less commonly) D&C - dilataion and caradarch
Hysteroscopy: gold standard to assess uterine cavity
Transvaginal Ultrasound: useful for investigation of PMB, use >5mm cut off for endometrial thickness
1) women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
2) first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
3) hysteroscopy with endometrial biopsy
other Ix for endometrial cancer
- Metastases rare at presentation in Type 1 cancers
- Intraperitoneal, lung, bone, brain
- FBC, U&E, LFT
- CT chest/abdo/pelvis
- MRI Pelvis
preferref Mx for endometrial cancer and factors influencing it
Surgical treatment is the preferred treatment option where possible.
Factors influencing primary treatment are stage, age & fitness for surgery, patient preference
surgical Mx for endometrial cancer
Hysterectomy PLUS bilateral salpingo-oophorectomy, peritoneal washings
Laparoscopic / Open
non-surgical alternatives for endometrial cancer
Progestagens
Primary Radiotherapy
adjuvant radiotherapy if high risk of recurrence of endometrial cancer
External beam
Brachytherapy
advanced disease/inoperatble disease/ unfit for surgery for endometrial cancer
Chemotherapy
Radiotherapy
Hormones
Palliative Care
what will happen at one stop postmenopausal bleeding
History & Examination
FBC
Transvaginal ultrasound
Hysteroscopy and endometrial biopsy
epidemiology of ovarian cancer
- Second commonest gynae cancer in the UK
- Incidence is rising
- Lifetime risk 1:50
- Peak age 70-74 years, occurs predominantly in 5th, 6th and 7th decade
pathology of ovarian cancer
cystadenocarcinoma - commonest histological subtype surface epithelium - most common serous - mucinous endmetriod - clear cell brenner tumpurs
germ cells
- dysgerminoma
- teratoma
- yolk sac
- choriocarcinoma
stroma
- granulosa
- theca
- sertoli-leydig
krukenberg tumour from stomach or breast cancer
which types of ovarian cells can be benign/malignant
serous
mucinous
teratoma
high risk factors for ovarian cancer
- Genetic
- FH of ovarian cancer
- BRCA 1/2
HNPCC - Environmental
- asbestos exposure
- talcum powder use - physical
- Obesity - Hormonal
- Nulliparity
- Early Menarche
- Late Menopause
- Unopposed Oestrogen HRT - Medical Hx
- Endometriosis / cysts
risk factors that reduce ovarian cancer
Combined oral contraceptive pill Pregnancy Breastfeeding Hysterectomy Oophorectomy Sterilisation ? Statins
ovarian cancer presentation
not specific
- abdominal swelling
- pain
- anorexia
- N/V
- weight loss
- vaginal bleeding
- bowel Sx
adenocarcinoma cells and a complex pelvic mass
Ovarian cancer diagnosis and work up
CA125 - baseline
Pelvic examination
Ultrasound
FBC, U&E, LFT
(CXR) - staging
CT to assess peritoneal, omental and retroperitoneal disease
Cytology of ascitic tap
Surgical exploration
Histopathology
ovarian cancer staging
1 - Limited to ovary / ovaries
2 - Spread to pelvic organs
3 - Spread to rest of peritoneal cavity
Omentum
Positive Lymph nodes
4 - Distant metastatsis
Liver parenchyma
Lung
epithelial ovarian cancer Tx
Surgery + chemotherapy
Staging laparotomy, TAH PLUS BSO and debulking
Platinum (Cisplatin, carboplatin) and Taxane (paclitaxel)
In women of reproductive age, where the tumour is confined to one ovary, ophorectomy only may be considered
non-epithelial ovarian tumours Tx
often occur in young women and can be extremely chemo-sensitive (e.g. germ cell). Often treated with combination of ‘conservative’ surgery and chemo
Tx if recurrent ovarian tumours
palliative chemotherapy
factors that increase risk of cervical cancer
- HPV
- Young age at first intercourse
- Multiple sex partners
- Exposure (no barrier contraception)
- Smoking
- Long term use of COCP
- Immunosuppression/HIV
Non compliance with cervical screening
factors that may reduce cervical cancer
HPV vaccine
Cervical screening compliance
which HPV types increase risk of cervical cancer
16, 18
what is HPV
HPV (esp subtypes 16 & 18): produce proteins (E6&7) which suppress the products of ‘p53’ tumour suppressor gene in keratinocytes
Most women will be infected at some time
HPV infection is common in late teens and early twenties
Infection lasts on average 8 months
history of HPV
Asymptomatic
Can be cleared or persist or cause CIN
CIN history
Asymptomatic
Can regress, persist or progress to cancer
what is CIN
Pre-malignant condition
Occurs at the TZ
Asymptomatic
diagnosis of cervical cancer
histological
cervical presentation
PCB
PMB
IMB
Blood stained vaginal discharge
In very advanced disease:
Fistulae, renal failure, nerve root pain, lower limb oedema
staging of cervical cancer
1
Confined to cervix A Microinvasive (depth<5 mm/width<7mm)
B Clinical lesion
2
Beyond cervix but not pelvic side wall or lower 1/3 of vagina
A Upper 1/3 Vagina
B Parametrium
3
Pelvic spread, reaches side wall or lower 1/3 of vagina
A Lower 1/3 of vagina, hydronephrosis
B Extends to pelvic side wall, hydronephrosis
4
Distant spread
A Invades adjacent organs (bladder/bowel)
B Distant sites
Mx for cervical cancer
Microinvasive carcinoma: can be more conservative. If fertility is an issue, then cone biopsy can be used. Once family is complete, hysterectomy is appropriate.
Clinical Lesions (1b - 2a): Wertheim’s radical hysterectomy or chemoradiotherapy (survival same)
- Clinical lesions beyond stage 2a: Chemoradiotherapy
- Postoperative radiotherapy: with lymph node involvement
- Recurrent disease: Radiotherapy, chemotherapy, exenteration, palliative care
surgical complications of cervical cancer Mx
Surgery:
Infection VTE Haemorrhage Vesicovaginal fistula Bladder dysfunction Lymphocyst formation Short vagina
radiotheraphy complications of cervical cancer
Vaginal dryness Vaginal stenosis Radiation cystitis Radiation proctitis Loss of ovarian function
Principles of cervical screening
The condition should be an important health problem.
There should be a treatment for the condition.
Facilities for diagnosis and treatment should be available.
There should be a latent stage of the disease.
There should be a test or examination for the condition.
The test should be acceptable to the population.
The natural history of the disease should be adequately understood.
There should be an agreed policy on whom to treat.
The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
cervical smear frequency
First invitation age 25
3 yearly from 25 to 50
5 yearly from 50 – 65
After 65 selected patients only
cervical cytology
Cells collected from cervix (transformation zone) and exfoliated morphology examined
Liquid based cytology- UK
classification of cytology
Normal Inadequate Borderline Mild Dyskaryosis Moderate Dyskaryosis Severe Dyskaryosis Possible Invasion
what is colposcopy
- Low-power binocular microscopy of cervix
To look for features suggestive of CIN or invasion
- — abnormal vascular pattern (mosaicism, punctation)
- — abnormal staining of the tissue (aceto-white, brown iodine)
Mx for CIN
See-and-treat concept
Excisional: LLETZ (large loop excision of the transformation zone), cold knife cone
Destructive: cryocautery, diathermy, laser vaporisation (less common in UK)
Following colposcopy, follow up depends on results, but may be 6 monthly, yearly for 10 years, or routine recall
what vaccination is given preveneting cervical cancer
Gardasil: 6,11,16,18
Cervarix:16 & 18
3 injections over 6 months
Ideally prior to SI
5 years protection
Still need smears (HPV 31, 45 & others)
how does vulval cancer look
ulcerated lesion or raised in labia or clitoris
what is VIN vulval intraepithelial neoplasia
presentation
Mx
Pre malignant condition
- Can resolve spontaneously
- Can progress to vulval cancer
Can be asymptomatic
Can present with itching/burning/pain
Treatment
Conservative: Antihistamine
Medical: Imiquimod
Surgical: Excision
risk factors for VIN
Herpes Simplex Virus Type 2 Smoking Immunosuppression Chronic vulvar irritation Conditions such as Lichen Sclerosus
vulval cancer cell type
SCC caused by HPV
Meig’s syndrome three features
a benign ovarian tumour
ascites
pleural effusion
what is serous cystadenoma
benign
Most common benign ovarian tumour, often bilateral
Cyst lined by ciliated cells (similar to Fallopian tube)
what is serous cystadenocarcinoma
malignant
Often bilateral
Psammoma bodies seen (collection of calcium)
what is mucinous cystadenoma
benign
Cyst lined by mucous-secreting epithelium (similar to endocervix)
what is mucinous cystadenocarcinoma
malignant
May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause)
what is brenner tumour
Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have ‘coffee bean’ nuclei.
benign
what is teratoma
Ix
Mature teratoma (dermoid cyst) - most common: benign Immature teratoma: malignant
Ix - AFP, LDH, hCG
Account for 90% of germ cell tumours
Contain a combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue
what is dysgerminoma
malignant
Most common malignant germ cell tumour
Histological appearance similar to that of testicular seminoma
Associated with Turner’s syndrome
Typically secrete hCG and LDH
what is yolk sac tumour
malignant
secrete AFP
Schiller-Duval bodies on histology are pathognomonic
what is choriocarcinoma
malignant
estational trophoblastic disease
Typically have increased hCG levels
Often characterised by early haematogenous spread to the lungs
what is granulosa cell tumour
malignant
Produces oestrogen leading to precocious puberty if in children or endometrial hyperplasia in adults.
Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)
what is sertoli-leydig tumour
benign
Produces androgens → masculinizing effects
Associated with Peutz-Jegher syndrome
what is fibroma
benign
Associated with Meigs’ syndrome (ascites, pleural effusion)
Solid tumour consisting of bundles of spindle-shaped fibroblasts
Typically occur around the menopause, classically causing a pulling sensation in the pelvis
what is krukenberg tumour
malignant
Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma
if a woman is pregnant but she is due for cervical smear what should u do
3 months post-partum
for ovarian cancer if it spread lymphatically where will it go first and its haematological where will it go first
lymphatically - para-aortic lymph nodes
haematological - liver
epidemiology of ovarian cancer
leading cause of death from gynaecological cancer
most common in the postmenopausal group
what investigations are done to assess ascites
- ascitic tap for cytology
exudative causes of ascites
malignant infiltration peritoneum
pancreatitis
abdominal TB
transudative causes of ascites
cardiac failure
hypoalbuminaemia
hepatic cirrhosis
renal failure
cervical screening interpretation
HRPV +VE
HRPV -VE
-ve -> routine recall
+ve -> cytology
cytology abnormal -> colposcopy
cytology normal -> repeat test
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
sample inadequate
- repeat within 3 months
- > if two consecutive inadequate samples then → colposcopy
why may be a cervical sample be inadequate
Was taken but the cervix was not fully visualized.
Was taken in an inappropriate manner (for example, using an unapproved device).
Contains insufficient cells.
Contains an obscuring element (for example lubricant, inflammation, or blood).
Is incorrectly labelled.
role of a colposcopy
chemicals used
look for abnormal changes
pre cancerous CIN
cancer
acetic acid - abnormal areas turn white (ACETOWHITE)
iodine solution - normal tissue outside of cervis stains brown
epidemiology of endometrial cancer
Commonest gynaecological cancer in UK Incidence is rising Rare before the age of 35 Peak age group 64 – 74 Declines after 80 Commoner in western world
epidemiology of cervical cancer
Worldwide - in some areas commonest cancer in women
UK 3rd commonest gynae cancer
80% of cervical cancer occurs in developing world
5% lifetime risk in some regions
Incidence declined by 40% with cervical screening
Bimodal age distribution (30s and 80s)
More common in low socio-economic groups
2/3 are squamous & ca 15% are adenocarcinoma
symptoms of lichen slerosis
Itch Soreness Dyspareunia if introital narrowing Urinary symptoms Other symptoms, e.g. constipation, can occur if there is peri-anal involvement Can be asymptomatic, but this is rare
signs of lichen sclrosus
Pale, white atrophic areas affecting the vulva
Purpura (ecchymosis) is common
Fissuring
Erosions, but blistering is very rare
Hyperkeratosis can occur
Changes may be localised or in a ‘figure of eight’ distribution including
the perianal area
Loss of architecture may be manifest as loss of the labia minora and/or
midline fusion. The clitoral hood may be sealed over the clitoris so that
it is buried
complications of lichen sclerosus
Development of squamous cell carcinoma
Development of clitoral pseudo cyst
Sexual dysfunction
Dysaesthesia
Mx of lichen sclerosus
ultra potent steroids
DDx of PMB
incomplete cessation of menses cervical cancer ovarian cancer cervical poly endometrial polyp atrophic vaginitis
Risks of hysterectomy w bilateral salpingo-oopherectomy
damage to urethra, ureters, bowel
thromboembolism
stress incontinence
risk of herniation through scat site
other gynae conditions requiring hysterectomy
severe endometriosis fibroids other gynae cancers menorrhagia PID w chronic pain
