Gynaecological Malignancies Flashcards
What kind of epithelium is found in the cervix?
- Has 2 types:
- Vaginal portion has stratified squamous cells.
- Supravaginal part contains columnar cells.
- Where they meet is the squamo-columnar junction.
Describe squamous metaplasia in the cervix.
Refers (in the cervix) to the physiological replacement of the everted columnar epithelium on the ectocervix with newly formed squamous epithelium from the columnar reserve cells. Where this occurs is called the transformation zone and this is where most cancers will arise.
Which virus is implicated in cervical cancer? Describe.
- Almost all squamous cervical cancers are caused by HPV.
- HPV is a family of viruses with >100 subtypes, ~80 of which are associated with the development of cervical cancer.
- ~80% of adults have ben exposed to HOV during their lifetime, but 90% of people clear the virus within 2 years of exposure.
- ~70% of cervical cancers are caused by HPV 16 & 18.
- Incidence of cervical cancer is falling due to vaccination against HPV.
How are abnormal cells classified and graded in the cervix?
- Abnormal cells = CIN (cervical intraepithelial neoplasia) – this is graded 1-3.
- The number shows how deep the cell changes go into the outer surface of the cervix.
- CIN1 – 1/3 of the thickness of outer cervix is affected. Highly unlikely that these cell changes will develop into cervical cancer; they will likely go back to normal by themselves. CIN1 is not treated but patients are invited back for cervical screening after 12 months instead of the usual 5 years.
- CIN2 – 2/3 of thickness of outer surface is affected. Higher chance that these cells will develop into cervical cancer (this risk is ~5%). Dependent on situation whether treatment or just monitoring every 6 months until cell changes have gone.
- CIN3 – highest grade; full thickness of outer surface of the cervix is affected. If not treated, more likely these cell changes will develop into cancer (~12%). Treatment is offered.
What are the risk factors for development of cervical cancer?
- Risk factors can be split into 3 groups.
- Risk factors for those who do not attend screening
- Socioeconomic class
- Geographical location
- Risk factors for those who have increased exposure to HPV
- Those with +++ sexual partners
- Those who are sexually active at a young age
- Risk factors which affect the immune system
- Smokers
- Immune deficiencies / diseases
What are the symptoms of cervical cancer?
- Intermenstrual bleeding
- Postmenopausal bleeding
- Abnormal discharge
- Dyspareunia
How should ?cervical CA be investigated?
And what should you consider if cervical cancer is confirmed?
- EXAMINE THE PATIENT PROPERLY.
- On speculum examination you might see distorted cervix or a growth.
- On bimanual, you may find a pelvic mass.
- If you suspect cervical cancer, refer to colposcopy. They can biopsy.
- If cervical cancer is confirmed, consider CT chest, abdo and pelvis to look for metastatic disease.
How is cervical cancer staged?
- 80% of cervical cancers are squamous cell carcinoma.
- 20% are adenocarcinoma.
- Stage 1a – cancer involves the cervix but has not spread to nearby tissue and a very small amount of cancer only visible under a microscope is found deeper in the tissues of cervix.
- Stage 1b – cancer involves the cervix but has not spread nearby.
- Stage 2a – Spread into nearby areas, but still inside the pelvic area. Beyond cervix into upper 2/3 of vagina.
- Stage 2b – cancer has spread to nearby areas – tissue around the cervix.
- Stage 3 – cancer has spread throughout pelvic area. Lower part of vagina or ureters can be involved.
- Stage 4a – cancer has spread to other areas such as bladder or rectum.
- Stage 4b – distant metastasis (lungs etc.).
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Describe the management of cervical cancer.
- Depends on grade and stage and age of patient. Whether or not you are trying to preserve fertility also has an impact on how you manage.
- Trachelectomy is the removal of the cervix and the upper part of the vagina. This is an option if disease is less widespread and patient wants option of future pregnancy.
- If disease is more widespread hysterectomy is an option. If it is even more widespread, may consider pelvic excenteration.
- Pelvic exenteration (or pelvic evisceration) is a radical surgical treatment that removes all organs from a person’s pelvic cavity. The urinary bladder, urethra, rectum, and anus are removed. The procedure leaves the person with a permanent colostomy and urinary diversion.
- Neoadjuvant chemotherapy or radiotherapy may be offered depending.
What is the prognosis for patients with cervical cancer?
- Stage 1a – 5 year survival is 99%.
- Stage 1b – 5 year survival is 90-95%.
- Stage 2a - 5 year survival is 70-90%.
- Stage 2b - 5 year survival is 60-70%.
- Stage 3 - 5 year survival is 30-50%.
- Stage 4 - 5 year survival is 20%.
What is the most common gynaecological cancer in the UK?
Endometrial cancer
What are the layers of the uterus?
What is the blood supply to the uterus?
- Endometrium (split in 2)
- Functional layer (shed during menstruation)
- Basal layer
- Myometrium
- Perimetrium
- Blood supply to uterus is from uterine artery which is a branch of internal iliac.
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Describe the endometrial cycle.
- Proliferative phase is fuelled by oestrogen (which is secreted by the ovary). At the start of proliferative phase there is proliferation of the stroma and the glands. Moving through the proliferative phase, the glands become large and dilated and their vessels become more prominent.
- Secretory phase – driven by progesterone. Progesterone acts to induce secretory changes in the glands and the blood supply increases further. Nearer the end of the cycle the stroma becomes more vascular and oedematous. As the level of progesterone drops near the end of the cycle, the endometrium breaks down and menstruation occurs. This is in response to the drop in progesterone.
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What are the 2 types of endometrial cancer?
And what are their subtypes?
- 80% of endometrial cancers are adenocarcinomas.
- Within this, there are 2 subdivisions:
-
Type 1 - endometroid cancers. These are very much linked to excess oestrogen. They tend to be slow growing and are less likely to spread.
- Grade I
- Grade II
- Grade III
-
Type 2 - non-endometroid cancers (~10% of endometrial cancers). These are not linked by the same extent to excess oestrogen. They are faster growing and much more likely to spread.
- Serous
- Clear cell
- Carcinosarcoma
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Type 1 - endometroid cancers. These are very much linked to excess oestrogen. They tend to be slow growing and are less likely to spread.
What are the risk factors for endometrial cancer?
- Most endometrial cancers are linked to excess oestrogen so many risk factors are associated with this.
- Nulliparity - have had more ovulatory cycles, so oestrogen exposure is greater.
- Late menopause for the same reason.
- Obesity - fat produces oestrogen. Endometrial cancer is strongly linked to obesity.
- PCOS
- Use of tamoxifen
- Genetics - Lynch syndrome (autosomal dominant condition associated with bowel, ovarian and endometrial cancer). Lifetime risk in these patients of endometrial CA between 30 and 60%.