Gynaecological Malignancies Flashcards
What is the most common presentation of endometrial cancer?
Post-menopausal bleeding
If endometrial cancer occurs in pre-menopausal women, how would it present?
Inter-menstrual bleeding
At what age range is the peak incidence of endometrial cancer?
50-60 years
If endometrial cancer is diagnosed in a woman aged < 40, what should be considered?
Lynch syndrome
80% of endometrial cancers are what histological type?
Adenocarcinomas
What is the precursor lesion to endometrial adenocarcinomas?
Atypical endometrial hyperplasia
What is the main risk factor for the development of endometrial adenocarcinomas?
Exposure to unopposed oestrogen
In type 2 (non-endometrioid) endometrial cancers, what protein is almost always mutated?
Tp53
What is the biggest risk factor contributing to unopposed oestrogen exposure in women with endometrial cancer?
Obesity
How is Lynch syndrome (HNPCC) inherited?
Autosomal dominant
What screening do women with Lynch syndrome (HNPCC) undergo?
Colonoscopy from age 25, TVUS and CA125 levels from age 35
What endocrine condition is a risk factor for endometrial cancer?
PCOS
What are some medications that are risk factors for endometrial cancer?
Tamoxifen and oestrogen-only HRT
What are some examples of protective factors for endometrial cancer?
Hysterectomy, COCP, Mirena-IUS, pregnancy
Who should receive an urgent referral using the suspected cancer pathway for endometrial cancer?
Women aged 55+ with post-menopausal bleeding
What is the first line investigation for endometrial cancer? What is this used to establish?
TVUS- used to establish the endometrial thickness
What is a normal endometrial thickness in post-menopausal women?
< 4mm
Other than TVUS, what investigations are indicated for women with post-menopausal bleeding and suspected endometrial cancer?
Hysteroscopy and endometrial biopsy
How is endometrial cancer managed in the first instance?
Total abdominal hysterectomy, with bilateral salpingo-oophorectomy
What adjuvant treatment options can be used for endometrial cancer?
Radiotherapy +/- chemotherapy
What treatment can be utilised for women with endometrial cancer who are not suitable candidates for surgery, or who wish to preserve their fertility?
Progesterone supplements (POP or Mirena-IUS)
Who is cervical cancer most likely to present in?
Pre-menopausal women (most common aged 25-29)
How does cervical cancer present?
Post-coital, inter-menstrual or persistent vaginal bleeding
What are some clinical features of advanced cervical cancer?
Weight loss, back/pelvic pain, urinary/faecal leakage
What are the two most common types of cervical cancer, and how common is each?
Squamous cell carcinoma (80%) and adenocarcinoma (20%)
What is the precursor lesion to squamous cell cervical cancer?
Cervical intra-epithelial neoplasia
What is the precursor lesion to adenocarcinoma of the cervix?
Cervical glandular intra-epithelial neoplasia
Which histological type of cervical cancer is more associated with low socioeconomic status and early onset of sexual activity?
Squamous cell carcinoma
What is the most common cause of cervical cancer (be specific)?
HPV infection, mainly types 16 and 18
What are some risk factors for persistent genital HPV infection which doesn’t clear up on its own?
Smoking and immunosuppression
Which women get screened for cervical cancer, and how often do they get screened?
Women aged 25-49 get screened every 3 years, women aged 50-64 get screened every 5 years
Who is the HPV vaccine offered to?
Boys and girls aged 12-13 and MSM
What is the first line investigation for suspected cervical cancer?
Colposcopy and punch biopsy
For a final diagnosis of cervical cancer to be made, one of which two types of biopsy must be done?
LLETZ or cone biopsy
What imaging investigation is used to determine the size and assess the spread of a cervical cancer?
Pelvic MRI
What is the gold standard management for early stage (localised to the cervix) cervical cancer?
Hysterectomy +/- lymph node clearance
What surgical management is available for women with early stage cervical cancer who want to maintain their fertility?
Cone biopsy
What adjuvant treatment is recommended in addition to surgery, in women with cervical cancer who have positive surgical margins or where lymph nodes are positive for metastatic disease?
Chemotherapy
What is the gold standard management for late stage (outwith the cervix) cervical cancer?
Radical chemoradiotherapy
What chemotherapy agent is commonly used in the management of cervical cancer?
Cisplatin
What are two fertility sparing treatment options for cervical cancer?
Cone biopsy and LLETZ
What happens with regard to cervical screening in pregnancy, assuming the woman is up to date with her smears?
Withhold until 3 months post-partum
How long does it take for results of cervical screening to come back?
2 weeks
What action is required for a cervical screening result that states ‘borderline or mild dyskaryosis’?
High risk HPV test
What action is required if a woman has undergone high-risk HPV testing and it comes back negative?
Back to routine screening
What action is required if a woman has undergone high-risk HPV testing and it comes back positive?
Colposcopy within 6 weeks
What action is required for a cervical screening result that states ‘moderate or severe dyskaryosis’ or ‘invasive cancer or glandular neoplasia suspected’?
Refer for colposcopy within 2 weeks
What action is required for a cervical screening result that states ‘inadequate’?
Repeat test in 3 months
How many inadequate cervical smears warrant a colposcopy?
Three
How is CIN 1 normally treated?
It usually resolves spontaneously, a repeat colposcopy should be done at 12 months to ensure resolution
If CIN 1 has not resolved after a year, what treatment is required?
LLETZ or cold coagulation
How is CIN 2 normally treated?
LLETZ
What are some treatment options for CIN 3?
LLETZ, cone biopsy or hysterectomy
After a LLETZ procedure, women are advised to avoid sex, the use of tampons and swimming for how long?
4 weeks
What is the main obstetric complication associated with LLETZ and cone biopsies?
Preterm delivery
What test of cure is required after undergoing treatment for CIN?
Cervical cytology and high-risk HPV testing at 6 months
If a woman has undergone follow-up after treatment of CIN, and high-risk HPV testing comes back negative, what is done next with regards to future screening?
Return to routine screening
If a woman has undergone follow-up after treatment of CIN, and high-risk HPV testing comes back positive or if moderate/severe dyskaryosis is detected, what is done next?
Colposcopy
Vulval carcinoma is usually seen in who?
Older women
Vulval carcinoma is now sometimes seen in younger women (30s/40s) as a result of what?
High-risk HPV infection
How does vulval carcinoma tend to present?
Vulval lump or ulcer (may be associated with pain, discharge, itch)
What is the most common histological type of vulval cancer?
Squamous cell carcinoma
What are some factors contributing to carcinogenesis of vulval cancer?
Intra-epithelial neoplasia, lichen sclerosus and chronic inflammation
What is the gold standard investigation for vulval cancer?
Vulval biopsy
What imaging investigations are required for advanced cases of vulval cancer?
Pelvic CT/MRI
Where are vulval carcinomas most likely to spread to?
Inguinal lymph nodes
How is vulval cancer normally managed?
Radical vulvectomy + bilateral inguinal lymphadenectomy
What adjuvant treatment may be required for vulval cancer?
Radiotherapy
80% of vaginal cancers are metastatic spread from where?
The endometrium or cervix
When is the peak incidence of vaginal cancer?
60-70 years
How is a vaginal cancer most likely to present?
Vaginal bleeding or discharge
What is the most common histological type of vaginal cancer?
Squamous cell carcinoma
What is responsible for 60% of vaginal cancers?
HPV (especially type 16)
What iatrogenic treatment may contribute to the development of vaginal cancer?
Radiotherapy
What is the gold standard investigation for vaginal cancer?
Examination under anaesthesia and biopsy
How are most cases of vaginal cancer treated?
Radiotherapy
Where do leiomyosarcomas arise from?
The myometrium
What are the three red flag symptoms for ovarian cancer, especially if they are persistent or frequent?
Bloating, abdominal pain, fluctuating bowel habit
At what age is the median diagnosis of ovarian cancer?
60 years
What are two things that may be noted on examination of a woman with ovarian cancer?
Pelvic mass and free fluid (ascites)
> 90% of ovarian cancers are what broad type?
Epithelial cancers
What is the most common type of epithelial ovarian cancer?
Serous carcinoma
Which type of ovarian cancer is associated with BRCA mutations?
Serous carcinoma
After serous, what is the next most common type of epithelial ovarian cancer?
Mucinous carcinoma
Having endometriosis increases the risk of developing which ovarian epithelial cancers?
Endometrioid and clear cell
What is the name for a rare, placental, trophoblastic tumour that can develop in the ovary, and is associated with a raised HCG?
Choriocarcinoma
What is the most common malignant germ cell tumour of the ovary, which is seen almost exclusively in children and young women, and is associated with a raised HCG and AFP?
Dysgerminoma
What type of ovarian cancer is a slow growing tumour that produces oestrogen, is associated with raised inhibin levels, and presents with irregular/heavy bleeding or precocious puberty in young females?
Granulosa cell tumour
Which type of ovarian cancer produces androgens +/- testosterone, and leads to progressive masculinisation?
Sertoli cell tumour
What diagnosis should always be considered in cases of small, bilateral ovarian cancers?
Metastases from another primary
What are the most common mutations causing genetic ovarian cancer?
BRCA1 and BRCA2
How are the BRCA genes inherited?
Autosomal dominant
What prophylactic management for ovarian cancer is offered to women aged > 35 with a BRCA mutation?
Bilateral salpingo-oophorectomy
What is the tumour marker for ovarian cancer?
CA125
What can be a useful test to rule out a GI primary in someone with suspected ovarian cancer?
CEA
What is the first line imaging investigation for ovarian cancer?
Trans-vaginal ultrasound
If an ovarian cancer is suspected following TVUS, what is the next line imaging investigation?
CT or MRI chest/abdo/pelvis
What is the gold standard method of obtaining a sample of ovarian cancer for pathology?
Laparoscopy
Patients with an RMI score of more than what should be referred to gynae-oncology?
200
Which lymph nodes do ovarian cancers spread to?
Para-aortic (lumbar)
How is ovarian cancer which is confined to the ovary managed?
Surgery only
How is ovarian cancer which is not confined to the ovary managed?
Surgery + chemotherapy (adjuvant or neo-adjuvant)
What is the most commonly used chemotherapy agent for ovarian cancer?
Platinum based agents e.g. carboplatin
What are Krukenberg tumours? What histological feature do they show?
Gastric adenocarcinomas which metastasise to the ovary, they show signet-ring cells
How often should HIV positive women receive cervical cytology testing?
Annually
