Gynaecological Malignancy Flashcards
How common is ovarian cancer?
Fairly uncommon, decreasing perhaps due to protective effect of the COCP
Where do ovarian tumours orginate from?
Most cases originate from the fallopian tube
Some derive from pre-existing benign ovarian cysts
What is the most common type of ovarian cancer?
Serous cystadenocarcinoma
What is the prognosis of ovarian cancer?
Poor as most people present with late stage disease
Give risk factors for ovarian cancer
>Age
Genetics
- HNPCC
- BRCA 1 and 2
Incessant ovulation
- Pregnancy and breast feeding is protective as ovaries are dormant during this time
- Early menarche and late menopause
Oral contraceptive pill reduces risk
What mode of inheritence is BRCA 1/2?
Autosomal dominant
How does ovarian cancer present?
Vague GI Symptoms
- Indigestion
- Early satiety
- Poor appetite
- Bloating
- Altered bowel habit
Pelvic mass, with pressure symptoms, late presentation
Ascites
Pain if ovarian torsion
Palpable lymph nodes
Usually systemically well
What investigations are used in ovarian cancer diagnosis?
Pelvic US picks up mass
Surgical laparotomy stages disease and obtain tissue diagnosis
CA 125
Staging imaging
What histological sign is associated with ovarin serous cystadenocarcinoma?
Psammoma bodies
Other associated cancers with this are papillary thyroid cancer, meningoma and mesothelioma
What is CA 125?
Glyco-protein antigen/marker in blood elevated due to peritoneum disease, so not a specific marker
What is a normal value of CA 125?
1-35
What CA 125 value is suggestive of malignancy?
>200 is considered significant risk
What is the screening programme for ovarian cancer?
Screening is not effective as there is not a sufficient pre-malignant stage to offer treatment for
However, prophylactic oophorectomy is offered to high risk women (cancer gene mutation carriers, 2 or more relatives)
Give differential diagnoses of ovarian cancer
Irritable Bowel Syndrome (IBS)
What is FIGO stage 1 ovarian cancer?
Limited to ovaries with capsule intact
What is FIGO stage 2 ovarian cancer?
One or both ovaries with pelvic extension
What is FIGO stage 3 ovarian cancer?
One or both ovaries with peritoneal implants outside the pelvis or + node
What is FIGO stage 4 ovarian cancer?
Distant metastasis
How is ovarian cancer managed?
Chemotherapy, unlikely to cure
Laparotomy for isease clearance or debulk disease
What is the first line chemotherapy for ovarian cancer?
Platinum and taxane (Taxol)
What is the recurrent management of ovarian cancer?
Chemotherapy
- re-challenge disease with platinum
Palliative care
Tamoxifen
- Anti-oestrogen, hormonal treatment, for those not suitable for other treatments
What is the risk of malignancy index?
RMI (risk of malignancy index) = Ultrasound (U) + menopausal status (M) + CA 125
What strains of HPV are low risk?
6, 11, 42, 44
Genital warts and low grade cervical intraepithelial neoplasia
What strains of HPV are high risk?
16, 18, 31, 45
Persistent infection increases risk of developing high grade cervical intraepithelial neoplasia and cancer
What strain of HPV has the highest risk?
HPV 16
(Group 1 carcinogenic and in its own category)
What type of epithelium is in the endocervix?
Columnar epithelium
What type of epithelium is in the ectocervix?
Squamous epithelium
What is the transformation zone?
During puberty, cervix becomes bigger and cells in squamous-columnar junction change/grow, so the area between the original squamous-epithelial junction and new one is the transformation zone
What is cervical intraepithelial neoplasia (CIN)?
Disorganised proliferation of abnormal cells in squamous epithelium (dysplasia), precursor of invasive cancer
What are the two classifications of cervical cancer?
Squamous carcinoma
Adenocarcinoma
Which type of cervical cancer is most common?
Squamous carcinoma
Descibe stage 1A1 cervical cancer
Invasive cancer identified only microscopically
Depth <3mm, width <7mm
Describe stage 1A2 cervical cancer
Invasive cancer identified only microscopically
1A2: Depth <5mm, width <7mm
Describe stage 1B cervical cancer
Clinically visible tumours confined to the cervix, or greater size than 1A
Describe stage 3 cervical cancer
Spread to lower vagina and pelvis
Describe stage 4 cervical cancer
Spread to rectum and bladder
What is the overall prognosis of cervical cancer?
Good cure rate If detected early
Major cause of death in women in developing countries
Give risk factors for cervical cancer
Age
- Peak is 45-55 years
- Those who did not benefit from cervical screening and immunisation
HPV related
Multiple partners
Early age at first intercourse
- Transformation zone is more susceptible to infection at a younger age
Older age of partner
Smoking
HIV
- HIV positive women who have low-grade lesions (CIN1) do not clear these lesions and these can progress to high-grade CIN or cervical cancer
What is the strongest risk factor for cervical cancer?
Smoking
How does cervical cancer present?
Abnormal vaginal bleeding
- PCB
- IMB
- PMB
Discharge
Pain
- Unusual, suggests very advanced cancer extended outwith the pelvis
Describe the cervical cancer screening programme
Women aged 25-50 have smears every 3 years, then 50-64 have smears every 5 years
Brush cervix to obtain cells and microscopically assess the vial using reflex cervical cytology to look for abnormal cells/dyskaryosis/CIN
If dyskaryosis, test vial for HPV
If negative, repeat in 1 year
If dyskaryosis, refer for urgent colposcopy
If 3 inadequate samples in a row, refer for colposcopy
What investigation is used in cervical cancer diagnosis
Colposcopy and Biopsy
- Refer if HPV positive and cytology abnormality
- Use of acetic acid or iodine to identify lesion
- Treat on visit if obvious high grade changes
- Urgent is within 2 weeks
How is cervical cancer managed?
Large loop Excision of the Transformational Zone
- Stage 1a and CIN
Chemo-radiotherapy
- Stage 1b>
Radical hysterectomy
- Stage 1b-2a
Thermal coagulation and laser ablation
- CIN
Can pregnant women recieve cervical smear tests?
Reschedule for 12 weeks post delivery, unless missed screening or previous abnormal smears
How does the cervical screening programme differ for HIV+ women?
Should be offered cervical cytology at diagnosis and cervical cytology should then be offered annually for screening
What are the two types of endometrial cancer?
Adenocarcinoma
Uterine serous and clear cell carcinoma
Which type of endometrial cancer is most common?
Adenocarcinoma
Which type of endometrial cancer has worst prognosis?
Serous and clear cell is high grade and more aggressive
What age group does each type of endoemtrial cancer affect?
Adenocarcinoma is typically younger patients
Serous clear cell is older patients
Describe stage 1A endometrial cancer
Inner half of myometrium
Describe stage 1B endometrial cancer
Outer half of myometrium
Describe stage 2 endometrial cancer
Invades cervix
Describe stage 3A endometrial cancer
Invades serosa/adnexa
Describe stage 3B endometrial cancer
Invades vagina/parametrium
Describe stage 3C endometrial cancer
Invades pelvic or para-aortic nodes
Describe stage 4 endometrial cancer
Invades bladder, bowel, intra-abdominal, inguinal nodes
At what stage does endometrial cancer mostly present?
Stage 1
Give risk factors for endometrial cancer?
Post-menopausal women
Obesity, peripheral fat produces oestrogen
Unopposed E2 therapy/tamoxifen
PCOS
Early menarche/late menopause, longer time exposed to oestrogen
HRT
Oestrogen secreting tumours
Atypical endometrial hyperplasia
HNPCC/Lynch type 2 familial cancer syndrome
DM
Give protective factors for endometrial cancer?
Parity
COCP
Smoking
How does endometrial cancer present?
PMB
Usually no pain, urinary or bowel symptoms
Give differential diagnoses of PMB
Hormone replacement therapy
Peri-menopausal bleeding
Atrophic vaginitis
Polyps (cervical/endometrial)
Other cancers such as cervix, vulva, bladder, anal
What investigations are used in endometrial cancer diagnosis
Trans-vaginal US, to look at endometrial thickness and contour
Endometrial Biopsy
Hysteroscopy to look at endometrial cavity via camera
MRI to assess lymph node involvement
At what endometrial thickness is patient referred for a biopsy?
>4cm (or irregular)
How is endometrial cancer managed?
Total abdominal hysterectomy and bilateral salpingo-oophorectomy
- Removal of uterus, tubes, ovaries and peritoneal washings due to residual malignant activity, early stage
Additional chemotherapy
- High risk histology, for any residual malignant activity
Additional radiotherapy
- Advanced stage
Progesterone
- Palliative
What is the management of endometrial hyperplasia?
Total hysterectomy with bilateral salpingo-oophorectomy, in addition, is advisable for all postmenopausal women with atypical endometrial hyperplasia, due to the risk of malignant progression
What is vulval intraepithelial neoplasia?
Abnormal proliferation of squamous epithelium, can progress to carcinoma
Give risk factors for VIN
Smoking
Other genital intra-epithelial neoplasia
Immunosuppression
Previous related malignancy
HPV infection
How does VIN present?
Raised papular or plaques lesions
Erosions, nodules, warty
Keratotic roughened appearance
Sharp border
Discoloration
How is VIN managed?
Topical
- Multiple lesions, as have to preserve tissue so can not use excision
CO2 laser
- Suitable for mucosal skin
What are the types of vulval cancer?
Mostly squamous cell carcinoma
Basal cell carcinoma
Melanoma
Bartholin’s gland
What is the most common type of vulval cancer?
Squamous cell carcinoma
How is vulval cancer managed?
Radiotherapy
Chemotherapy
Radical local excision and skin flap repair
What investigations are used in VIN/Vulval cancer diagnosis?
Punch biopsy or excisional biopsy
Groin node dissection
- Associated with wound infection, Lymphocysts and nerve damage
How does vulval cancer present?
Pain
Itch
Bleeding
Lump/ulcer
Describe stage 1 vulval cancer
<2cm
Describe stage 2 vulval cancer
>2cm
Describe stage 3 vulval cancer
Local spread
Unilateral nodes
Describe stage 4 vulval cancer
Distant or advanced local spread
Pelvic nodes
Describe the properties of HPV related vulval cancer/VIN
Usual type VIN
Younger women
Multifocal and multizonal
Past history of intra-epithelial neoplasia
Associated with Immunosuppression
Can be low or high grade
Describe the properties of non HPV related vulval cancer/VIN
Differentiated VIN
Older women
Lichen Sclerosus
Presents as cancer at first diagnosis
High grade
