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Gynaecological Malignancy Flashcards

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1
Q

How common is ovarian cancer?

A

Fairly uncommon, decreasing perhaps due to protective effect of the COCP

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2
Q

Where do ovarian tumours orginate from?

A

Most cases originate from the fallopian tube

Some derive from pre-existing benign ovarian cysts

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3
Q

What is the most common type of ovarian cancer?

A

Serous cystadenocarcinoma

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4
Q

What is the prognosis of ovarian cancer?

A

Poor as most people present with late stage disease

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5
Q

Give risk factors for ovarian cancer

A

>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

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6
Q

What mode of inheritence is BRCA 1/2?

A

Autosomal dominant

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7
Q

How does ovarian cancer present?

A

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

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8
Q

What investigations are used in ovarian cancer diagnosis?

A

Pelvic US picks up mass

Surgical laparotomy stages disease and obtain tissue diagnosis

CA 125

Staging imaging

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9
Q

What histological sign is associated with ovarin serous cystadenocarcinoma?

A

Psammoma bodies

Other associated cancers with this are papillary thyroid cancer, meningoma and mesothelioma

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10
Q

What is CA 125?

A

Glyco-protein antigen/marker in blood elevated due to peritoneum disease, so not a specific marker

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11
Q

What is a normal value of CA 125?

A

1-35

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12
Q

What CA 125 value is suggestive of malignancy?

A

>200 is considered significant risk

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13
Q

What is the screening programme for ovarian cancer?

A

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)

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14
Q

Give differential diagnoses of ovarian cancer

A

Irritable Bowel Syndrome (IBS)

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15
Q

What is FIGO stage 1 ovarian cancer?

A

Limited to ovaries with capsule intact

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16
Q

What is FIGO stage 2 ovarian cancer?

A

One or both ovaries with pelvic extension

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17
Q

What is FIGO stage 3 ovarian cancer?

A

One or both ovaries with peritoneal implants outside the pelvis or + node

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18
Q

What is FIGO stage 4 ovarian cancer?

A

Distant metastasis

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19
Q

How is ovarian cancer managed?

A

Chemotherapy, unlikely to cure

Laparotomy for isease clearance or debulk disease

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20
Q

What is the first line chemotherapy for ovarian cancer?

A

Platinum and taxane (Taxol)

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21
Q

What is the recurrent management of ovarian cancer?

A

Chemotherapy

  • re-challenge disease with platinum

Palliative care

Tamoxifen

  • Anti-oestrogen, hormonal treatment, for those not suitable for other treatments
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22
Q

What is the risk of malignancy index?

A

RMI (risk of malignancy index) = Ultrasound (U) + menopausal status (M) + CA 125

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23
Q

What strains of HPV are low risk?

A

6, 11, 42, 44

Genital warts and low grade cervical intraepithelial neoplasia

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24
Q

What strains of HPV are high risk?

A

16, 18, 31, 45

Persistent infection increases risk of developing high grade cervical intraepithelial neoplasia and cancer

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25
What strain of HPV has the highest risk?
HPV 16 (Group 1 carcinogenic and in its own category)
26
What type of epithelium is in the endocervix?
Columnar epithelium
27
What type of epithelium is in the ectocervix?
Squamous epithelium
28
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
29
What is cervical intraepithelial neoplasia (CIN)?
Disorganised proliferation of abnormal cells in squamous epithelium (dysplasia), precursor of invasive cancer
30
What are the two classifications of cervical cancer?
Squamous carcinoma Adenocarcinoma
31
Which type of cervical cancer is most common?
Squamous carcinoma
32
Descibe stage 1A1 cervical cancer
Invasive cancer identified only microscopically Depth \<3mm, width \<7mm
33
Describe stage 1A2 cervical cancer
Invasive cancer identified only microscopically 1A2: Depth \<5mm, width \<7mm
34
Describe stage 1B cervical cancer
Clinically visible tumours confined to the cervix, or greater size than 1A
35
Describe stage 3 cervical cancer
Spread to lower vagina and pelvis
36
Describe stage 4 cervical cancer
Spread to rectum and bladder
37
What is the overall prognosis of cervical cancer?
Good cure rate If detected early Major cause of death in women in developing countries
38
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
39
What is the strongest risk factor for cervical cancer?
Smoking
40
How does cervical cancer present?
Abnormal vaginal bleeding * PCB * IMB * PMB Discharge Pain * Unusual, suggests very advanced cancer extended outwith the pelvis
41
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
42
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
43
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
44
Can pregnant women recieve cervical smear tests?
Reschedule for 12 weeks post delivery, unless missed screening or previous abnormal smears
45
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
46
What are the two types of endometrial cancer?
Adenocarcinoma Uterine serous and clear cell carcinoma
47
Which type of endometrial cancer is most common?
Adenocarcinoma
48
Which type of endometrial cancer has worst prognosis?
Serous and clear cell is high grade and more aggressive
49
What age group does each type of endoemtrial cancer affect?
Adenocarcinoma is typically younger patients Serous clear cell is older patients
50
Describe stage 1A endometrial cancer
Inner half of myometrium
51
Describe stage 1B endometrial cancer
Outer half of myometrium
52
Describe stage 2 endometrial cancer
Invades cervix
53
Describe stage 3A endometrial cancer
Invades serosa/adnexa
54
Describe stage 3B endometrial cancer
Invades vagina/parametrium
55
Describe stage 3C endometrial cancer
Invades pelvic or para-aortic nodes
56
Describe stage 4 endometrial cancer
Invades bladder, bowel, intra-abdominal, inguinal nodes
57
At what stage does endometrial cancer mostly present?
Stage 1
58
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
59
Give protective factors for endometrial cancer?
Parity COCP Smoking
60
How does endometrial cancer present?
PMB Usually no pain, urinary or bowel symptoms
61
Give differential diagnoses of PMB
Hormone replacement therapy Peri-menopausal bleeding Atrophic vaginitis Polyps (cervical/endometrial) Other cancers such as cervix, vulva, bladder, anal
62
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
63
At what endometrial thickness is patient referred for a biopsy?
\>4cm (or irregular)
64
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
65
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
66
What is vulval intraepithelial neoplasia?
Abnormal proliferation of squamous epithelium, can progress to carcinoma
67
Give risk factors for VIN
Smoking Other genital intra-epithelial neoplasia Immunosuppression Previous related malignancy HPV infection
68
How does VIN present?
Raised papular or plaques lesions Erosions, nodules, warty Keratotic roughened appearance Sharp border Discoloration
69
How is VIN managed?
Topical * Multiple lesions, as have to preserve tissue so can not use excision CO2 laser * Suitable for mucosal skin
70
What are the types of vulval cancer?
Mostly squamous cell carcinoma Basal cell carcinoma Melanoma Bartholin's gland
71
What is the most common type of vulval cancer?
Squamous cell carcinoma
72
How is vulval cancer managed?
Radiotherapy Chemotherapy Radical local excision and skin flap repair
73
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
74
How does vulval cancer present?
Pain Itch Bleeding Lump/ulcer
75
Describe stage 1 vulval cancer
\<2cm
76
Describe stage 2 vulval cancer
\>2cm
77
Describe stage 3 vulval cancer
Local spread Unilateral nodes
78
Describe stage 4 vulval cancer
Distant or advanced local spread Pelvic nodes
79
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
80
Describe the properties of non HPV related vulval cancer/VIN
Differentiated VIN Older women Lichen Sclerosus Presents as cancer at first diagnosis High grade

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