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Obs & Gynae > Gynaecological malignancy and other pelvic masses > Flashcards

Gynaecological malignancy and other pelvic masses Flashcards

1
Q

What is endometriosis?

A

Endometrial stroma and glands found outside the body of the uterus

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2
Q

What are the symptoms of endometriosis?

A

Pelvic pain

Infertility

Menorrhagia

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3
Q

What are the most common sites for endometriosis?

A

Ovary (‘chocolate’ cyst)

Pouch of Douglas

Peritoneal surfaces, including uterus

Cervix, vulva, vagina

Bladder

Bowel

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4
Q

Why are ovarian cysts caused by endometriosis called chocolate cysts?

A

Endometrial tissue bleeds monthly due to hormonal influence but blood has no where to go

Collects in cysts, and blood becomes altered and a dark brown colour

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5
Q

What are some of the complications of endometriosis?

A

Pain

Cyst formation

Adhesions

Infertility

Ectopic pregnancy

Malignancy (endometrioid carcinoma)

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6
Q

What condition is endometrioid and clear cell carcinoma associated with?

A

Endometriosis of the ovary

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7
Q

What conditions are associated with Lynch syndrome?

A

Ovarian cancer - endometrioid and clear cell cancer

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8
Q

What is the main type of ovarian cancer?

A

Epithelial cancers

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9
Q

How are ovarian epithelial tumours classified?

A

Benign, borderline or malignant

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10
Q

What features would classify an ovarian epithelial tumour as benign?

A

No cytological abnormalities

Proliferative activity absent or scant

No stromal invasion

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11
Q

What features would classify an ovarian epithelial tumour as borderline?

A

Cytological abnormalities

Proliferative

No stromal invasion

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12
Q

What features would classify an ovarian epithelial tumour as malignant?

A

Stromal invasion

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13
Q

What is the theory of incessant ovulation?

A

Each ovulation damages the ovarian surface epithelium

So the more a women ovulates, the higher her risk of ovarian cancer

Hence factors such as multiparity, OCP etc. are protective

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14
Q

What is the peak age of incidence of ovarian cancer?

A

60-70

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15
Q

How might ovarian cancer present?

A

Pelvic mass

Bloating

Metasatic disease i.e. weight loss, fatigue

Pressure symptoms e.g. constipation, urinary frequency

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16
Q

What is the most common type of epithelial ovarian cancer?

A

Serous

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17
Q

What is the precursor lesion and origin of high grade serous carcinoma?

A

Serous tubal intraepitelial carcinoma

Tubal in origin

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18
Q

What is the precursor lesion of low grade serous carcinoma?

A

Serous borderline tumour

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19
Q

Which epithelial ovarian tumours are associated with endometriosis of the ovary?

A

Endometrioid and clear cell

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20
Q

What investigations should be done if ovarian cancer suspected?

A

Pregnancy test

Tumour markers - Ca-125, bHCG, placental ALP

Transabdominal or transvaginal ultrasound

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21
Q

Which tumour marker may be raised non-specifically for ovarian cancer?

A

Ca-125

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22
Q

What score can be calculated to decide whether to refer a lady to gynaecology with the suspicion of ovarian cancer?

A

Risk of malignancy index

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23
Q

How is the risk of malignancy index calculated?

A

RMI = menopausal status score x ultrasound assessment score x Ca 125 result

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24
Q

What is the RMI threshold for referral for ovarian cancer?

A

Score >200

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25
Q

How is ovarian cancer staged?

A
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26
Q

What is the mainstay of treatment for ovarian cancer?

A

Surgery

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27
Q

When is an exploratory laparotamy performed in ovrian cancer?

A

For tumour debulking and formal surgical staging

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28
Q

What is involved in an exploratory laparotamy in ovarian cancer?

A

Generally comprises:

  • total abdominal hysterectomy (TAH)
  • bilateral salpingo-oophorectomy (BSO)
  • infracolic omentectomy
  • pelvic and para-aortic lymph node sampling
  • peritoneal biopsies
  • multiple pelvic washings
  • sampling of ascites
  • inspection and sampling of the underside of the diaphragm
  • removal of pretty much anything else that looks suspicious e.g. bowel, appendix, liver, spleen
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29
Q

Which patients is adjuvant chemotherapy for ovarian cancer given to?

A

Anyone > stage Ic

Anyone stage Ia/Ib with a high grade malignancy

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30
Q

What chemotherapy agents are given in ovarian cancer?

A

Carboplatin and paclitaxel

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31
Q

When do endometrial polyps often occur?

A

Around or after the menopause

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32
Q

How does endometrial hyperplasia present?

A

Dysfunctional uterine bleeding or post-menopausal bleeding

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33
Q

What is the difference between focal and complex endometrial hyperplasia

A

In complex hyperplasia:

  • focal distribution, not general
  • consists of glands
  • glands are crowded, not dilated
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34
Q

What is the difference between simple or complex endometrial hyperplasia and atypical hyperplasia?

A

Atypical endometrial hyperplasia has abnormal cytology

35
Q

What is the peak age of incidence of endometrial cancer?

A

50-60

36
Q

If a young woman (<40) has endometrial cancer, what other things must be considered?

A

An underlying predisposition e.g. polycystic ovary syndrome or Lynch syndrome

37
Q

What are the two main types of endometrial cancer?

A

Endometrioid

Serous

38
Q

What is the precursor lesion to endometrioid cancer?

A

Atypical endometrial hyperplasia

39
Q

What is the precursor lesion to serous endometrial cancer?

A

Serous intraepithelial carcinoma

40
Q

What gene is often mutated in serous endometrial cancer?

A

TP53

41
Q

Which type of endometrial cancer is associated with unopposed oestrogen?

A

Endometrioid (and mucinous)

42
Q

Which endometrial tumours are type 1 tumours?

A

Endometrioid and mucinous

43
Q

Which women are generally affected by type 2 tumours?

A

Elderly post-menopausal women

44
Q

Which tumour phenotypes are type 2 tumours?

A

Serous and clear cell

45
Q

Why does obesity increase risk of developing endometrial cancer?

A

Adipose tissue expresses aromatase which converts androgen to estrogen

This causes endometrial proliferation

46
Q

What mode of inheritence does Lynch syndrome have?

A

Autosomal dominant

47
Q

Why does Lynch syndrome predispose to endometrial carcinoma?

A

Inheritance of a defective DNA mismatch repair gene

Lynch syndrome tumours also show microsatellite instability (MSI), a characteristic of defective mismatch repair

48
Q

Why might type 2 tumours present with extrauterine disease?

A

The tumours tend to spread along the Fallopian tube mucosa and along the peritoneal membrane early

49
Q

Why do endometrioid tumours generally have a good progonosis?

A

Usually confined to uterus at presentation

50
Q

What is the grading system for endometrioid carcinoma?

A

Grade 1: 5% or less solid growth

Grade 2: 6-50% solid growth

Grade 3: >50% solid growth

51
Q

What is the staging for endometrial carcinoma?

A

Stage I Tumour confined to the uterus

IA no or < 50% myometrial invasion

IB Invasion equal to or > 50% of myometrium

II Tumour invades cervical stroma

III Local and or regional tumour spread

IIIA Tumour invades serosa of uterus and/or adnexae

IIIB Vaginal and/or parametrial involvement

IIIC Metastases to pelvic and/or para-aortic lymph nodes

IV Tumour invades bladder and or bowel mucosa (IVA) and/or distant metastases (IVB)

52
Q

What is a fibroid?

A

A benign tumour of the smooth muscle of the uterus/myometrium

53
Q

What is the most common uterine sarcoma?

A

Leiomyosarcoma

54
Q

What is a leiomyosarcoma?

A

A malignant smooth muscle tumour commonly displaying a spindle cell morphology

55
Q

What are classifications of fibroids according to location?

A
56
Q

How might fibroids present?

A

Menhorrhagia

Pelvic mass

Pain/tenderness

Pressure symptoms

57
Q

How should fibroids be investigated?

A

Hb if heavy bleeding

Ultrasound usually diagnostic - smooth echogenic mass often multiple

MRI for more precise localisation

58
Q

What is the treatment for fibroids?

A

If asymptomatic - expectant management

Traditionally: total hysterectomy if family complete

Otherwise: myomectomy, uterine artery embolisation, hysteroscopic resection

59
Q

What might cause tubal swellings?

A

Ectopic pregnancy

Pyosalpinx

Hydrosalpinx

Paratubal cysts - Wolfine duct remnants

60
Q

What are functional cysts?

A

Cysts related to ovulation: follicular cysts or luteal cysts rarely >5cm in diameter and usually resolve spontaneously

61
Q

What is a Krukenberg tumour?

A

A metastatic tumour on the ovary with classic signet ring histology

Most commonly from stomach cancer

62
Q

What is the triad in Meig’s syndrome?

A

Ascites

Pleural effusion

Benign ovarian tumor

63
Q

How is Meig’s syndrome resolved?

A

Resection of tumour

64
Q

What is the red flag symptom of cervical cancer?

A

Post-coital bleeding

65
Q

What is the endocervix?

A

Columnar epithelium between the internal and external os

66
Q

What is the ectocervix?

A

Squamous epithelium that projects into the vagina

67
Q

Where is the site of origin of most cervical malignancies and why?

A

Transformation zone

Physiologically, columnar cells of the endocervix undergo metaplasia and become squamous cells in response to exposure to the harsh acidic environment in the vagina

68
Q

What is cervical ectropion?

A

The columnar epithelium of the endocervix protrudes from the external os, causing the transformation zone to move outwards and producing a red ring on the cervix

69
Q

What are the symptoms of cervical ectropion?

A

Excess discharge or bleeding

70
Q

What age groups does cervical cancer affect?

A

30-34

Over 80s

71
Q

How long after CIN develops does cervical carcinoma develop?

A

10-15 years

72
Q

What is the main risk factor for cervical cancer?

A

HPV infection

73
Q

What HPV strains cause cervical cancer?

A

16, 18

31, 33, 35, 45

74
Q

What other risk factors for cervical cancer are there?

A

Smoking

Non-attendance at smears

Family history

75
Q

What are the different grades of CIN?

A

CIN1 – bottom third of epithelium

CIN2 – 2/3 of the way through the epithelium

CIN3 – full thickness

76
Q

How does HPV cause cervical cancer?

A

HPV switches off E6 and E7, which switches off p53 and retinoblastoma

77
Q

How is CIN 3 treated?

A

Long loop excision of the transformation zone (LLETS)

Cold ablation of the lesion

78
Q

What is the next step in investigation if smear is abnormal?

A

Refer for colposcopy

79
Q

How is cervical cancer staged?

A
80
Q

What are the complications associated with LLETS?

A

Cervical incompetence

Therefore, spontaneous abortions are a risk

81
Q

When is surgical management of cervical cancer used?

A

Young women with disease confined to the pelvis

82
Q

What is the other alternative if surgical management of cervical cancer is not an option?

A

Radiotherapy - useful even in advanced disease

83
Q

What are the complications of radiotherapy?

A

Long term bowel dysfunction

Long term cystitis

Infertility

Menopause

Sexual dysfunction

Fibrosis of the endometrium

84
Q

What is the role of brachytherapy in cervical cancer?

A

Used to follow up the five week course of radiotherapy to potentiate its effects

Obs & Gynae (20 decks)

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