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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
How is ovarian cancer staged?
26
What is the mainstay of treatment for ovarian cancer?
Surgery
27
When is an exploratory laparotamy performed in ovrian cancer?
For tumour debulking and formal surgical staging
28
What is involved in an exploratory laparotamy in ovarian cancer?
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
29
Which patients is adjuvant chemotherapy for ovarian cancer given to?
Anyone \> stage Ic Anyone stage Ia/Ib with a high grade malignancy
30
What chemotherapy agents are given in ovarian cancer?
Carboplatin and paclitaxel
31
When do endometrial polyps often occur?
Around or after the menopause
32
How does endometrial hyperplasia present?
Dysfunctional uterine bleeding or post-menopausal bleeding
33
What is the difference between focal and complex endometrial hyperplasia
In complex hyperplasia: - focal distribution, not general - consists of glands - glands are crowded, not dilated
34
What is the difference between simple or complex endometrial hyperplasia and atypical hyperplasia?
Atypical endometrial hyperplasia has abnormal cytology
35
What is the peak age of incidence of endometrial cancer?
50-60
36
If a young woman (\<40) has endometrial cancer, what other things must be considered?
An underlying predisposition e.g. polycystic ovary syndrome or Lynch syndrome
37
What are the two main types of endometrial cancer?
Endometrioid Serous
38
What is the precursor lesion to endometrioid cancer?
Atypical endometrial hyperplasia
39
What is the precursor lesion to serous endometrial cancer?
Serous intraepithelial carcinoma
40
What gene is often mutated in serous endometrial cancer?
TP53
41
Which type of endometrial cancer is associated with unopposed oestrogen?
Endometrioid (and mucinous)
42
Which endometrial tumours are type 1 tumours?
Endometrioid and mucinous
43
Which women are generally affected by type 2 tumours?
Elderly post-menopausal women
44
Which tumour phenotypes are type 2 tumours?
Serous and clear cell
45
Why does obesity increase risk of developing endometrial cancer?
Adipose tissue expresses aromatase which converts androgen to estrogen This causes endometrial proliferation
46
What mode of inheritence does Lynch syndrome have?
Autosomal dominant
47
Why does Lynch syndrome predispose to endometrial carcinoma?
Inheritance of a defective DNA mismatch repair gene Lynch syndrome tumours also show microsatellite instability (MSI), a characteristic of defective mismatch repair
48
Why might type 2 tumours present with extrauterine disease?
The tumours tend to spread along the Fallopian tube mucosa and along the peritoneal membrane early
49
Why do endometrioid tumours generally have a good progonosis?
Usually confined to uterus at presentation
50
What is the grading system for endometrioid carcinoma?
Grade 1: 5% or less solid growth Grade 2: 6-50% solid growth Grade 3: \>50% solid growth
51
What is the staging for endometrial carcinoma?
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
What is a fibroid?
A benign tumour of the smooth muscle of the uterus/myometrium
53
What is the most common uterine sarcoma?
Leiomyosarcoma
54
What is a leiomyosarcoma?
A malignant smooth muscle tumour commonly displaying a spindle cell morphology
55
What are classifications of fibroids according to location?
56
How might fibroids present?
Menhorrhagia Pelvic mass Pain/tenderness Pressure symptoms
57
How should fibroids be investigated?
Hb if heavy bleeding Ultrasound usually diagnostic - smooth echogenic mass often multiple MRI for more precise localisation
58
What is the treatment for fibroids?
If asymptomatic - expectant management Traditionally: total hysterectomy if family complete Otherwise: myomectomy, uterine artery embolisation, hysteroscopic resection
59
What might cause tubal swellings?
Ectopic pregnancy Pyosalpinx Hydrosalpinx Paratubal cysts - Wolfine duct remnants
60
What are functional cysts?
Cysts related to ovulation: follicular cysts or luteal cysts rarely \>5cm in diameter and usually resolve spontaneously
61
What is a Krukenberg tumour?
A metastatic tumour on the ovary with classic signet ring histology Most commonly from stomach cancer
62
What is the triad in Meig's syndrome?
Ascites Pleural effusion Benign ovarian tumor
63
How is Meig's syndrome resolved?
Resection of tumour
64
What is the red flag symptom of cervical cancer?
Post-coital bleeding
65
What is the endocervix?
Columnar epithelium between the internal and external os
66
What is the ectocervix?
Squamous epithelium that projects into the vagina
67
Where is the site of origin of most cervical malignancies and why?
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
What is cervical ectropion?
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
What are the symptoms of cervical ectropion?
Excess discharge or bleeding
70
What age groups does cervical cancer affect?
30-34 Over 80s
71
How long after CIN develops does cervical carcinoma develop?
10-15 years
72
What is the main risk factor for cervical cancer?
HPV infection
73
What HPV strains cause cervical cancer?
16, 18 31, 33, 35, 45
74
What other risk factors for cervical cancer are there?
Smoking Non-attendance at smears Family history
75
What are the different grades of CIN?
CIN1 – bottom third of epithelium CIN2 – 2/3 of the way through the epithelium CIN3 – full thickness
76
How does HPV cause cervical cancer?
HPV switches off E6 and E7, which switches off p53 and retinoblastoma
77
How is CIN 3 treated?
Long loop excision of the transformation zone (LLETS) Cold ablation of the lesion
78
What is the next step in investigation if smear is abnormal?
Refer for colposcopy
79
How is cervical cancer staged?
80
What are the complications associated with LLETS?
Cervical incompetence Therefore, spontaneous abortions are a risk
81
When is surgical management of cervical cancer used?
Young women with disease confined to the pelvis
82
What is the other alternative if surgical management of cervical cancer is not an option?
Radiotherapy - useful even in advanced disease
83
What are the complications of radiotherapy?
Long term bowel dysfunction Long term cystitis Infertility Menopause Sexual dysfunction Fibrosis of the endometrium
84
What is the role of brachytherapy in cervical cancer?
Used to follow up the five week course of radiotherapy to potentiate its effects

Obs & Gynae (20 decks)

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