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Obstetrics & Gynaecology > Gynaecological masses and malignancies > Flashcards

Gynaecological masses and malignancies Flashcards

1
Q

Genes associated with ovarian cancer

A

BRCA 1&2

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2
Q

When does ovarian cancer present?

A

Late

75% present @ stage 3

Mean age 60yrs

Ovarian = deadliest

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3
Q

Marker associated with ovarian cancer

A

CA125

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4
Q

Which type of ovarian cancer is associated with BRCA 1&2 mutations?

A

Serous ovarian cancer - most common types

90% high grade have an increased CA125

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5
Q

Which ovarian cancer is associated with endometriosis?

A

Clear cell - 6% ovarian cancers

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6
Q

What is choriocarcinoma?

A

Rare and agressive placental trophoblastic tumour

Causes irregular bleeding, abdo pain, N&V

Increased BhCG

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7
Q

What is a Krukenberg’s tumour?

A

Refers to a malignancy in ovary from a primary site

Most commonly stomach and colon, then breast/ lung/ other ovary

Mucin secreting signet rings = pathognomonic

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8
Q

What % of ovarian cancers are hereditary?

A

10-15% associated with BRCA 1&2

These mutations increase the risk of ovarian ca by 15-40% and breast ca by 50-85%

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9
Q

Risk factors for ovarian ca

A

Nulliparity/ early menarche/ late menopause: longer time exposed to oestrogen

Endometriosis

HRT

Previous benign ovarian cysts

FHx

Obesity

PMHx breast ca/ colon ca/ ovarian ca

Infertility

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10
Q

Protective factors from ovarian ca

A

Pregnancy

Breast feeding

COCP use

Hysterectomy

Tubal ligation

Normal BMI and regular exercise

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11
Q

Widely accepted pathophysiology of ovarian ca

A

Ovulation causes repeated damage and repair to epithelial surface of ovary

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12
Q

Clinical features of ovarian cancer

A

Presents in advanced stage with vague symptoms e.g. bloating, abdo pain, fluctuating bowel habits, urinary symptoms

Examination may find mass or ascites

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13
Q

Investigation for ovarian cancer

A

Bloods: CA125 - serial measurements showing a rise

Imaging: transvaginal USS - bilateral cysts, septations, papillary projections, solid components, ascites and lymphadenopathy = higher suspicion of malignancy

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14
Q

Management of ovarian cancer

A

Early: midline laparotomy, hysterectomy, removal of tubes and ovaries, pertioneal wash, omentectomy & paraoartic lymphadenopathy

Advanced: complete surgical debulking + 6 chemo cycles

Prognostic factors: stage, degree of ascites, residual disease after surgery, patients age

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15
Q

Why are cases of endometrial cancer rising?

A

More people are obese

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16
Q

Most common presenting complain associated with endometrial ca

A

Post menopausal bleeding

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17
Q

Which genetic predisposition is associated with endometrial cancer?

A

HNPCC (lynch syndrome)

Endometrial hyperplasia also predisposes to endometrial ca

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18
Q

Classification of ovarian ca

A

Type 1 tumours: endometroid (80%)

Associated with exposure to unopposed oestrogen

Preceded by a pre-malignant precursor (atypical endometrial hyperplasia)

Good prognosis

Caused by obesity - androgens converted to oestrogens in fat and oestrogens cause endometrial hyperplasia

Type 2: non-endometroid (20%)

More aggressive

Not associated with oestrogen

No precursor

Prognosis is poor

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19
Q

What is Lynch syndrome?

A

Autosomal dominant co susceptibility syndrome caused by germline mutation in one allele of a DNA mismatch repair gene - if second gene inactivated cell unable to correct mistakes

Lifetime risk of endometrial ca = 40-60%

Hysterectomy offered to women who have completed families

20
Q

Clinical features of endometrial cancer

A

Post menopausal bleeding most common

Premenopausal women present with heavy intermenstrual bleeding

21
Q

Diagnosis of endometrial cancer

A

PMB = urgent gynae referral

Investigations: imaging (transvaginal USS showing endometrial thickness >5mm prompts hysterectomy

Endometrial biopsy to confirm diagnosis

22
Q

Management of endometrial cancer

A

Mainly surgical - hysterectomy is curative in most

Brachytherapy for intermediate risk disease

High risk disease

Hormone treatment for women who want to preserve fertility - unlikely to cure and high risk of recurrence on discontinuation of treatment

23
Q

Risk factors for endometrial ca

A

Obesity

Unopposed oestrogenic stimulation of endometrium

PCOS

Tamoxifen use

Ealry menarche/ late menopause

Nulliparity

Oestrogen secreting ovarian tumour

HNPCC

HTN

Increasing age

24
Q

Protective factors against endometrial cancer

A

Hysterectomy

COCP

Mirena

Normal weight

Pregnancy

25
Q

Discuss trend of incidence rates of cervical cancer

A

Incidence decreasing because of cervical ca screening and HPV vaccine

26
Q

Which cell types does cervical ca arise from?

A

Squamous epithelium lining ectocervix or in glandular epithelium lining endocervix

27
Q

Most common type of cervical cancer

A

Squamous celss = 75-80%

HPV 16 = 55%, HPV 18 = 15%

28
Q

Pathogenesis of cervical cancer

A

HPV infections persist and lead to malfunctioning of p53 and Rn - cellular turnover increases and apoptosis decreases

HPV 16, 18 and 33 produce oncogenes E6 and E7

E6: inhibits p53 (tumour suppressor)

E7: inhibits Rb (tumour supressor)

29
Q

Discuss CIN grading

A

CIN = cervical intraepithelial neoplasia

CIN 1: unlilely cells will become cancerous - 12 month recall

CIN 2: removal recommended

CIN 3: removal recommended

CIN = cervical glandular intraepithelial neoplasia, equivalent of CIN 3: removal recommended

30
Q

How can cervical canncer be prevented?

A

Women aged 25-49 screened every 3yrs

Women aged 50-64 screened every 5 years

Immunisation of girls and boys (gardasil) aged 12-13 protects against HPV 16 & 18 (cancer) and 6 & 11 (warts)

31
Q

Why are we screening for cervical ca if we have a vaccine?

A

30% cases are caused by HPV not covered by the vaccine - vaccine does not protect against all types

32
Q

Clinical features of cervical cancer

A

Most common age - 30-45yrs

50% asymptomatic and detected by screening

Unusual vaginal bleeding

Pelvic pain

Back pain

Urinary/ faecal leakage

33
Q

Investigation for cervical cancer

A

Histological: cervical ca diagnosed following biopsy

MRI: determine tumour size and spread

Prognosis: if confined to cervix - 80-90% @ 5yrs

34
Q

Managenent of cervical ca

A

Surgery: early disease + chemo if narrow margins or positive LNs

Chemoradio: cisplatin + brachytherapy + pelvic external xRT

35
Q

Outline follow up following cervical screening

A

Step 1: smear looks for high risk HPV

Not found: repeat screen in 3 or 5 yrs depending on age

Found: proceed to step 2

Step 2: HPV +/- abnormal cells

HPV + abnormal cells: colposcopy

HPV - abnormal cells: repeat smear in 12 months

Inadequate sample: repeat in 3 months

Following treatment for CIN1, 2 or 3 - follow up in 6 months

36
Q

Discuss vulval cancer

A

5% gynae malignancies

Disease of elderly - 74yrs mean age

90% = SCC

5% = malignant melanoma

Becoming more common in younger women due to HPV

37
Q

Precursors of vulval cancer

A

Vulval intra-epithelial neoplasia

Lichen sclerosus

Paget’s disease

38
Q

Causes of vulval cancer

A

Persistent infection with HPV

Older women: lichen sclerosus and chronic inflammation

Extra-mammary Paget’s

39
Q

Clinical features of vulval cancer

A

Lump/ ulcer associated with pain, itch or bleed

40
Q

Discuss vaginal ca

A

Rare - 1-2% gynae malignancies

80% due to mets from cervix or endometrium

90% SCCs

Vaginal clear cell ca occurs in young women exposed to DES in utero

Aetiology: HPV found in 60% tumours

RFs: prev. cervical neoplasia, xRT, vulval intraepithelial neoplasia

Clinical features: vaginal bleeding, discharge, late disease causes haematuria, urinary retention, constipation and tenderness

Examination: mass or ulcer, usually at top of vagina

Ix: MRI, cystoscopy, sigmoidoscopy

Tx: surgery, xRT

41
Q

Prevalence of fibroids

A

50% women

20% white women

50% black women

42
Q

Types of benign ovarian cysts

A

Functional cysts: common, small, fluid filled, resolve spontaneously

Endometrioma: chocolate cysts: endometrium within ovary, may cause pelvic pain

Teratoma: germ cell tumour, very common

Cystadenoma: common, originate from ovarian epithelium and produce mucinous or serous fluid, 10-15% are bilateral

Thecoma: originate from hormone secreting stromal cells, solid and cystic components, secrete oestrogen, 20% have associated endometrial pathology, can cause abnormal vaginal bleeding

43
Q

Discuss ovarian torsion

A

Most common in women of reproductive age

Ovary twists on pedicle and blood supply is lost

Venous retuns lost first so ovary engorged n

Presence of cysts makes torsion more likely (most commonly dermoid cysts)

OHSS makes torsion more likely

Presentation: acute pain, radiation to thigh/ groin, N&V, low grade pyrexia, mild shock, local tenderness

Examination: cervical excitation, adnexal tenderness, adnexal mass

USS: enlarged ovary, whirlpool sign

44
Q

Cancer associated with tamoxifen use?

A

Endometrial

45
Q

Cervical screenning freq. for HIV+ women?

A

Every year

46
Q

Are pregnant women screened for cervical cancer?

A

No - done 3 months PP

Obstetrics & Gynaecology (25 decks)

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