Gynaecological masses and malignancies Flashcards
Genes associated with ovarian cancer
BRCA 1&2
When does ovarian cancer present?
Late
75% present @ stage 3
Mean age 60yrs
Ovarian = deadliest
Marker associated with ovarian cancer
CA125
Which type of ovarian cancer is associated with BRCA 1&2 mutations?
Serous ovarian cancer - most common types
90% high grade have an increased CA125
Which ovarian cancer is associated with endometriosis?
Clear cell - 6% ovarian cancers
What is choriocarcinoma?
Rare and agressive placental trophoblastic tumour
Causes irregular bleeding, abdo pain, N&V
Increased BhCG
What is a Krukenberg’s tumour?
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
What % of ovarian cancers are hereditary?
10-15% associated with BRCA 1&2
These mutations increase the risk of ovarian ca by 15-40% and breast ca by 50-85%
Risk factors for ovarian ca
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
Protective factors from ovarian ca
Pregnancy
Breast feeding
COCP use
Hysterectomy
Tubal ligation
Normal BMI and regular exercise
Widely accepted pathophysiology of ovarian ca
Ovulation causes repeated damage and repair to epithelial surface of ovary
Clinical features of ovarian cancer
Presents in advanced stage with vague symptoms e.g. bloating, abdo pain, fluctuating bowel habits, urinary symptoms
Examination may find mass or ascites
Investigation for ovarian cancer
Bloods: CA125 - serial measurements showing a rise
Imaging: transvaginal USS - bilateral cysts, septations, papillary projections, solid components, ascites and lymphadenopathy = higher suspicion of malignancy
Management of ovarian cancer
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
Why are cases of endometrial cancer rising?
More people are obese
Most common presenting complain associated with endometrial ca
Post menopausal bleeding
Which genetic predisposition is associated with endometrial cancer?
HNPCC (lynch syndrome)
Endometrial hyperplasia also predisposes to endometrial ca
Classification of ovarian ca
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
What is Lynch syndrome?
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
Clinical features of endometrial cancer
Post menopausal bleeding most common
Premenopausal women present with heavy intermenstrual bleeding
Diagnosis of endometrial cancer
PMB = urgent gynae referral
Investigations: imaging (transvaginal USS showing endometrial thickness >5mm prompts hysterectomy
Endometrial biopsy to confirm diagnosis
Management of endometrial cancer
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
Risk factors for endometrial ca
Obesity
Unopposed oestrogenic stimulation of endometrium
PCOS
Tamoxifen use
Ealry menarche/ late menopause
Nulliparity
Oestrogen secreting ovarian tumour
HNPCC
HTN
Increasing age
Protective factors against endometrial cancer
Hysterectomy
COCP
Mirena
Normal weight
Pregnancy
Discuss trend of incidence rates of cervical cancer
Incidence decreasing because of cervical ca screening and HPV vaccine
Which cell types does cervical ca arise from?
Squamous epithelium lining ectocervix or in glandular epithelium lining endocervix
Most common type of cervical cancer
Squamous celss = 75-80%
HPV 16 = 55%, HPV 18 = 15%
Pathogenesis of cervical cancer
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)
Discuss CIN grading
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
How can cervical canncer be prevented?
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)
Why are we screening for cervical ca if we have a vaccine?
30% cases are caused by HPV not covered by the vaccine - vaccine does not protect against all types
Clinical features of cervical cancer
Most common age - 30-45yrs
50% asymptomatic and detected by screening
Unusual vaginal bleeding
Pelvic pain
Back pain
Urinary/ faecal leakage
Investigation for cervical cancer
Histological: cervical ca diagnosed following biopsy
MRI: determine tumour size and spread
Prognosis: if confined to cervix - 80-90% @ 5yrs
Managenent of cervical ca
Surgery: early disease + chemo if narrow margins or positive LNs
Chemoradio: cisplatin + brachytherapy + pelvic external xRT
Outline follow up following cervical screening
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
Discuss vulval cancer
5% gynae malignancies
Disease of elderly - 74yrs mean age
90% = SCC
5% = malignant melanoma
Becoming more common in younger women due to HPV
Precursors of vulval cancer
Vulval intra-epithelial neoplasia
Lichen sclerosus
Paget’s disease
Causes of vulval cancer
Persistent infection with HPV
Older women: lichen sclerosus and chronic inflammation
Extra-mammary Paget’s
Clinical features of vulval cancer
Lump/ ulcer associated with pain, itch or bleed
Discuss vaginal ca
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
Prevalence of fibroids
50% women
20% white women
50% black women
Types of benign ovarian cysts
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
Discuss ovarian torsion
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
Cancer associated with tamoxifen use?
Endometrial
Cervical screenning freq. for HIV+ women?
Every year
Are pregnant women screened for cervical cancer?
No - done 3 months PP
