Gynaecological neoplasias and cancers Flashcards
What is the most common gynaecological cancer?
Endometrial cancer
What are the risk factors for endometrial cancer?
Excess endogenous oestrogen • PCOS • Obesity • Early menarche/Late adrenarche • Nulliparity Excess exogenous oestrogen • Tamoxifen • Oestrogen-only HRT Other • Diabetes • HNPCC
What is the treatment of endometrial hyperplasia?
Without atypia = Progesterone-only pill or Mirena. Dilatation and curettage is an option
With atypia = Hysterectomy with bilateral salpingo-oophorectomy (If fertility is important, use above medications but have 3-6 monthly hysteroscopy and biopsy
What are the clinical features of endometrial cancer?
Post menopausal bleeding (Most common)
In premenopausal women, may seen intermenstrual bleeding or recent-onset menorrhagia
What are the stages of endometrial cancer?
Stage 1a = <50% myometrial invasion
Stage 1b = >50% myometrial invasion
Stage 2 = Cervical invasion
Stage 3 = Invasion through the uterus
3a = Serosa/Adnexae
3b = Vagina
3c = Pelvic/Para-aortic node involvement
Stage 4 = Metastasis
4a = Bowel/Bladder
4b = Distant metastases
What are the investigations for endometrial cancer?
Ultrasound plus endometrial biopsy (biopsy via pipelle or hysteroscopy)
MRI may be performed to determine myometrial invasion
Chest x-ray for pulmonary spread
What is the management of endometrial cancer?
Total laparoscopic hysterectomy and bilateral salpingo-oophorectomy
If there is high risk of lymph node involvement, following surgery, the patient will have external beam radiotherapy
What are the stages of cervical intraepithelial neoplasia?
CIN I (Mild dyskaryosis) = Atypical cells in lower third of epithelium CIN II (Moderate dyskaryosis) = Atypical cells in lower 2/3 of epithelium CIN III (Severe dyskaryosis) = Atypical cells through full thickness of epithelium (carcinoma in situ)
Carcinoma in situ appears malignant but there is no invasion, once there is invasion of abnormal cells through the basement membrane, it is then considered malignant
What are the risk factors for cervical cancer?
HPV (Hence, having multiple sexual partners)
COCP
Smoking
Immunocompromised patients are at greater risk of early progression to malignancy
What is the management of smear results?
Normal = Repeat smear after 3 years (or 5 if >50)
Borderline/Mild dyskaryosis = Test HPV
• Positive HPV = Routine colposcopy
• Negative HPV = Return to routine smears
Moderate dyskaryosis = Urgent colposcopy
Severe dyskaryosis = Urgent colposcopy
Suspected invasive cancer = Urgen colposcopy
Inadequate smear = Repeat, up to 3 times. If still inadequate, routine colposcopy
Note: Those who have had treatment should have repeat smear in 6 months to confirm
What is the treatment of cervical intraepithelial neoplasia?
LLETZ procedure
The specimen is then examined histologically to look for unsuspected malignancy
What are the clinical features of cervical cancer?
Postcoital bleeding
Offensive vaginal discharge
Intermenstrual bleeding or Postmenopausal bleeding
What are the stages of cervical cancer?
Stage 1 = Confined to cervix
Stage 2 = Invasion into upper vagina
Stage 3 = Invasion into lower vagina or pelvic wall
Stage 4 = Invasion of bladder or rectal mucosa
What are the investigations for cervical cancer?
To confirm diagnosis = Biopsy
To stage the disease = Vaginal/Rectal examination and MRI
What is the treatment of cervical malignancies?
Stage 1ai (<3mm depth, <7mm spread) = Cone biopsy
Stage 1aii-2a = Chemo-radiotherapy or surgery
• Lymph node -ve = Radical hysterectomy (Wertheim’s hysterectomy)
• Lymph node +ve = Chemo-radiotherapy
• LN -ve & preserve fertility = Radical trachelectomy
Stage 2b-4 = Chemo-radiotherapy
What are some epithelial ovarian tumours and how do they present?
Most common in postmenopausal
Serous cystadenoma
Endometrioid carcinoma - Similar histologically to endometrial carcinoma
Clear cell carcinoma - Malignant with poor prognosis
Mucinous cystadenoma - Very large
What are some germ cell tumours and how do they present?
Teratoma/Dermoid cyst:
• Arise in young premenopausal women
• May contain differentiated tissue from all cell lines (hair, teeth)
• Often asymptomatic, though rupture is very painful
Yolk sac tumours:
• Highly malignant
• Present in children/young women
What are examples of sex cord tumours and how do they present?
Granulosa cell tumours:
• Malignant but slow growing
• Found in postmenopausal women
• Secrete high levels of oestrogen & inhibin
• May lead to endometrial hyperplasia, PMB, encometrial cancer
• Serum inhibin used as tumour marker for recurrence
Thecoma:
• Benign
• May secrete oestrogen/androgens (granulosa more likely to)
Fibroma:
• Benign
• May cause Meigs’ sign: Ascites, pleural effusion, ovarian mass (cured by removing mass)
What are functional cysts?
Follicular cyst (enlarged follicles) & Corpus luteal cyst (enlarged corpus luteum)
Only found in premenopausal women
COCP protects against functional cysts as it stops ovulation
> 3 cm considered pathological
In most cases, should provide reassurance and conduct serial in 3-4 months
If >5 cm, a CA-125 should be conducted and potentially laparoscopy to remove the cyst
How are cysts managed?
Premenopausal women:
A conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists (for laparoscopic removal)
Postmenopausal women:
By definition physiological cysts are unlikely. Any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment (for laparoscopic removal)
What are the most common ovarian malignancies?
Serous adenocarcinoma (75%) Endometroid carcinoma (10%) Clear cell carcinoma (10%)
What are the risk factors for ovarian cancer?
Risk is related to number of ovulations (Early menarche, late menopause, nulliparity)
Familial: BRCA1/BRCA2 or HNPCC
HRT
Protective factors = Pregnancy, lactation and COCP
What screening is conducted for ovarian cancer?
There is no current screening program
Those who have a family history of ovarian cancer can be offered testing for BRCA mutations and if positive, may be offered Prophylactic salpingo-oopherectomy
What are the clinical features of ovarian cancer?
Symptoms are vague • Persistent abdominal distension • Feeling of fullness (Satiety) • Urinary urgency and/or frequency • Abdominal pelvic mass • Ascites • Pleural effusion • Peripheral oedema
What is the staging for ovarian cancer?
Stage 1 = Macroscopically confined to ovaries
Stage 2 = Disease extends to pelvis (fallopian tubes, uterus etc)
Stage 3 = Spreads to abdomen (omentum, small bowel)
Stage 4 = Distant metastasis (Lungs, liver)
What investigations are conducted for suspected ovarian cancer?
1st: CA-125
If CA-125 raised (>35): Ultrasound
If ascites, abdominal mass or suspicious ultrasound, urgent secondary care referral
CT Chest, Abdomen, Pelvis for lymph node involvement and extent of disease
How is the risk of malignancy index calculated? (RMI)
RMI = Ultrasound score x Menopausal status x CA-125 level
If >250 then referred to MDT
What is the management of ovarian cancer?
Laparotomy & hysterectomy with bilateral salpingo-oophorectomy
Platinum based carboplatin may be used as adjuvant depending on spread
What are the risk factors for vulval intraepithelial neoplasia/vulval cancer?
- HPV
- Cervical intraepithelial neoplasia
- Smoking
- Lichen sclerosus
- Chronic immunosuppression
What is the presentation of VIN/Vulval cancer?
Ulcer or mass on the labia majora or clitoris
Patient may experience pruritus, bleeding or discharge
There may be lymph node enlargement
What is the management of VIN?
Pruritus and pain are common in VIN, hence emollients or a mild topical steroids may help
Gold standard treatment is local surgical excision, confirmation of histology and exclude invasive disease
What is the staging for vulval cancer?
Stage 1 = Confined to vulva/perineum
Stage 2 = Adjacent spread to lower urethra/vagina/anus
Stage 3 = Positive inguinofemoral nodes
Stage 4 = Invasion of upper urethra, rectum, bladder or distant metastases
What is the investigation of vulval cancer?
A biopsy is required to establish diagnosis and histological type
What is the management of vulval cancer?
Stage 1a = Wide local excision
Other stages = Conduct sentinel lymph node biopsy:
• If no sentinel nodes present = Complete inguinofemoral lymphadenectomy
• If sentinel nodes present = Wide local excision and groin lymphadenectomy (gruesome, hence why SLNB is done first in hopes only inguinofemoral lymphadenectomy is needed)
