Gynaecological neoplasias and cancers

Question 1

What is the most common gynaecological cancer?

Answer 1

Endometrial cancer

Question 2

What are the risk factors for endometrial cancer?

Answer 2

Excess endogenous oestrogen
	• PCOS
	• Obesity
	• Early menarche/Late adrenarche
	• Nulliparity
Excess exogenous oestrogen
	• Tamoxifen
	• Oestrogen-only HRT
Other
	• Diabetes
	• HNPCC

Question 3

What is the treatment of endometrial hyperplasia?

Answer 3

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

Question 4

What are the clinical features of endometrial cancer?

Answer 4

Post menopausal bleeding (Most common)

In premenopausal women, may seen intermenstrual bleeding or recent-onset menorrhagia

Question 5

What are the stages of endometrial cancer?

Answer 5

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

Question 6

What are the investigations for endometrial cancer?

Answer 6

Ultrasound plus endometrial biopsy (biopsy via pipelle or hysteroscopy)

MRI may be performed to determine myometrial invasion

Chest x-ray for pulmonary spread

Question 7

What is the management of endometrial cancer?

Answer 7

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

Question 8

What are the stages of cervical intraepithelial neoplasia?

Answer 8

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

Question 9

What are the risk factors for cervical cancer?

Answer 9

HPV (Hence, having multiple sexual partners)
COCP
Smoking
Immunocompromised patients are at greater risk of early progression to malignancy

Question 10

What is the management of smear results?

Answer 10

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

Question 11

What is the treatment of cervical intraepithelial neoplasia?

Answer 11

LLETZ procedure

The specimen is then examined histologically to look for unsuspected malignancy

Question 12

What are the clinical features of cervical cancer?

Answer 12

Postcoital bleeding
Offensive vaginal discharge
Intermenstrual bleeding or Postmenopausal bleeding

Question 13

What are the stages of cervical cancer?

Answer 13

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

Question 14

What are the investigations for cervical cancer?

Answer 14

To confirm diagnosis = Biopsy

To stage the disease = Vaginal/Rectal examination and MRI

Question 15

What is the treatment of cervical malignancies?

Answer 15

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

Question 16

What are some epithelial ovarian tumours and how do they present?

Answer 16

Most common in postmenopausal
Serous cystadenoma
Endometrioid carcinoma - Similar histologically to endometrial carcinoma
Clear cell carcinoma - Malignant with poor prognosis
Mucinous cystadenoma - Very large

Question 17

What are some germ cell tumours and how do they present?

Answer 17

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

Question 18

What are examples of sex cord tumours and how do they present?

Answer 18

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)

Question 19

What are functional cysts?

Answer 19

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

Question 20

How are cysts managed?

Answer 20

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)

Question 21

What are the most common ovarian malignancies?

Answer 21

Serous adenocarcinoma (75%)
Endometroid carcinoma (10%)
Clear cell carcinoma (10%)

Question 22

What are the risk factors for ovarian cancer?

Answer 22

Risk is related to number of ovulations (Early menarche, late menopause, nulliparity)

Familial: BRCA1/BRCA2 or HNPCC

HRT

Protective factors = Pregnancy, lactation and COCP

Question 23

What screening is conducted for ovarian cancer?

Answer 23

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

Question 24

What are the clinical features of ovarian cancer?

Answer 24

Symptoms are vague
	• Persistent abdominal distension
	• Feeling of fullness (Satiety)
	• Urinary urgency and/or frequency
	• Abdominal pelvic mass
	• Ascites
	• Pleural effusion
	• Peripheral oedema

Question 25

What is the staging for ovarian cancer?

Answer 25

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)

Question 26

What investigations are conducted for suspected ovarian cancer?

Answer 26

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

Question 27

How is the risk of malignancy index calculated? (RMI)

Answer 27

RMI = Ultrasound score x Menopausal status x CA-125 level

If >250 then referred to MDT

Question 28

What is the management of ovarian cancer?

Answer 28

Laparotomy & hysterectomy with bilateral salpingo-oophorectomy

Platinum based carboplatin may be used as adjuvant depending on spread

Question 29

What are the risk factors for vulval intraepithelial neoplasia/vulval cancer?

Answer 29

• HPV
  
  • Cervical intraepithelial neoplasia
  • Smoking
  • Lichen sclerosus
  • Chronic immunosuppression

Question 30

What is the presentation of VIN/Vulval cancer?

Answer 30

Ulcer or mass on the labia majora or clitoris
Patient may experience pruritus, bleeding or discharge
There may be lymph node enlargement

Question 31

What is the management of VIN?

Answer 31

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

Question 32

What is the staging for vulval cancer?

Answer 32

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

Question 33

What is the investigation of vulval cancer?

Answer 33

A biopsy is required to establish diagnosis and histological type

Question 34

What is the management of vulval cancer?

Answer 34

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)