Gynaecological Oncology Flashcards
What is the most common uterine malignancy?
Endometrial adenocarcinoma
High levels of estrogen increase risk of endometrial malignancy - what factors increase estrogen levels in the body?
Polycystic ovarian syndrome (PCOS) Early menarche/late menopause Nulliparity Obesity Unopposed estrogen HRT Tamoxifen Oestrogen-secreting tumours (granulose/theca cell ovarian tumours)
What is the principle symptom of endometrial malignancy?
Abnormal uterine bleeding (commonly postmenopausal)
What is the first line investigation for suspected endometrial cancer?
Transvaginal ultrasound
What finding on transvaginal ultrasound would raised suspicion of malignancy?
Endometrial thickness >4mm
What investigation/s should be carried out after a finding of thickened endometrium?
Hysteroscopy + endometrial biopsy +/- dilatation and curettage
What are the histological findings of endometrial hyperplasia?
Increased number of endometrial cells
Increase in the gland-to-stromal ratio
What are the different types of endometrial hyperplasia and what is the recommended treatment?
Simple/complex - progesterone treatment (e.g. Mirena)
Atypical - risk of progression to malignancy - hysterectomy recommended
What are some histological appearances of endometrial carcinoma?
Purely glandular
Areas of squamous differentiation
Papillary
Clear cell pattern
How does endometrial Ca commonly spread?
Usually direct into myometrium and cervix
Haematogenous or lymphatic spread can occur
What is the aetiology of type I endometrial cancer?
Most common (80% of all endometrial Ca) Usually diagnosed shortly after the menopause
What are the pathophysiological features of Type I endometrial cancer?
Endometrioid
- estrogen dependent
- atypical hyperplasia is a precursor
- microsatellite instability (Lynch syndrome)
What is the aetiology of type II endometrial cancer?
Older women
What are the pathophysiological features of Type II endometrial cancer?
Serous and clear cell
- not associated with unopposed estrogen
- TP53 mutation
- common extrauterine spread
- poor prognosis
What is a common presentation of endometrial sarcoma?
Lung or ovarian metastasis
Locally aggressive and metastasizes early
Define carcinosarcoma?
Mixed tumours with malignant epithelial and stromal elements
What staging system is used in endometrial cancer?
International Federation of Gynaecology and Obstetrics (FIGO) scheme
What is the mainstay of treatment for endometrial cancer?
Surgical - hysterectomy and bilateral salpingo-oophorectomy
+/- lymphadenectomy
What treatment is available for endometrial Ca in patients not fit for surgery?
Radiotherapy
High dose progestogens
What is the most common uterine sarcoma and how does it present?
Leiomyosarcoma
Women >50 years old
Abnormal vaginal bleeding, palpable pelvic mass, pelvic pain
What is the most common type of primary ovarian tumour?
Epithelial tumours (70% of cases)
The number of times a women ovulates is the main risk factor for ovarian Ca. What factors influence this?
Parity (multiparity reduces risk)
Breastfeeding reduces risk
COCP reduces risk
What genetic conditions are associated with ovarian cancer?
HNPCC (Lynch syndrome)
BRCA1/BRCA2
How are epithelial ovarian tumours classified?
Benign
Borderline (malignant characteristics with no stromal invasion)
Malignant
What is the most common ovarian cancer?
Serous carcinoma
What are precursor lesions for serous carcinomas?
Serous tubal intraepithelial carcinoma (STIC) –> high grade serous carcinoma
Serous borderline tumour –> low grade serous carcinoma
What are the features of mucinous ovarian tumours?
Often benign (unilateral) but can be malignant (bilateral) Contain mucinous fluid
What are the features of endometrioid ovarian tumours?
Usually malignant but present early
30% of women will also have a primary tumour in endometrium
Associated with Lynch syndrome
What are the features of clear cell ovarian tumours?
Almost all malignant
Associated with endometriosis
Associated with Lynch syndrome
What are the features of urothelial-like ovarian tumours?
Rarely malignant
Transitional type epithelium
What are the features of granulosa cell ovarian tumours?
Low grade but potentially malignant
75% secrete sex hormones - can cause precocious pseudopuberty and/or abnormal bleeding
Call-Exner bodies (coffee bean nuclei and gland-like spaces)
What are the features of thecoma/fibroma ovarian tumours?
Usually benign
Contain theca cells or fibroblastic-type cells
May produce estrogen
Can cause Meigs syndrome
What are the features of sertoli/leydig cell ovarian tumours?
Very rare
Young women
Unilateral
Can be androgenic
What are the features of teratoma ovarian tumours?
Most common germ cell tumour
Usually benign
Mature teratomas may contain hair/teeth/epithelium/sebum - ‘dermoid cyst’
What are the features of dysgerminoma ovarian tumours?
Most common malignant germ cell tumour
Associated with gonadoblastoma in gonadal dysgenesis
hCG may be increased
What are the features of endodermal sinus/yolk sac ovarian tumours?
Usually present with sudden pelvic mass
hCG normal
Alpha-fetoprotein increased
What are the features of choriocarcinoma ovarian tumours?
Secrete hCG - precocious pseudopuberty
Poor prognosis
How do ovarian cancers normally spread?
Trans-coelomically
- tumour seeds into peritoneal cavity
- death can result from intestinal blockage and cachexia
- para-aortic node metastases are common finding
How does ovarian cancer typically present?
Late
GI complications/bowel obstruction
Abdominal distention
What is the risk of malignancy index (RMI) made up of?
USS score
Menopausal score
CA125
What are suspicious USS findings of ovarian cancer?
Complex mass with solid + cystic area Multi-loculated Thick septations Associated ascites Bilateral disease
CA125 is raised in 80% of ovarian cancers. What are other causes for it being raised?
Endometriosis Peritonitis Pregnancy Pancreatitis Ascites
What is the typical treatment for epithelial ovarian cancer?
Chemotherapy + surgery
+/- fertility preservation
What are risk factors for cervical neoplasia?
Multiple sexual partners Starting intercourse at younger age Intercourse without barrier protection COCP Smoking
What types of HPV are closely linked to the development of cervical neoplasia?
16 and 18
What are the preinvasive phases of cervical/endocervical cancer?
Cervical intraepithelial neoplasia –> squamous cervical cancer
Cervical glandular intraepithelial neoplasia –> endocervical adenocarcinoma
What are features of endocervical adenocarcinoma?
Harder to detect by screening
Worse prognosis than squamous
Risk factors:
Later onset of sexual activity, smoking, HPB (particularly HPV18, higher SE class)
Who is recommended to have cervical screening and how often?
Anyone with a cervix aged 25-65 every 5 years
Define the ‘transformation zone’?
The area where the columnar epithelium of the endocervix meets the squamous epithelium of the ectocervix
The area targeted during a cervical smear test
What test is carried out at a cervical smear?
HPV test
Cytology is investigated only after a positive HPV result
How is CIN classified?
I-III
CIN I: dyskaryosis (abnormal cells) in a third of the basal epithelium
CIN II: abnormal cells have extended into middle third
CIN III: abnormal cells span full thickness of epithelium
What is the purpose of colposcopy?
Allows the cervix to be examined in more detail and the squamocolumnar junction visualised
+/- biopsy/treatment
Why is acetic acid applied during colposcopy?
Abnormal epithelium contains more protein and less glycogen
When acetic acid is applied, abnormal epithelium appears white
What is the risk of progression of CIN III to invasive disease?
30% over 5-20 years
What is the treatment for high grade CIN?
Excision at colposcopy or after biopsy
Usually done by large loop excision of the transformational zone (LLETZ)
Ablation is alternative option
What is the typical presentation of cervical cancer?
Post-coital bleeding Intermenstrual bleeding Menorrhagia Pelvic pain Offensive vaginal discharge
Often asymptomatic
How does cervical cancer typically spread?
Spread to adjacent structures - parametrium, upper vagina, pelvic sidewall, bladder, rectum
Lymphatic spread usually results in metastases to the pelvic and para-aortic nodes
How is cervical cancer staged?
Based on clinical examination and confirmed by histological biopsy (does not include imaging results)
What is the management of cervical cancer?
Stage 1A1 - local excision
Stage 1A2 - simple hysterectomy + pelvic lymphadenectomy
Stage IB-IIA - Radical hysterectomy + pelvic lymphadenectomy OR radical radiotherapy +/- cisplatin
Stage IIB-IV - Radical radiotherapy + cisplatin chemotherapy
What are the side effects of radiotherapy to the cervix?
Cystitis
Diarrhoea
Fibrosis which can cause vaginal stenosis
Sexual dysfunction
