Gynaecological Oncology Flashcards
Which HPV subtypes are most commonly associated with cancer?
16 and 18
Which HPV subtypes are most commonly associated with genital warts?
6 and 11
How is HPV transmitted?
Skin to skin contact
Who gets HPV vaccine?
All girls aged 12-13 - three injections over 12 months
How often is cervical screening done?
25-49 = every 3 years 50-64 = every 5 years
How is cervical screening done?
Liquid based cytology
Plastic broom swept over the transformation zone aiming to remove thin layer of cells. This is placed in liquid transport medium to be examined microscopically for any cells with dyskaryotic features. HPV test also done.
What does high-grade dyskaryosis mean?
Reduced ratio of nucleus to cytoplasm
What is colposcopy?
Examination of cervix with bright light and magnification to identify any abnormal areas – cervical intraepithelial neoplasia (CIN I, II and III)
What is done and identified in colposcopy?
Whole transformation zone should be identified.
o 5% Acetic acid – CIN cells appear white – these areas biopsied.
o Lugol’s solution – Schiller’s test – less well taken up by CIN cells
o Abnormal capillary patterns- punctuation, mosaicism
What action is taken if borderline/mild dyskaryosis is found at smear
HPV test
if +ve –> colposcopy
if -ve –> normal recall
What action is taken if moderate or severe dyskaryosis is found at smear
Straight to colposcopy
Definition of CIN I, II and III?
I = dyskaryosis 1/3 thickness of cervix II = dyskaryosis 2/3 thickness of cervix III = dyskaryosis full thickness of cervix
How is CIN managed?
I = Treatment vs no treatment
II/III = LLETZ – large loop excision of the transformation zone. Mostly performed in clinic under local anaesthesia
Most common types of cervical cancer?
Squamous cell carcinomas or adenocarcinomas
Features of cervical cancer?
- Post-coital bleeding, inter-menstrual bleeding and postmenopausal bleeding
- Persistent, offensive, blood-stained discharge
- Pain in late disease - loin (obstructed ureter), buttock and back- metastatic (compression by mass)
- Swollen leg- thrombosis in the pelvis
Examination in cervical cancer?
- Speculum examination
- Bimanual examination
- PR
Investigations in cervical cancer?
- Colposcopy
- Cervical biopsy
- FBC, U&Es, LFTs
- MRI pelvis
- CT abdomen and chest (or CXR)
Direct/local spread of cervical cancer?
Vagina, bladder, parametrium, bowel
Lymphatic spread of cervical cancer?
Parametrial nodes, internal, external and common illiac nodes, obturator nodes, pre-sacral, para-aortic nodes
Bloodborne spread of cervical cancer?
Lungs, liver
Staging of cervical cancer?
FIGO staging
0 = in situ I = confined to cervix II = beyond cervix but not to pelvic wall or lower 1/3 of vagina III = disease in pelvic wall or lower 1/3 of vagina IV = invades bladder, rectum or metastasis
What does cervical cancer treatment depend on?
Depends on stage, desire for future fertility, and concurrent medical conditions
Treatment of cervical cancer in early stages when future fertility desired?
Repeat cone biopsy with laparoscopic pelvic nodes dissection.
Treatment of cervical cancer up to stage 2a?
Surgical treatment
LETZ/conisation
Radical hysterectomy
Trachelectomy (simple/radical)
Cervical cancer treatment stage 2a and above?
Chemoradiotherapy
What is the most common gynae cancer?
Endometrial
Risk factors for endometrial cancer?
- Obesity (~1/3 of all cases)
- Diabetes
- Sedentary life-style (23% reduction in risk in active women)
- Menstrual factors: early menarche, late menopause, low parity
- Anovulatory amenorrhoea, e.g. PCOS • Unopposed oestrogen HRT
- Oestrogen-secreting ovarian tumours
- Tamoxifen
- FH of colorectal, endometrial or breast cancer
- Smoking slightly reduces the risk
How does endometrial hyperplasia occur?
- Subcutaneous fat produces oestrogen post-menopausally owing to aromatisation of adrenal steroids oestrogenic effect on endometrium without protection of progesterone.
- Unopposed oestrogen –> hyperplasia
What can endometrial hyperplasia lead to?
Hyperplasia predisposes to cytological atypia (simple, complex, atypical)
Atypical hyperplasia is precancerous and develops into invasive cancer 10-50% over 20 years
Management of endometrial hyperplasia?
Simple and complex - progesterone treatment
Atypical - hysterectomy
Most common type of endometrial cancer?
Adenocarcinoma is commonest (90%) – endometrioid type
Clinical features of endometrial cancer?
Postmenopausal bleeding (PMB) = endometrial ca until proven otherwise - 10% of women with PMB will have a malignancy
Premenopausal women – irregular, heavy or inter-menstrual bleeding especially if < 40 years old
Examination in endometrial cancer?
Speculum
• To exclude other causes such as cervical or vaginal lesions
PV
• Fixed or bulky uterus occurs with advanced disease
Investigations in endometrial cancer?
- TV USS with endometrial thickness
- Biopsy
- Pipelle in clinic
- Hysteroscopy and biopsy (>4mm)
- MRI – depth of invasion, cervical involvement, lymphadenopathy
- CT abdomen and chest if high-risk cancer, e.g. sarcoma
Why does endometrial cancer have a good prognosis?
The myometrium acts as a barrier to spread of the cancer – early presentation and high cure rate
Where does endometrial cancer spread to?
- Direct – cervical stroma, fallopian tubes and ovaries
- Across peritoneal cavity to omentum, surface of other organs – liver, bowel
- Lymphatic – pelvic, para-aortic and rarely inguinal lymph nodes
- Blood-borne – liver, lungs
Staging of endometrial cancer?
Stage I Confined to body of uterus
Stage II Involving the cervix
Stage III Spread outside the uterus
Stage IV With bowel, bladder or distant organ involvement
Management of endometrial cancer (early stage)?
Total hysterectomy, bilateral salpingo-oophorectomy, peritoneal washings
Management of endometrial cancer (late stage)?
Staging laparotomy/laparoscopic staging
Management of endometrial cancer (advanced stage)?
Chemoradiotherapy/ NACT/ Hormone therapy
Where does ovarian cancer rank in diagnosis in women, gynae cancers and gynae cancer death
5th most common cancer in women
2nd most common gynae cancer
Most common cause of gynae cancer death
Risk factors for ovarian cancer
- Nulliparity
- HRT
- Endometriosis
- Difficulties conceiving
- 5-10% of patients with epithelial ovarian cancer have a genetic predisposition: BRCA1 and BRCA2 gene mutations
Why does nulliparity increase risk of cervical cancer?
o Increased ovulation puts trauma on the follicle as it must rupture and repair more times
o Contraception that stops ovulation is beneficial
Histopathology of ovarian cancers?
- Epithelial – derived from Mullerian epithelium
- Sex cord or stromal – derived from ovarian stroma, sex cord derivatives or both
- Germ cell – derived from ovarian germ cells
When do ovarian cancers tend to present?
Usually present very late (stage 3 or 4)
History in ovarian cancer?
- Abdominal pain and swelling
- Pressure effects on the bladder and rectum
- Dyspnoea
- Gastrointestinal upset and anorexia
- Abnormal vaginal bleeding
- Up to 15% of patients will remain asymptomatic at diagnosis
Examination in ovarian cancer?
- Adnexal or pelvic mass
- Shifting dullness
- Irregular abdominal mass – omental cake
Investigations in ovarian cancer?
- Pelvic USS
- Tumour Markers
- Chest X-ray
- FBC, U&Es, LFTs
- CT abdomen and pelvis
- Paracentesis of ascites
Tumour markers in ovarian cancer?
o CA125 – Serous, endometrioid
o CA19.9 – Mucinous
o Carcinoembryonic antigen – CEA
o AFP, HCG, LDH
Staging of ovarian cancer?
Stage I Limited to one or both ovaries
Stage II Pelvic extension or implants
Stage III Microscopic peritoneal implants outside of the pelvis; or limited to the pelvis with extension to the small bowel or omentum
Stage IV Distant metastases
Treatment of ovarian cancer?
- Total abdominal hysterectomy, bilateral salpingoophretcomy, omentectomy, lymph node sampling and peritoneal biopsies with peritoneal washings or ascitic fluid obtained for cytology
- Adjuvant chemotherapy with platinum based compounds has been shown to benefit women with no residual disease following surgery, improving survival (ICON 1)
