Gynaecological tumours Flashcards
ovarian Ca risk factors?
FH-BRCA1 or 2 gene mutations, ?FH of breast or ovarian Ca
HNPCC (Lynch syndrome)
many ovulations-early menarche, late menopause, nulliparity
HRT
clinical features of ovarian cancer?
abdo bloating and distension abdo or pelvic pain early satiety urgency diarrhoea weight loss
3 cardinal features of meig’s syndrome?
benign ovarian tumour (fibroma or fibroma-like tumour) ascites pleural effusion (exudate) *Lights criteria if borderline pleural fluid protein (25-35g/L)
most common benign ovarian tumour in young women? (under 30 years)
dermoid cyst (teratoma)
with which ovarian tumours is torsion more likely?
teratomas (dermoid cysts)
what is dyskaryosis?
this refers to an abnormality of the nucleus
can be identified under the microscope from a cervical smear
mild, moderate and severe types
what is CIN?
cervical intraepithelial neoplasia
describes how far abnormal cells have gone into the surface layer of the cervix
CIN 1=1/3 of the thickness of the surface layer of the cervix is affected
CIN 2=2/3 of the thickness of the surface layer of the cervix
CIN 3=full thickness of the surface layer of the cervix is affected (CIS)
RFs for endometrial cancer?
- nulliparity
- late menopause (past age of 52)
- obesity
- endometrial hyperplasia
- HNPCC
- oestrogen secreting ovarian tumours-granulosa cell tumours
- PCOS-anovulatory cycles so not producing corpus luteum with subsequent progesterone production, so prolonged periods of unopposed oestrogen
- type 2 DM
- tamoxifen
- oestrogen only HRT
- ?immunosuppression and infection
significance of endometrial hyperplasia?
precursor to endometrial cancer
management of endometrial hyperplasia without atypia?
less than 5% will progress to endometrial cancer over 20 years
- minimise RFs e.g. lose weight, stop HRT
- may be managed with observation alone with f/u endometrial biopsies
- progestogen tment indicated in women who fail to regress spontaneously with observation alone and in those with abnormal uterine bleeding e.g. LNG-IUS or oral progestogens for minimum 6 mnths to cause histological regression.
- hysterectomy can be offered if progression to atypical disease on f/u, no histological regression after 12mnths of treatment, endometrial hyperplasia relapse after completing progestogen tment, peristence of bleeding symptoms.
management of atypical endometrial hyperplasia?
total hysterectomy due to risk of underlying malignancy or progression to cancer. preferably lap approach so that shorter hosp stay, quicker recovery + less post op pain.
if wish to maintain fertility, or pt unsuitable for surgery, offer LNG-IUS 1st line, oral progestogens 2nd line.
if postmenopausal should offer bilateral salpingo-oopherectomy, if premenopausal should consider, to reduce risk of future ovarian malignancy.
complications of lichen sclerosis?
- vulval cancer (4%)
- dysparenunia
- dysuria
- distress associated with itch and discomfort
why does PCOS increase your risk of endometrial cancer?
anovulatory cycles, so prolonged time of unopposed oestrogen exposure as not producing the corpus luteum so not producing progesterone
why might hCG be raised outside of pregnancy?
ovarian germ cell tumours
seminomatous and non seminomatous testicular tumours
what are the internal and external cervical os?
external cervical os is the external opening of the cervix, between the ectocervix (stratified squamous NK epithelium) and the vagina
internal cervical os=between the endocervix (simple columnar) and the body of the uterus
what name is given to the boundary between endocervix and ectocervix?
=SCJ-squamocolumnar junction
the transformation zone-area for cervical smears, is where columnar epithelium is undergoing squamous metaplasia, and is between the SCJ as it was before puberty and where it was at its lowest point during puberty.
what is a cervical ectropion?
columnar epithelium present on the vaginal surface of the cervix (ectocervix)
undergoes squamous metaplasia, transforming to stratitifed squamous epithelium
o/e: may be erythematous around the external cervical os as vascular columnar epithelium
can be excess secretion of mucus as columnar epithelium contains mucus secreting glands, and may be *post coital bleeding as delicate blood vessels in columnar epithelium.
risk associated with increased levels of oestrogen e.g. young women, COCP-may stop if troublesome symptoms, or if very severe then ablation therapy may be used.
histological subtype of cervical cancer that is most common?
squamous cell carcinoma (80%)
if cells of endocervix affected (columnar) then this would be a cervical adenocarcinoma (more than 10%)
also small cell and lymphomas
when does the SCJ migrate out of the external cervical os?
during puberty and pregnancy
cervical cancer symptoms?
PV bleeding-intermenstrual-may occur after micturition or defecation, postcoital, postmenopausal
dyspareunia
smelly vaginal discharge
pelvic pain
urinary symptoms, chronic urinary frequency
painless haematuria
altered bowel habit
leg oedema, pain and hydronephrosis leading to CKD
treatment options for cervical carcinoma in situ (CIS/CIN III)?
laser therapy cryotherapy cone biopsy large loop excision of transformation zone (LLETZ) (wire and electrical current used)-increased risk of premature labour and low birthweight baby hysterectomy
problems in pregnancy associated with a large loop excision of the transformation zone?
risk of premature labour*
risk of late miscarriage
cervical cancer risk factors?
HPV-subtypes 16 and 18 smoking young age FH multiple sexual partners, infection with both HIV and chlamydia lack of barrier contraception use COCP low SE class immunosuppression e.g. HIV, post transplant non attendance at cervical screening
stage of cervical cancer if it has spread outside of the cervix, and what treatment is given for this?
stage 2
stage 2A-spread into top of vagina
stage 2B-spread up into tissues around cervix
2A-surgery (hysterectomy) or chemoradiotherapy
2B-chemoradiotherapy
treatment options for stage 1 cervical cancer?
surgery or radiotherapy-brachytherapy or external
surgery-usually hysterectomy, but a radical trachelectomy-cervix and upper 1/3 of the vagina removed, but internal cervical os is left behind, and patient still able to get pregnant., can be used if small stage 1 cervical cancer.
stage 1B2-might have chemoradiotherapy.
what is stage 3 cervical cancer?
3A=spread into lower 1/3 of vagina but not pelvic wall
3B=grown through the pelvic wall or is blocking 1 or both of the ureters.
stage 3 cervical cancer treatment?
chemoradiotherapy
what is stage 4 cervical cancer?
4A-spread to nearby organs e.g. bladder, rectum
4B-spread to distant organs
may use combination of surgery, chemo, radiotherapy
diagnostic tests for cervical cancer?
- colposcopy-assessment of cervix with speculum and microscopy-colposcope
- cone biopsy-done under GA, includes the whole area of the cervical canal where they might be abnormal cells.
complications of cone biopsy?
bleeding
cervical stenosis
prematurity, low birth weight, birth by C section, patient may have a purse string suture to prevent early birth.
why is the mirena coil (IUS) not recommended for contraception in those that have had endometrial or cervical cancer?
as coil has side effect of spotting which can mask the symptoms of cancer.
what are the different results possible following cervical screening?
- normal
- inadequate
- inflammatory
- dyskaryosis-may be reported as borderline/mild cell changes (low grade dyskaryosis) or moderate or severe cell changes (high grade dyskaryosis).
further investigation for low grade dyskaryosis following cervical smear?
borderline or mild cell changes seen on sample-sample then tested for HPV-if +ve for high risk types then sent for colposcopy straight away, if -ve then go back into routine screening.
who is screened for cervical cancer?
women aged 25-49=every 3 years
women aged 50-64=every 5 years
signs of cervical cancer?
white or red patches on the cervix
pelvic bulkiness/masses due to pelvic spread on bimanual examination
PR-mass or bleeding due to erosion
leg oedema-vascular or lymphatic obstruction
hepatomegaly-liver mets
what should be discussed with patients regarding what will happen following treatment for abnormal cervical cells?
- problems patient might experience which they shouldn’t worry about-pain-may take paracetamol or ibuprofen, PV bleeding and watery vaginal discharge-can last up to 4 weeks.
- problems that should prompt medical attention-discharge starts to smell bad, bleeding becomes heavier.
- avoid intercourse for at least 4wks to prevent infection
- pt should be able to get back to normal after 6 wks
- f/u screening test at 6 months (+HPV testing)
- screening at 6mnths and 18mnths following hysterectomy-abnormal cells may affect vaginal vault
- if the abnormal cells come back more than once, or dr thinks risks too great, you may be offered a hysterectomy to prevent cancer development.
symptoms of vulval cancer?
lasting itch pain/soreness dysuria vaginal discharge or bleeding thickened, raised red, white or dark patches on vulval skin an open sore or growth mole on vulva that changes shape or colour lump or swelling in vulva lump in groin
RFs for vulval cancer?
- increasing age
- HPV-type 16 most commonly, then 33 and 18
- vulval intraepithelial neoplasia (VIN)-80% associated with HPV
- lichen sclerosis-associated with differentiated vulval intraepithelial neoplasia (VIN), lichen planus, pagets
- previous cervical cancer or CIN
- smoking
- weakened immune system
- radiotherapy for uterine cancer
- SLE
presentation of endometrial cancer?
post menopausal bleeding
may present with menstrual cycle irregularities around or before the menopause
treatment of stage 1 endometrial cancer?
total abdominal hysterectomy and bilateral salpingo-oopherectomy
progestogen in tment of stage 1a without myometrial invasion, in those who want to preserve their fertility.
gold standard for endometrial cancer diagnosis?
hysteroscopy and biopsy (curettage)
differentials for post menopausal bleeding?
endometrial cancer endometrial hyperplasia cervical cancer endometrial polyps atrophic vaginitis bleeding disorder
what test is used to screen for cervical cancer?
liquid cytology-a cytology brush is used, rotated 360 degrees 5 times to get a sample, in the external cervical os, then put brush into cytology preservative solution.
if the SCJ is further up in the cervical canal, can use a different brush*
however, in the future will be moving towards primary HPV testing.
what are we looking for when assessing the cervix on colposcopy?
acetowhiteness (stain cervix with 5% acetic acid)-dense whiteness associated with high grade lesions vasculature size border topocography
what lesions are seen on colposcopy with active HPV?
satellite lesions
features of high grade changes on the cervix on colposcopy?
dense acetowhiteness
marked border
punctation
mosaic pattern-vasculature
what can prevent cervical cancer developing?
HPV vaccination
complications of a previous LLETZ in pregnancy?
premature labour
PROM
types of endometrial hyperplasia?
- simple without atypia
- complex without atypia
- simple with atypia
- complex with atypia
with atypia, initial management=total hysterectomy.
what type of virus is HPV?
single stranded DNA virus
risks and side effects of colposcopy?
- pain/discomfort
- brown vaginal discharge, should pass quickly
- light vaginal bleeding-should pass after 3-5 days
a/v to contact GP is have persistent PV bleeding, heavy bleeding (heavier than normal period), smelly PV discharge or abdo pain.
most common type of endometrial Ca?
adenocarcinoma
symptoms of vaginal atrophy/atrophic vaginitis?
- vaginal dryness
- vaginal or vulva itching or burning
- dyspareunia
- vaginal discharge, usually white or yellow
- post menopausal bleeding, post coital bleeding
- urinary symptoms-frequency, dysuria, nocturia, recurrent UTIs, stress incontinence or urgency-note lack of oestrogen can affect periurethral tissues and contribute to pelvic laxity and stress incontinence.
signs of atrophic vaginitis?
- reduced pubic hair, reduced tugor, narrow introitus
- PV examination-pain
- thin vaginal mucosa with diffuse erythema
- occasional petechiae or ecchymoses
- dryness
- lack of vaginal folds
possible investigation in a woman presenting with PMB, plus vaginal dryness, urinary frequency, and dyspareunia?
- must consider investigation for endometrial cancer with TV ultrasound, pipelle biopsy, gold standard=hysteroscopy+biospy
- if discharge also present may consider infection screen-high vaginal, endocervical swabs
- consider screening for diabetes
- atrophic vaginitis confirmation-vaginal pH testing-pH paper and sampling from mid-vagina, pH more alkaline in atrophic vaginitis.
- vaginal cytology-lack of maturation of vaginal epithelium
management option for atrophic vaginitis?
- non hormonal lubricants and moisturisers to improve dryness and relieve pain during sex
- HRT-systemic or topical-topical is better for atrophic vaginitis, and may be given as vaginal pessary, tablet or cream-creams associated with more PV discharge.
aspects to examination of pt with PMB where ?endometrial cancer?
- unlikely to be any physical abnormality of endometrial Ca o/e
- if a recent C smear has not been taken this should be done-using a cytology brush
- look for other differentials e.g. atrophic vaginitis-reduced pubic hair, reduced elasticity, painful PV examination with thin and diffusely erythematous vaginal mucosa, may be petechiae, reduced vaginal folds.
1st line investigation for endometrial cancer?
transvaginal ultrasound scan-looks at mean endometrial thickness. note that endometrial thickness is only relevant post menopause.
higher mean endometrial thickness=increased likelihood of endometrial cancer. if thickness is 4mm or greater, then biospy required. can use pipelle endometrial sampler, then gold standard diagnostic tool=hysteroscopy with biopsy (curettage)-can be IP or OP.
proportion of patients with PMB who will have an underlying malignancy?
10%
treatment of stage 2 endometrial Ca (not extended outside uterus but involves cervical stroma)?
radical hysterectomy with systematic pelvic node clearance
may be para-aortic lymphadenectomy
stage 3+4-maximal debulking surgery, usually combined with chemo and radio.
most common benign epithelial tumour?
seruous cystadenoma
most common ovarian cancer?
serous carcinoma
complication of mucinous cystadenoma rupture?
pseudomyxoma peritonei-mucus producing cancerous cells which spread to the peritoneum.
