Gynaecology: Cancer Flashcards
What is CIN?
Cervical intraepithelial neoplasia - occurs when dyskaryosis (dysplasia) occurs in transformation zone (TZ).
NB: squamous epithelium is found in the ectocervix, columnar in endocervix, both regions meet at squamous-collumnar junction in ectocervix.
What is the peak incidence of CIN?
25-29 years old
90% of CIN is found in women < 40yo
What are the key RFs for CIN?
Infection with HPV
- strain 16, 18 most infective also 31, 33 found in 70% of cervical cancers
COCP
Smoking
What is the national screening system for cervical cancer?
National cervical screening
Speculum and smear
Every 3 years from 25-49
Every 5 years from 50-65
What are the grading of CIN?
CIN1 = mild dysplasia present in lower 1/3rd of TZ epithelium
CIN2 = moderate dysplasia present in lower 2/3rd of epithelium
CIN3 = severe dysplasia present in full thickness of epithelium
What is the investigative ladder for CIN?
- Speculum and Smear
a. mild dysplasia with high risk HPV –> refer to colposcopy
b. mild dysplasia with no HPV –> return to 3/5 year recall
c. severe dysplasia –> colposcopy - Colposcopy - biopsy and diagnosis via histology sample
a. CIN 1 = r/v in 6 months with cytology
b. CIN2/3 = LLETZ (large loop excision of transformation zone)
c. nothing seen –> refer to hysteroscopy
What is the investigation pathway for cervical cancer?
- Colposcopy and biopsy - confirms diagnosis
- FIGO system stages cancer
- Vaginal and Rectal exam under anaesthetic (EUA)
- Cystoscopy detects bladder involvement
- MRI detects size, spread and LN involvement
- CXR detects chest involvement
What are the four stages of cervical cancer?
FIGO system staging:
Stage 1 - confined to cervix
Stage 2 - invasion into vagina
Stage 3 - invasion into lower vagina and pelvic wall which causes ureteric obstruction
Stage 4 - invasion into bladder, rectal mucosa or beyond pelvis
What is the treatment of cervical cancer?
Treatment depends on staging of tumour according to FIGO system
stage 1a
- LLETZ
stage 1b-4 - surgical or chemo-radiotherapy
- Other stage 1 = hysterectomy + pelvic node resection
- stage 3/4 and LN involvement = chen-radiotherapy
What are the symptoms and signs of cervical cancer?
separate into occult and clinical
Occult carcinoma
- often asymptomatic, detected only after speculum/colposcopy or LLETZ
Clinical carcinoma
- PMB
- Offensive vaginal discharge
- IMB
- PCB
- Later develops into uraemia, haematuria, rectal bleeding or pain, cervical mass
What is the most common types of cervical cancer?
Squamous cell carcinoma 90%
Adenocarcinoma 10%
What is the peak incidence of cervical cancer?
Peaks in 30s and 80s
What is the most common genital tract cancer in women?
Endometrial cancer
What is the peak incidence of endometrial cancer?
Post-menopausal
What are the risk factors for endometrial cancer?
Concept: high in patients with high oestrogen to progesterone ratio. Risk is highest when there is high, unopposed oestrogen
- Obesity - peripheral conversion of androgens in fat to oestrogen
- HRT - oestrogen only
- PCOS - polycystic ovaries have high levels of oestrogen and cause early menarche and late menopause
- Tamoxifen - antagonist of oestrogen in breast but agonist in uterus
What are protective factors against endometrial cancer?
COCP and pregnancy
What is the most common kind of endometrial cancer
Adenocarcinoma
What is the investigative pathway for endometrial cancer?
- Bimanual and Speculum - exclude causes of bleeding and identify uterine size and adnexal masses
- TV USS
- if < 4mm = endometrial Ca unlikely
- if ≥ 4mm = endometrial Ca likely send for biopsy and hysteroscopy
- MRI if suspected spread - Hysteroscopy (staging) and biopsy (confirms diagnosis)
What is the investigative pathway for endometrial cancer?
- Bimanual and Speculum - exclude causes of bleeding and identify uterine size and adnexal masses
- TV USS
- if < 4mm = endometrial Ca unlikely
- if ≥ 4mm = endometrial Ca likely send for biopsy and hysteroscopy
- MRI if suspected spread - Hysteroscopy (staging) and biopsy (confirms diagnosis)
What is the treatment for endometrial cancer?
Stage 1 =
- hysterectomy and salpingostomy
Late stage =
- Hysterectomy, LN excision and adjuvant radiotherapy
What are the symptoms of ovarian cancer?
Often present in late stages (3-4) of cancer
- Persistant chronic abdominal or pelvic pain
- Bloating
- Early satiety or loss of appetite
- Increased urinary frequency due to bladder compression
- Pelvic or adnexal mass
- Ascites or pleural effusion
What is the most common site of mets for ovarian Ca?
Breast
What is the investigative pathway for ovarian cancer?
- CA125 level
- if > 35IU/ml refer for USS abdomen and pelvis - USS abdomen and pelvis
- if ascites or pelvic/abdominal mass found on USS or physical exam refer secondary care for CT - CT
- size, spread and stage of cancer
What is the most common type of ovarian cancer?
Epithelial caricinoma (90%)
Germ cell tumours rare
