Gynaecology Oncology Flashcards by Grace Ella

Look at anatomy notes

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Which types of HPV are most frequently associated with cervical cancer?

types 16, 18, 31 and 33

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What is the screening programme for cervical cancer?

cervical smears (from age 25 or after first intercourse, every 3 years and then every 5 years >50) 
abnormal smear identifies women likely to have CIN and therefore risk of invasive cancer

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What is the method of a cervical smear?

Cusco’s speculum
Brush scraped around external os of cervix to pick up loose cells over
transformation zone
Brush tip broken into preservative fluid
Transport to lab
Fluid centrifuged + spread on slide for microscopy, can test for HPV
Identify cellular abnormalities (dyskaryosib)

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What is the management of a normal smear result?

repeat in 3 years time

5 if over 50

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What is the management for borderline or mild dyskaryosis?

CIN 1

HPV negative - back to routine recall

HPV positive - colposcopy

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What is the management for moderate dyskaryosis?

CIN 2

Colposcopy

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What is the management for severe dyskaryosis?

CIN 3

urgent colposcopy

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What is the management of cervical glandular intraepithelial neoplasia?

(any grade)

colposcopy

if no abnormality then hysteroscopy

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How does the HPV vaccination work?

Reduces incidence of pre-cancerous cervical lesions (+ therefore potentially cervical
cancer)

Vaccine given before first sexual contact

Does not help to treat established CIN

UK national vaccination programme in 2008, targeting types 16 and 18

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What are the risk factors for the premalignant and malignant squamous cell carcinoma of the cervix?

HPV - number of sexual contacts, types 16/18/31/33 most risky
Oral contraceptive
Smoking
Immunocompromised

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What are the symptoms of premalignant squamous cell carcinoma of the cervix?

none

not visible on the cervix

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What is the management of premalignant squamous cell carcinoma of the cervix?

if CIN II or III transformation zone excised using diathermy under local anaesthetic

specimen examined histologically

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What are the symptoms of squamous cell carcinoma?

no symptoms 
postcoital bleeding 
offensive vaginal discharge + IMB/PMB
later stage - uraemia, maematuria, rectal bleeding and pain 
Ulcer/mass may be palpable or visible

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What investigations should take place for a squamous cell carcinoma?

biopsy to confirm diagnosis
vaginal and rectal examination to assess size of lesion for parametrical/rectal invasion
examine under anaesthetic
cystoscopy to detect bladder involvement
MRI to detect tumour size, spread and LN involvement
CXR, FBC, U&Es to check fitness for surgery

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How is stage 1a cervical cancer treated?

cone biopsy or simple hysterectomy

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How is 1a-b cervical cancer treated?

laparoscopic lymphadenopathy and radial trachelectomy

How is 1a-2a cervical cancer treated?

radical hysterectomy (if lymph nodes negative) or chemotherapy

How is 2b and above treated or LNS positive?

Chemo-radiotherapy alone

What are the risks of a cone biopsy?

risk of post op haemorrhage and pre term labour in subsequent pregnancies

What is a radial hysterectomy?

pelvic node clearance, hysterectomy + removal of parametrium + upper 1/3 of vagina, complications of haemorrhage, ureteric and bladder damage + fistulae, voiding problems + accumulation of lymph

What is a radical trachelectomy?

removal of 80% of cervix + upper vagina, for women who wish to conserve fertility, laparoscopic pelvic lymphadenectomy first (if LN then chemo) cervical suture inserted to prevent preterm delivery

What is endometrial hyperplasia of the uterus?

oestrogen acting unopposed or erratically can cause ‘cystic hyperplasia’ of endometrium

further stimulation predisposes to ‘atypical hyperplasia’

What are the symptoms of endometrial hyperplasia?

menstrual abnormalities
postmenopausal bleeding
premalignant

What is the management of endometrial hyperplasia?

if uterus must be preserved then progesterone in combination with 6 months endometrial biopsy otherwise hysterectomy

What are the RFs for adenocarcinoma of the uterus?

endogenous oestrogen excess - PCOS, obesity, oestrogen secreting tumours, nulliparity and late menopause exogenous oestrogen - unopposed oestrogen therapy, tamoxifen therapy others - diabetes, HTN, lynch type II syndrome

What are the clinical features of adenocarcinoma?

postmenopausal bleeding premenstrual symptoms - irregular or inter menstrual bleeding or recent onset menorrhagia cervical smear may contain abnormal columnar cells pelvis appears normal or strophic vaginitis may co-exist

What are the investigations for adenocarcinoma? depends on age, menopause status and symptoms, US scans and endometrial biopsy

endometrial biopsy to make diagnosis staging only after hysterectomy MRI in all patients where spread is suspected or high risk CXR to exclude pulmonary spread FBC, renal function, glucose testing, ECG to assess patients fitness

How are adencarcinomas of the uterus treated?

stage 1 - hysterectomy and bilateral sapling-oophrectomy abdominally or laparoscopically routine lymphadenopathy not beneficial in early stage radiotherapy used following hysterectomy in patients with or considered high risk for lymph node involvement chemo used in high risk early stage and advanced stage disease

What are the risk factors for ovarian cancers?

easy menarche late menopause nulliparity familial via BRCA 1/2 or HNPCC gene mutations

What is protective against ovarian cancer?

pregnancy, lactation and use of the pill are protective

What are the symptom of ovarian cancer?

symptoms usually vague/absent 70% present with stage 3-4 disease - persistent abdominal distention (bloating) - feeling full early - loss of appetite - pelvic or abdominal pain - increased urinary urgency and/or frequency - cachexia - abdomina or pelvic mass and ascites (if v large, less likely to be malignant)

How does ovarian cancer spread?

spreads directly within the pelvis and abdomen lymphatic and blood bourne spread

What are the investigation - blood test can be used to detect ovarian cancer in primary care?

CA125 levels should be measured in women >50 with many abdominal symptoms e.g. persistent abdo pain or distention, loss of appetite, weight loss, fatigue, change in bowel habit, urinary frequency and/or urgency

What investigation should take place if CA125 is raised?

US of abdomen and pelvis arranged if US or physical exam identifies ascites and/or pelvic/abdo mass, urgent referral to secondary care

What investigations for ovarian cancer should take place in secondary care?

If <40, levels of alpha fetoprotein + hCG measured (raised in germ cell tumours) CT pelvis + abdomen (+ thorax if clinically indicated) performed to establish extent of disease, further staging during surgery

What is the surgical treatment for ovarian cancer?

midline laparotomy total hysterectomy, bilateral salpingo-oophrxectomy and partial omentectomy biopsies of any peritoneal deposits and peritoneum

How should ovarian cancer be treated in young women who wish to preserve fertility?

if disease early or borderline | uterus and unaffected ovary may be preserved but staging and follow up

How should ovarian cancer be treated with chemotherapy?

prolongs short term survival and improves QoL | CA125 levels can be used to measure response to chemotherapy

When is radiotherapy used to treat ovarian cancer?

dysgerminomas

How are ovarian cancer patients followed up?

levels of CA125 useful after as well as during chemo CT scanning - aids detection of residual disease or relapse