Gynaecology Oncology Flashcards
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Which types of HPV are most frequently associated with cervical cancer?
types 16, 18, 31 and 33
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
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)
What is the management of a normal smear result?
repeat in 3 years time
5 if over 50
What is the management for borderline or mild dyskaryosis?
CIN 1
HPV negative - back to routine recall
HPV positive - colposcopy
What is the management for moderate dyskaryosis?
CIN 2
Colposcopy
What is the management for severe dyskaryosis?
CIN 3
urgent colposcopy
What is the management of cervical glandular intraepithelial neoplasia?
(any grade)
colposcopy
if no abnormality then hysteroscopy
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
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
What are the symptoms of premalignant squamous cell carcinoma of the cervix?
none
not visible on the cervix
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
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
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
How is stage 1a cervical cancer treated?
cone biopsy or simple hysterectomy
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
