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Obstetrics and Gynaecology > Gynaecology Oncology > Flashcards

Gynaecology Oncology Flashcards

1
Q

What cancers may present with abnormal vaginal bleeding or discharge?

A

Cervical
Ovarian
Uterine
Vaginal

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2
Q

What cancers may present with pelvic pain or pressure?

A

Ovarian
Uterine
Vulvar

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3
Q

What cancers present with abdominal pain and bloating?

A

Ovarian

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4
Q

What cancers present with change in bowel habits?

A

Ovarian

Vaginal

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5
Q

What cancers present with itching or burning of the vulva?

A

Vulvar

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6
Q

What cancers present with changes in vulva colour or skin?

A

Vulvar

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7
Q

When does cervical cancer most commonly affect women?

A

25-34yo

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8
Q

Histologically, what type of cancer can cervical cancer be?

A

70% squamous
15% adenocarcinoma
15% mixed

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9
Q

What is squamous cell cervical cancer commonly associated with?

A

99.7% contain HPV DNA

HPV 16 and 18

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10
Q

How do HPV16 and 18 cause cervical cancer?

A

HPV 16 produce E6 oncogene - inhibit p53 (tumour suppressor)

HPV 18 produce E7 oncogene - inhibit RB (tumour suppressor)

Uncontrolled cervical epithelium division

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11
Q

What is CIN?

A

Cervical intraepithelial neoplasia - dysplasia of the cervical epithelium

Can progress to cancer over 10-20 years

Most cases don’t progresses and spontaneously regress

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12
Q

What risk factors are associated with cervical cancer?

A 
Persistent HPV infection
Smoking
Other STD's 
>8 years COCP use
Immunodeficiency
Early first intercourse
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13
Q

How does cervical cancer present?

A

Majority asymptomatic - picked up on screening

!!Abnormal vaginal bleeding
!!Discharge

Dyspareunia
Pelvic pain
Weight loss
Symptoms of invasion - loin pain, haematuria, oedema, rectal bleeding, radiculopathy

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14
Q

How would you investigate suspected cervical cancer in a woman pre-menopause?

A

Chlamydia screen

Positive - treat
Negative - colposcopy and biopsy

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15
Q

How would you investigate suspected cervical cancer in a woman post-menopause?

A

Urgent colposcopy and biopsy

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16
Q

How is cervical cancer staged?

A

I - Only in cervical tissue
II - Spread to upper 2/3 vagina or other tissue next to cervix
III - Spread tor issues on side of pelvic and/or lower 1/3 vagina
IV - Spread to bladder or rectum or beyond pelvis

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17
Q

Where does cervical cancer metastasise to?

A

Lung
Liver
Bone
Bowel

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18
Q

Briefly, how is cervical cancer managed surgically?

A

Preserve fertility - radical trachelectomy

Stage 1: Laparoscopic hysterectomy + cervical lymphadenectomy
Stage 2: radical hysterectomy
Stage 4: pelvic exenteration

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19
Q

What is a trachelectomy?

A

Removal of the uterine cervix

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20
Q

What other management options are there for cervical cancer?

A

Radiotherapy - external beam or brachytherapy

Chemotherapy - chemoradiation gold standard for stage Ib to III

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21
Q

What is a Lletz biopsy and what are the complications?

A

Transformation zone is removed with diathermy

Scarring and stenosis
Pyometra (uterus infection)
Cervical incompetence = PROM

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22
Q

When are women screened for cervical cancer?

What happens to screening if a women becomes pregnant?

A

25-49 yo = 3 yearly screening

50-64 yo = 5 yearly screening

Delay in pregnancy until 3 months post partum

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23
Q

How is cervical cancer screened?

When in the cycle is it best to do this?

A

Smear - brush rotated at squamo-columnar junction

Liquid based cytology to analyse fluid collected

Best to take mid cycle

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24
Q

What is a smear poor at picking up?

A

Adenocarcinomas

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25
Q

How are smear results categorised?

A 
Borderline or mild dyskaryosis
Moderate dyskaryosis - CIN II
Severe dyskaryosis - CIN III
Suspected invasive cancer
Glandular neoplasia
Inadequate
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26
Q

What is done if a smear comes back as HPV negative?

A

Return to normal recall

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27
Q

What is done if a smear comes back as HPV positive?

A

Cytology is done on the sample:
abnormal (including borderline dyskaryosis)
= 2wk colposcopy

normal
= yearly smear

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28
Q

A women returns a year later for a smear as she is HPV positive… what now?

A women returns for the third year in a row due to being HPV positive… what now?

A

HPV -ve = return to normal 3 yearly
HPV +ve but cytology still normal = yearly

HPV -ve = return to normal 3 yearly
HPV +ve but cytology still normal = colposcopy

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29
Q

What should be done if a smear is inadequate?

A

Repeat smear

If persistent (3 inadequate samples) - colposcopy assessment

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30
Q

What is the peak age of endometrial cancer?

A

65-75 years old

31
Q

What is the most common type of endometrial cancer?

A

Adenocarcinoma

32
Q

What is happening to the incidence of endometrial cancer?

A

Rising - possibly due to obesity

33
Q

What is the pathophysiology of endometrial cancer?

A

Most due to unopposed oestrogen stimulating endometrium

No protective effects of progesterone

34
Q

What risk factors are associated with endometrial cancer?

A

OESTROGEN

Anovulation 
- Early menarche and late menopause
- Low parity
- PCOS
- HRT - oestrogen alone
- Tamoxifen
Increasing age
Obesity 
HNPCC - Lynch syndrome
35
Q

How does endometrial cancer present?

A

Post-menopausal bleeding
Clear/white vaginal discharge

Pre-menopausal - abnormal bleeding, pelvic pain and dyspareunia

36
Q

Describe the staging of endometrial cancer

A

1 - confined to uterine body
2 - extend to cervix but not beyond uterus
3 - extend beyond uterus but confined to pelvis
4 - Involved bladder or bowel or metastasis

37
Q

How is stage 1 endometrial cancer managed?

A

Total hysterectomy + bilateral salpingo-oophorectomy + peritoneal washing

38
Q

How is stage 2 endometrial cancer managed?

A

Radical hysterectomy + pelvic lymphadenectomy + radiotherapy

39
Q

How are stage 3/4 endometrial cancer managed?

A

Maximal debulking + chemo + radio

May palliate

40
Q

What is the difference between a total and radical hysterectomy?

A

Total: uterus + cervix removed

Radical: uterus + cervix + parametrium + top part of vagina removed

41
Q

What can be protective against endometrial cancer?

A

COCP

Smoking

42
Q

What is endometrial hyperplasia?

A

Thickening of uterine cavity due to too much oestrogen with too little progesterone

43
Q

How is endometrial hyperplasia managed?

A

Hyperplasia without atypia - progesterone (Mirena coil) + surveillance biopsies

Atypical hyperplasia - as stage 1 - total hysterectomy + bilateral salpingo-oophorectomy + peritoneal washing
High risk of becoming malignant

44
Q

What is the peak age women get ovarian cancer?

A

60 years old

45
Q

How can ovarian cancer be classified?

A

Epithelial - 90%
Germ cell
Sex cord stromal

46
Q

What are the types of epithelial ovarian cancers?

A

Serous, mucinous, endometriod etc.

Arise from surface epithelium due to irritation during ovulation

47
Q

What are germ cell ovarian tumour? How do they present?

A

Tumours arising from embryonic germ cells of gonad

Present in younger patients as rapidly enlarging abdominal mass

48
Q

What do sex-cord stroll ovarian cancers arise from?

A

Connective tissue cells

49
Q

How do ovarian cancers present?

A

Vague - 58% present in stage 3 or 4

Persistent bloating
Early satiety/loss of appetite
Pelvic or abdominal pain
Urinary frequency or urgency
Vaginal bleeding
50
Q

What must be done in women >50yo with a new onset of IBS?

A

Ovarian cancer testing - can present similarly

51
Q

How is ovarian cancer investigated in primary care?

A

CA125 >35 = USS
USS abdo/pelvis abnormal = secondary care
USS abdo/pelvis normal = safety netting

CA125 <35 = safety netting

52
Q

What other tests can be done in <40yo in primary care for suspected ovarian cancer? Why?

A

AFP
Beta HCG

Raised levels suggest alternate tumours

53
Q

What investigation is done in secondary care for patients referred with a raised CA125 and abnormal USS?

A

CT abdo-pelvis to look at extent of disease

Laparotomy for histology

54
Q

What are the risk factors for ovarian cancer?

A 
Increased ovulation - null parity, early menarche, late menopause
Increasing age
Oestrogen only HRT
Obesity
Genetics - BRCA 1/2, Lynch syndrome
55
Q

What are the protective factors against ovarian cancer?

A

Reduced ovulations

  • multiparity
  • breastfeeding
  • COCP
56
Q

What is important to know about CA125?

A

Reduced specificity in premenopausal women

Also raised due to:

  • Endometriosis, benign ovarian cysts, menstruation, pregnancy
  • Diverticulitis, cirrhosis
  • Other malignancies (bladder, breast, liver, lung)
57
Q

What is RMI (ovarian cancer)?

How is it calculated?

A

Score to calculate risk of malignancy in those with suspected ovarian cancer

M x U x CA125

Menopause: pre = 1, post = 3
USS score: 1 feature = 1 , >1 feature = 3

If score >250: specialist MDT

58
Q

What features on USS of ovaries cause concern?

A 
Multilocular cyst
Solid areas
Metastasis
Ascites
Bilateral lesions
59
Q

Describe the staging of ovarian cancer

A

FIGO system
I - one or both ovaries only
II - spread to other pelvic organs
III - spread to peritoneum or lymph nodes
IV - spread to distant organs - lung/liver

60
Q

What is the management for ovarian cancer?

A

Combination of surgery and chemo

Laparotomy - tumour debunking
Hysterectomy, salpingo-oophorectomy and infra colic omentectomy

61
Q

How is ovarian cancer followed up?

A

5 year CA125 monitoring

62
Q

What is the epidemiology of vulval cancer?

A

Very rare cancer
90% squamous
Mostly >75yo

63
Q

How do vulval cancers present?

A

Lump
Ulceration + bleeding
Pruritus
Pain

64
Q

When would you refer someone to gynae under 2 week wait for suspected vulval cancer?

A

Lump

Ulceration + bleeding

65
Q

Where do vulval cancers affect?

A

Labia majora - 50%
Labia minora - 20%
Clitoris and bartholin’s glands - infrequent

66
Q

What are the risk factors for vulval cancer?

A

VIN
HPV
Lichen sclerosus

67
Q

How is vulval cancer diagnosed?

A

Examination and biopsy

68
Q

Where do vulval cancers spread?

A

Inguinal and femoral lymph nodes

69
Q

How are vulval cancers managed?

A

Surgical - radical or wide local resection
Senitel lymph node biopsy +- groin node dissection
Reconstructive surgery often performed

70
Q

What is VIN?

A

Premalignant state that occurs spontaneously or due to pre-existing vulval disorder such as lichen sclerosis

71
Q

How does VIN present?

A

Itching

Plaque like white patches

72
Q

How is VIN diagnosed?

A

Biopsy - confirm not invasive cancer

73
Q

How is VIN managed?

A

Laser therapy

Wide local excision

74
Q

What are some complications of a Lletz biopsy (for suspected cervical cancer)

A

Scarring = cervical stenosis
Cervical incompetence
Infection and pyometra

Obstetrics and Gynaecology (21 decks)

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