Gynaecology Oncology Flashcards
What cancers may present with abnormal vaginal bleeding or discharge?
Cervical
Ovarian
Uterine
Vaginal
What cancers may present with pelvic pain or pressure?
Ovarian
Uterine
Vulvar
What cancers present with abdominal pain and bloating?
Ovarian
What cancers present with change in bowel habits?
Ovarian
Vaginal
What cancers present with itching or burning of the vulva?
Vulvar
What cancers present with changes in vulva colour or skin?
Vulvar
When does cervical cancer most commonly affect women?
25-34yo
Histologically, what type of cancer can cervical cancer be?
70% squamous
15% adenocarcinoma
15% mixed
What is squamous cell cervical cancer commonly associated with?
99.7% contain HPV DNA
HPV 16 and 18
How do HPV16 and 18 cause cervical cancer?
HPV 16 produce E6 oncogene - inhibit p53 (tumour suppressor)
HPV 18 produce E7 oncogene - inhibit RB (tumour suppressor)
Uncontrolled cervical epithelium division
What is CIN?
Cervical intraepithelial neoplasia - dysplasia of the cervical epithelium
Can progress to cancer over 10-20 years
Most cases don’t progresses and spontaneously regress
What risk factors are associated with cervical cancer?
Persistent HPV infection Smoking Other STD's >8 years COCP use Immunodeficiency Early first intercourse
How does cervical cancer present?
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
How would you investigate suspected cervical cancer in a woman pre-menopause?
Chlamydia screen
Positive - treat
Negative - colposcopy and biopsy
How would you investigate suspected cervical cancer in a woman post-menopause?
Urgent colposcopy and biopsy
How is cervical cancer staged?
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
Where does cervical cancer metastasise to?
Lung
Liver
Bone
Bowel
Briefly, how is cervical cancer managed surgically?
Preserve fertility - radical trachelectomy
Stage 1: Laparoscopic hysterectomy + cervical lymphadenectomy
Stage 2: radical hysterectomy
Stage 4: pelvic exenteration
What is a trachelectomy?
Removal of the uterine cervix
What other management options are there for cervical cancer?
Radiotherapy - external beam or brachytherapy
Chemotherapy - chemoradiation gold standard for stage Ib to III
What is a Lletz biopsy and what are the complications?
Transformation zone is removed with diathermy
Scarring and stenosis
Pyometra (uterus infection)
Cervical incompetence = PROM
When are women screened for cervical cancer?
What happens to screening if a women becomes pregnant?
25-49 yo = 3 yearly screening
50-64 yo = 5 yearly screening
Delay in pregnancy until 3 months post partum
How is cervical cancer screened?
When in the cycle is it best to do this?
Smear - brush rotated at squamo-columnar junction
Liquid based cytology to analyse fluid collected
Best to take mid cycle
What is a smear poor at picking up?
Adenocarcinomas
How are smear results categorised?
Borderline or mild dyskaryosis Moderate dyskaryosis - CIN II Severe dyskaryosis - CIN III Suspected invasive cancer Glandular neoplasia Inadequate
What is done if a smear comes back as HPV negative?
Return to normal recall
What is done if a smear comes back as HPV positive?
Cytology is done on the sample:
abnormal (including borderline dyskaryosis)
= 2wk colposcopy
normal
= yearly smear
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?
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
What should be done if a smear is inadequate?
Repeat smear
If persistent (3 inadequate samples) - colposcopy assessment
What is the peak age of endometrial cancer?
65-75 years old
What is the most common type of endometrial cancer?
Adenocarcinoma
What is happening to the incidence of endometrial cancer?
Rising - possibly due to obesity
What is the pathophysiology of endometrial cancer?
Most due to unopposed oestrogen stimulating endometrium
No protective effects of progesterone
What risk factors are associated with endometrial cancer?
OESTROGEN
Anovulation - Early menarche and late menopause - Low parity - PCOS - HRT - oestrogen alone - Tamoxifen Increasing age Obesity HNPCC - Lynch syndrome
How does endometrial cancer present?
Post-menopausal bleeding
Clear/white vaginal discharge
Pre-menopausal - abnormal bleeding, pelvic pain and dyspareunia
Describe the staging of endometrial cancer
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
How is stage 1 endometrial cancer managed?
Total hysterectomy + bilateral salpingo-oophorectomy + peritoneal washing
How is stage 2 endometrial cancer managed?
Radical hysterectomy + pelvic lymphadenectomy + radiotherapy
How are stage 3/4 endometrial cancer managed?
Maximal debulking + chemo + radio
May palliate
What is the difference between a total and radical hysterectomy?
Total: uterus + cervix removed
Radical: uterus + cervix + parametrium + top part of vagina removed
What can be protective against endometrial cancer?
COCP
Smoking
What is endometrial hyperplasia?
Thickening of uterine cavity due to too much oestrogen with too little progesterone
How is endometrial hyperplasia managed?
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
What is the peak age women get ovarian cancer?
60 years old
How can ovarian cancer be classified?
Epithelial - 90%
Germ cell
Sex cord stromal
What are the types of epithelial ovarian cancers?
Serous, mucinous, endometriod etc.
Arise from surface epithelium due to irritation during ovulation
What are germ cell ovarian tumour? How do they present?
Tumours arising from embryonic germ cells of gonad
Present in younger patients as rapidly enlarging abdominal mass
What do sex-cord stroll ovarian cancers arise from?
Connective tissue cells
How do ovarian cancers present?
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
What must be done in women >50yo with a new onset of IBS?
Ovarian cancer testing - can present similarly
How is ovarian cancer investigated in primary care?
CA125 >35 = USS
USS abdo/pelvis abnormal = secondary care
USS abdo/pelvis normal = safety netting
CA125 <35 = safety netting
What other tests can be done in <40yo in primary care for suspected ovarian cancer? Why?
AFP
Beta HCG
Raised levels suggest alternate tumours
What investigation is done in secondary care for patients referred with a raised CA125 and abnormal USS?
CT abdo-pelvis to look at extent of disease
Laparotomy for histology
What are the risk factors for ovarian cancer?
Increased ovulation - null parity, early menarche, late menopause Increasing age Oestrogen only HRT Obesity Genetics - BRCA 1/2, Lynch syndrome
What are the protective factors against ovarian cancer?
Reduced ovulations
- multiparity
- breastfeeding
- COCP
What is important to know about CA125?
Reduced specificity in premenopausal women
Also raised due to:
- Endometriosis, benign ovarian cysts, menstruation, pregnancy
- Diverticulitis, cirrhosis
- Other malignancies (bladder, breast, liver, lung)
What is RMI (ovarian cancer)?
How is it calculated?
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
What features on USS of ovaries cause concern?
Multilocular cyst Solid areas Metastasis Ascites Bilateral lesions
Describe the staging of ovarian cancer
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
What is the management for ovarian cancer?
Combination of surgery and chemo
Laparotomy - tumour debunking
Hysterectomy, salpingo-oophorectomy and infra colic omentectomy
How is ovarian cancer followed up?
5 year CA125 monitoring
What is the epidemiology of vulval cancer?
Very rare cancer
90% squamous
Mostly >75yo
How do vulval cancers present?
Lump
Ulceration + bleeding
Pruritus
Pain
When would you refer someone to gynae under 2 week wait for suspected vulval cancer?
Lump
Ulceration + bleeding
Where do vulval cancers affect?
Labia majora - 50%
Labia minora - 20%
Clitoris and bartholin’s glands - infrequent
What are the risk factors for vulval cancer?
VIN
HPV
Lichen sclerosus
How is vulval cancer diagnosed?
Examination and biopsy
Where do vulval cancers spread?
Inguinal and femoral lymph nodes
How are vulval cancers managed?
Surgical - radical or wide local resection
Senitel lymph node biopsy +- groin node dissection
Reconstructive surgery often performed
What is VIN?
Premalignant state that occurs spontaneously or due to pre-existing vulval disorder such as lichen sclerosis
How does VIN present?
Itching
Plaque like white patches
How is VIN diagnosed?
Biopsy - confirm not invasive cancer
How is VIN managed?
Laser therapy
Wide local excision
What are some complications of a Lletz biopsy (for suspected cervical cancer)
Scarring = cervical stenosis
Cervical incompetence
Infection and pyometra
