Gynaecology Oncology and Screening Flashcards
Which demographic does cervical cancer tend to affect?
Younger women
Peaks in reproductive years
What type of cancer is cervical cancer?
80% squamous cell carcinomas
Adenocarcinomas next most common
How is the risk of cervical cancer mitigated?
Children 12-13 vaccinated against HPV due to its association with cervical cancer
Which types of HPV are associated with cervical cancer?
16 & 18
Risk factors for cervical cancer
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
Non-engagement with cervical screening
Smoking
HIV
COCP >5 years
Increased number of full-term pregnancies
Family history
Presentation of cervical cancer
Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
Vaginal discharge
Pelvic pain
Dyspareunia (pain or discomfort with sex)
Colposcopy findings in cervical cancer
Ulceration
Inflammation
Bleeding
Visible tumour
What is cervical intraepithelial neoplasia?
Grading system for level of dysplasia in cells of the cervix
CIN is diagnosed at colposcopy (not with cervical screening)
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated (aka cervical carcinoma in situ)
Dysplasia vs. dyskaryosis
Dysplasia - premalignant change found during colposcopy
Dyskaryosis - precancerous changes found on smear
Cervical screening programme
Smear for women (and transgender men that still have a cervix):
Every three years aged 25 – 49
Every five years aged 50 – 64
Tested for high-risk HPV and dyskaryosis
Exceptions to cervical smear programme
Women with HIV are screened annually
Women over 65 may request a smear if they have not had one since aged 50
Women with previous CIN may require additional tests (e.g. test of cure after treatment)
Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
Pregnant women due a routine smear should wait until 12 weeks post-partum
Smear results and outcomes
Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy
What is colposcopy?
Magnified view of cervix
Punch biopsy or large loop excision of the transitional zone (LLETZ) can be used to get tissue sample
Cervical cancer staging
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
Management of cervical cancer
Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy
Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A: Chemotherapy and radiotherapy
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
HPV vaccine
Protects against stains 6, 11, 16 and 18
6 + 11 - genital warts
16 + 18 - cervical cancer
Which type of cancer is endometrial cancer?
Adenocarcinoma (80%)
Postmenopausal bleeding spot diagnosis
Endometrial cancer until proven otherwise
What is endometrial hyperplasia?
Precancerous condition involving thickening of the endometrium
Which types of endometrial hyperplasia can go on to become endometrial cancer?
Hyperplasia without atypic
Atypical hyperplasia
Endometrial hyperplasia management
Progestogens e.g.
IUS (Mirena)
Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
Risk factors of endometrial cancer
Unopposed oestrogen:
Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen
Why is obesity a risk factor for endometrial cancer?
Adipose tussle is a source of oestrogen
Protective factors against endometrial cancer
Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking
Presentation of endometrial cancer
POSTMENOPAUSAL BLEEDING
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
2-week wait referral criteria for endometrial cancer
Postmenopausal bleeding
TVUSS in >55 wit unexplained vaginal discharge or visible haematuria
Investigations in endometrial cancer
TVUSS for endometrial thickness (normal is less than 4mm post-menopause)
Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
Hysteroscopy with endometrial biopsy
Staging of endometrial cancer
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
Management of endometrial cancer
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Radical hysterectomy involves also removing pelvic lymph nodes, surrounding tissues top of vagina
Radiotherapy
Chemotherapy
Progesterone may slow the progression of the cancer
Ovarian cancer presentation
Tends to present late due to non-specific symptoms
More than 70% of patients present after it has spread beyond the pelvis
Types of ovarian cancer
Epithelial cell tumour (most common)
Dermoid cycle/germ cell tumours (teratomas, associated with ovarian torsion)
Sex-cord-stromal tumours
Krukenberg tumour (metastasis from GI cancer - signet ring cells on histology)
Risk factors for ovarian cancer
Age (peaks age 60)
BRCA1 and BRCA2 genes (consider the family history)
Increased number of ovulations
Obesity
Smoking
Recurrent use of clomifene
(Factors that increase number of ovulations)
Early-onset of periods
Late menopause
No pregnancies
Protective factors against ovarian cancer
(Factors that stop ovulation)
Combined contraceptive pill
Breastfeeding
Pregnancy
Presentation of ovarian cancer
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency/urgency)
Weight loss
Abdominal or pelvic mass
Ascites
May compress obturator nerve and cause hip/groin pain
2-week-wait referral criteria in ovarian cancer
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
Investigations in ovarian cancer
CA125 blood test (>35 IU/mL is significant)
Pelvic ultrasound
Further investigations in ovarian cancer
CT scan to establish the diagnosis and stage the cancer
Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells
Investigations in women under 40 with complex ovarian mass
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
Causes of raised CA125
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
Staging of ovarian cancer
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
Management of ovarian cancer
Gynaecology-oncology MDT
Combination of surgery and chemotherapy
What type of cancer is vulval cancer
Squamous cell carcinoma
Less commonly malignant melanoma
Risk factors for vulval cancer
Advanced age (particularly over 75 years)
Immunosuppression
Human papillomavirus (HPV) infection
Lichen sclerosus
What is vulval intraepithelial neoplasia
Premalignant condition affecting squamous epithelium that can precede vulval cancer
Presentation of vulval cancer
May be incidental finding in older women e.g. during catheterisation
Vulval lump
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in the groin
Most frequently affects labia majora, giving an appearance of: Irregular mass Fungating lesion Ulceration Bleeding
Investigations in vulval cancer
2-week-wait referral
Biopsy of the lesion
Sentinel node biopsy to demonstrate lymph node spread
Further imaging for staging (e.g. CT abdomen and pelvis)
Management of vulval cancer
Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy
