Gynaecology Pt. 3 Flashcards
1
Q
What is endometrial cancer?
A
- MOST COMMON type of uterine cancer
- MOST COMMON gynaecological malignancy
- Age-related incidence = 95/100,000
- Mean age of diagnosis = 62 years
- Arises from glandular component of endometrium
2
Q
How are endometrial cancers classified?
A
- Type 1: endometrioid adenocarcinomas
- Oestrogen-driven
- Arise from a background of endometrial hyperplasia
- Type 2: high-grade serous and clear cell carcinomas
- Arise from an atrophic endometrium
Range from Grades 1-3 (3 = high grade)
3
Q
What is the aetiology of endometrial cancer?
A
- Oestrogen causes proliferation of endometrial cells
- Progesterone can inhibit this effect
- Obesity is a major risk factor because women who are obese are more likely to have anovulatory menstrual cycles and less likely to get pregnant
- In addition, aromatisation of androgens to oestrogen in adipose tissue provides a continuous postmenopausal supply of oestrogen
4
Q
What are risk factors for endometrial cancer?
A
- Obesity
- Diabetes
- Nulliparity
- Late menopause > 52 years
- Unopposed oestrogen therapy
- Tamoxifen therapy (anti-oestrogenic in the breast but stimulatory in the endometrium)
- Family history of colorectal and endometrial cancer
- Lynch syndrome (caused by mutations in mismatch repair genes)
5
Q
What are protective factors against endometrial cancer?
A
- Hysterectomy
- COCP
- Progestin-based contraceptives, including injectables
- IUS (Cu-IUD, LNG-IUD)
- Pregnancy
- Smoking
6
Q
Describe prevention for endometrial cancer
A
- Hormonal contraceptives and IUDs reduce the risk of ovarian cancer
- Women with Lynch syndrome will be offered prophylactic hysterectomy following completion of family
7
Q
What are clinical features for endometrial cancer?
A
- Postmenopausal bleeding
- This is a RED FLAG that should be taken seriously
- Inspect the external genitalia and perform a speculum examination to rule out vulval, vaginal and cervical cancer
- Physical examination may be NORMAL
- Diagnosis can only be excluded with TVUSS, hysteroscopy and endometrial biopsy
- Benign causes of PMB:
- Unscheduled bleeding on HRT
- Atrophic vaginitis
- Abdominal pain
- Urinary dysfunction
- Bowel disturbance
- Respiratory symptoms
- May be detected incidentally on cervical smear (abnormal glandular cytology)
8
Q
How is endometrial cancer investigated and diagnosed?
A
- TVUSS
- Allows assessment of endometrial thickness
- If < 4 mm = endometrial cancer is very unlikely
- If > 4 mm = requires further evaluation by hysteroscopy and/or biopsy
- Hysteroscopy
- Performed under local anaesthetic in the outpatient setting where possible
- General anaesthetics may be used if cervical stenosis or if hysteroscopy is poorly tolerated
- A biopsy can be taken for histological analysis
- Complex hyperplasia with atypia is a premalignant condition that often co-exists with low-grade endometrioid tumours of the endometrium
- 25-50% risk of progression to endometrial cancer
9
Q
How is endometrial cancer staged?
A
- Determined by MRI
- FIGO staging
- Patients with high-grade tumours will under CT-TAP to exclude distant metastases
10
Q
What can the management of endometrial cancer be split into?
A
- Surgery
- Adjuvant Treatment
- Hormone Treatment
11
Q
What is the surgical management of endometrial cancer?
A
- Mainstay of treatment for endometrial cancer
- Extent depends on grade, stage and co-morbidities
- Standard surgery: total hysterectomy with bilateral salpingo-oophorectomy
- This can be abdominal or laparoscopic
- If the MRI is suggestive of cervical involvement, a modified radical hysterectomy is performed
- If high-grade or type 2 histology, pelvic and para-aortic node dissection may be performed in some centres
12
Q
What is adjuvant treatment of endometrial cancer?
A
- Postoperative radiotherapy reduces local recurrent rate but does NOT improve survival
- Local radiotherapy or brachytherapy are options
- Chemotherapy is used for advances or metastatic disease (little evidence to support its use)
13
Q
What is the hormone treatment of endometrial cancer?
A
- High-dose oral or intrauterine progestins
- Useful for women with complex atypical hyperplasia and low-grade stage 1A endometrial tumours
- Relapse rates are high
- May be suitable for women who are not fit for surgery or want to avoid surgery for fertility reasons
14
Q
How does endometrial cancer affect fertility?
A
- Primary infertility due to PCOS is a risk factor for pre-menopausal endometrial cancer
- Alternatives to hysterectomy for pre-menopausal women are only possible for pre-cancer or early-stage low-grade endometrial cancers
- Hormone therapy (oral progestogens or LNG-IUS) is associated with moderate response and high relapse rates
- Women faces with losing their fertility should be referred to a specialist to discuss ovarian conservation and/or stimulation for egg retrieval and surrogacy
15
Q
What is the prognosis of endometrial cancer?
A
- 5-year survival = 80%
- Dependent on type, stage and grade
- Bad prognostic features:
- Age
- Grade 3 tumours
- Type 2 histology
- Deep myometrial invasion
- Lymphovascular space invasion
- Nodal involvement
- Distal metastases
16
Q
What are sarcomas of the uterus?
A
- 5% of uterine cancers
- Pure Sarcomas
- Endometrial stromal sarcomas
- Leiomyosarcoma
- From the myometrium
- Rarely associated with malignant transformation of benign fibroids
- Present with rapidly growing pelvic mass and pain
- Surgery is the mainstay of treatment
- Mixed Epithelial Sarcomas (Carcinosarcomas)
- Contain both carcinomatous and sarcomatous elements
- Most present after menopause
- Post-menopausal bleeding
- Treated by surgery followed by post-operative radiotherapy
- Heterologous Sarcomas
- Consists of sarcomatous tissue not usually found in the uterus (e.g. striated muscle, bone and cartilage)
- Most common is rhabdomyosarcoma
- May present in children
- High recurrent rates with distant metastases
17
Q
What is the aetiology of cervical cancer?
A
- Low risk HPV = 6 + 13
- High risk HPV = 16 + 18
- 80% of adults show serological evidence of previous HPV infection
- Infection is usually transient with no clinical consequences
- A minority will develop a persistent genital infection that predisposes them to premalignant and malignant change
- Smoking increases the risk of persistent HPV infection
- HIV and immunosuppressed patients are at particular risk of developing cervical cancer
18
Q
What is the pathophysiology of cervical cancer?
A
- The tubular cervix consists of stromal tissue covered by:
- Squamous epithelium - in the vagina (ectocervix)
- Columnar epithelium - in the cervical canal (endocervix)
- Endocervix has deep folds (crypts) that are lined by columnar epithelium
- The meeting of the two types of epithelium is the squamocolumnar junction (SCJ)
- The position of the SCJ varies throughout life
- In CHILDREN it lies in the external cervical os
- At PUBERTY it extends outwards onto the ectocervix
- In ADULT LIFE it returns to the external cervical os through the process of metaplasia
- The transformation zone (TZ) is the area between the original SCJ and the current SCJ where the epithelium changes from columnar to squamous over time
- This is the site where malignancy and pre-malignancy develop
- Persistent HPV infection triggers oncogenic processes in the TZ
- Integration of HPV DNA into the basal epithelial cells leads to immortalisation and rapid cellular turnover
- Disordered immaturity within the epithelium is called cervical intraepithelial neoplasia (CIN)
- Immature cells are:
- Hyperchromatic
- Large nuclei
- Minimal cytoplasm
- Abnormal mitotic figures
- Classified as CIN1, CIN2 or CIN3
- CIN2 and 3 are considered ‘high grade’
- Immature cells are:
- Natural History of CIN
- Can regress or progress
- Low-grade disease is more likely to spontaneously regress
- High-grade disease requires treatment (20% risk of progression to cancer)
19
Q
How is cervical cancer investigated and diagnosed?
A
- Cervical cytology
- HPV Testing in Cervical screening
- National Cervical Screening Programme
- Colposcopy
20
Q
What is cervical cytology?
A
- Liquid-based cytology (LBC) is a technique by which a small brush is used to sample cells from the TZ and the brush head is placed in a fixative
- The cellular aspect from this sample is viewed under the microscope
- Abnormal cervical cytology shows squamous cells at different stages of maturity (dyskaryosis)
- Cervical cytology can be classified as:
- Normal
- Low grade - minor cytological abnormalities showing mild dyskaryosis and or borderline change
- High grade - moderate and severe dyskaryosis
- NOTE: there is some correlation between cytology grade and CIN grade but this is NOT totally reliable
- Cervical cytology allows triaging of patients to the colposcopy clinic for further assessment
- 95% of women will have normal cervical cytology
21
Q
What is the role of HPV testing in cervical screening?
A
- High-risk HPV screening improves sensitivity of cervical screening
- It has a high negative predictive value - i.e. if a woman tests negative for high-risk HPV, they have a very low risk of developing cervical cancer
- Women with minor cytological abnormalities undergo reflex testing with high-risk HPV
- Negative - return to routine recall
- Positive - refer to colposcopy
- UK is moving towards primary HPV screening - this means testing all cervical cytology specimens for HPV first, then carrying out reflex cytological assessment on any positive samples
22
Q
What is the National Cervical Screening Programme?
A
- Started in 1988
- Age range:
- 25-64 years = every 3-5 years
- Coordinated by the National Health Service Cervical Screening Programme (NHSCSP)
23
Q
What is a colposcopy?
A
- DEFINITION: examination of the magnified cervix using a light source
- The woman is placed in the semi-lithotomy position
- A speculum is placed in the vagina and the cervix is examined with a light source
- Application of acetic acid and iodine solutions highlight abnormal areas of the cervix
- Acetic acid - areas of increased cell turnover (including CIN) appear white
- Iodine - areas of CIN lack intracytoplasmic glycogen and, hence, fail to stain brown with iodine
- CIN can also be classified as low or high-grade based on colposcopy
- Low-grade - subsequent colposcopy and cytology in 6 months
- High-grade - treated in clinic on the same visit (‘see and treat’)
- Biopsies may be taken if unsure
24
Q
What is the management of premalignant disease of the cervix?
A
- Aim to effectively eradicate CIN (ensuring that post-treatment cytology is negative)
- High-grade CIN requires treatment with excision or ablation
- Low-grade CIN regresses spontaneously in up to 60% of cases
- Requires close follow-up with colposcopy and cytology 6 months after initial diagnosis
- Loop diathermy (large loop excision of transformation zone (LLETZ)) is the favoured method
- CIN can develop within the crypts of the epithelium and therefore excisional techniques need to be at least 7 mm deep
- This only take 15 mins under local anaesthetic
- 95% of patients will have negative cytology at 6 months
- Risks
- Large excision or repeat excisions are associated with an increased risk of midtrimester miscarriage and preterm delivery
- Other options
- Cold coagulation
- Effective but does not provide a specimen
- Cone biopsy
- Cuts away part of the cervix but requires general anaesthetic
- Associated with cervical stenosis and incompetence
- Superseded by loop diathermy
- Cold coagulation
- Patients who undergo treatment for CIN will receive a test of cure 6 months later
- HPV vaccination
- National vaccination programme for school girls aged 12-13 years
- Quadrivalent vaccine = 6, 13, 16 and 18
25
What is the presentation of cervical cancer?
- Small volume microscopic disease may be ASYMPTOMATIC
- Many are picked up incidentally
- Abnormal bleeding
- Post-coital bleeding
- Intermenstrual bleeding
- Postmenopausal bleeding
- A pelvic examination should be performed in any patient with these symptoms including visualisation of the cervix
- May see a cervical mass that bleeds on contact
- In advanced disease, there may be hardness or fixity of tissues
- A biopsy should be taken in the outpatient setting
- NOTE: endophytic tumours are less clinically revealing than exophytic
- Symptoms of advanced disease
- Pain
- Incontinence (vesicovaginal fistulae)
- Anaemia
- Renal failure (ureteric blockage)
26
What is the pathophysiology of malignant cervical cancer?
- 70% of cervical cancers are squamous cell carcinomas
- Adenocarcinomas make up the remainder
- Adenocarcinomas are less likely to be picked up on screening
- The precursor to adenocarcinoma, cervical glandular intraepithelial neoplasia (CGIN), can also be detected at colposcopy
- NOTE: lesions within the endocervical canal may be difficult to visualise
- CIN and CGIN can co-exist
- The tumour can grow through the cervix into the parametria, bladder, vagina and rectum
- Sites of metastasis
- Pelvic (iliac and obturator) lymph nodes
- Para-aortic nodes
- Liver
- Lungs
27
How is cervical cancer staged?
- FIGO staging
- Biopsy - confirm malignancy and assess tumour type
- MRI of abdomen and pelvic allows assessment of spread
- CXR - check for lung metastases
- Rectovaginal examination under anaesthetic may be necessary to assess tumour size, fixity and vaginal involvement
- Cystoscopy may be used to check for bladder involvement
- Small mobile tumours favour SURGERY
- Large fixed tumours favour the use of radiotherapy
- NOTE: staging is largely based on clinical findings rather than surgery and pathology
28
What is the management of malignant cervical cancer divided into?
- Preclinical lesions: Stage 1A
- Clinically Invasive Cervical Carcinoma: Stages 1B - 4
- Surgery
- Radiotherapy
- Chemotherapy
- Depends on stage, requirement for future fertility and patient factors
29
What is the management of preclinical lesions (Stage 1A)?
- Microscopic tumours usually picked up as incidental findings
- Small lesions should be removed with a clear margin and co-existing CIN should also be completely excised
- For these lesions, local excision with good clear margins is all that is required
30
What is the management of Clinically Invasive Cervical Carcinoma (Stage 1B - 4)
- Tumours are larger so fertility-preserving treatment is more difficult
- If small volume disease confined to the cervix
- Radical hysterectomy and bilateral pelvic node dissection (Wertheim's hysterectomy)
- If fertility-sparing is required: radical trachelectomy (removal of cervix and upper vagina) and pelvic node dissection
- NOTE: in Stage 1B disease, pelvic radiotherapy is as effective as surgery
- If the tumour is beyond the cervix (stage 2-4), radiotherapy is the mainstay of treatment
31
What is the surgical management of malignant cancer?
- Standard operation for stage 1B tumours is radical hysterectomy with pelvic lymph node dissection
- NOTE: pelvic lymph nodes include obturator, internal and external iliac nodes
- Ovaries in pre-menopausal women can be spared
- High cure rate
- Risks
- Bladder dysfunction (atony)
- Common in the immediate post-operative period and may require intermittent self-catheterisation
- Sexual dysfunction (due to vaginal shortening)
- Lymphoedema (due to pelvic lymph node removal)
- Can be managed with leg elevation, good skin care and massage
32
How does radiotherapy manage malignant cancer?
- TWO ways of delivering radiotherapy:
- External beam radiotherapy
- Usually given over 4 weeks
- Each delivery of radiotherapy usually lasts about 10 mins
- Internal radiotherapy (brachytherapy)
- Rods of radioactive selenium is inserted, under anaesthetic, into the affected area
- The effects extend up to 5 mm away from the rod
- Risks
- Lethargy
- Bowel and bladder urgency
- Skin erythema (external beam radiotherapy)
- Long-term:
- Fibrosis
- Vaginal stenosis
- Cystitis-like symptoms
- Malabsorption and mucous diarrhoea
- Radiotherapy-induced menopause
33
How does chemotherapy manage malignant cancer?
- Usually cisplatin
| - Ideally given in conjunction with radiotherapy (improves cure rates)
34
What is the epidemiology and aetiology of malignant disease of the vulva?
- UNCOMMON
- Mainly affects older women
- 90% are squamous cell carcinomas
- Remainder are malignant melanoma, basal cell carcinoma and adenocarcinoma of the Bartholin's gland
- TWO types of squamous cell carcinomas of the vulva:
- High-risk HPV associated
- Arise on a background of high-grade vulval intraepithelial neoplasia (VIN3)
- Usually young women
- Non-HPV associated
- Usually older women
- Associated with lichen sclerosus
35
What is the clinical presentation of malignant disease of the vulva?
- Lump or ulcer associated with bleeding or discharge
- May be painless or painful
- Examination
- Well-demarcated raised or ulcerated lesion that is hard and craggy and bleeds on touch
- Often associated pre-malignant change
- Younger women - VIN
- Older women - lichen sclerosus
- Vulval cancers spread locally and metastasise via the inguinofemoral lymph nodes before the pelvic nodes
36
How is malignant disease of the vulva investigated?
- Specialist gynaecological oncology MDT
- Biopsy to confirm the diagnosis
- Examination under anaesthetic may be required to assess suitability to resection
- CT scan may be required for large tumours with obvious groin node disease and potential distant metastases
- FIGO staging
37
How is malignant disease of the vulva managed?
- Vulval excision
- Radical surgical excision aiming for a clear margin of 10 mm is the mainstay
- If the tumour is close to the urethra or anus it can be more difficult to operate
- Large lesions may be shrunk with neoadjuvant radiotherapy often with chemotherapy
- Sentinel Lymph Node Biopsy
- Untreated groin node biopsies will be fatal
- Affected nodes cannot be reliably identified with radiology
- Current approach: full inguinofemoral lymphadenectomy (for all tumours with depth of invasion > 1 mm)
- NOTE: groin lymphadenectomy is a very morbid procedure with complications including wound healing problems, infection, VTE and chronic lymphoedema
- Groin nodes are involved in 15% of women with vulval cancer
- Full groin lymphadenectomy may be avoided by doing a sentinel lymph node biopsy (first node that the area drains to)
- A dye and radioactive nucleotide can be injected into the vulval tumour to identify the sentinel node
- If the sentinel node is positive for disease, then full groin lymphadenectomy is indicated
- Radiotherapy
- Adjuvant radiotherapy is indicated if the excision margins are close or in the presence of two or more groin node metastases
- Radical radiotherapy may be used instead of surgery if the patient is unfit for surgery
38
Describe a hysterectomy
- When the uterus is enlarged by fibroids or significant adhesions are expected or it is planned to remove the ovaries, hysterectomy is usually performed abdominally
- There are THREE pedicles that need to be removed in hysterectomy:
- Infundibulopelvic ligament (containing ovarian vessels)
- Uterine artery
- Angles of the vault of the vagina (containing vessels ascending from the vagina and the ligaments to support the uterus can be taken out with this)
- If the uterus is a normal size it can be taken out vaginally
- In prolapse surgery, the uterus is often taken out vaginally
- Vaginal surgery requires a shorter stay in hospital and less recovery time before full mobility and activity
- Increasingly, vaginal surgery is being done laparoscopicaly (laparoscopic-aided vaginal hysterectomy)
39
What are the complications of a hysterectomy?
- Haemorrhage
- DVT
- New bladder symptoms (overactive bladder and stress incontinence)
- Early onset of menopausal symptoms
- Immediate onset of menopausal symptoms
- Bladder injury
- Ureteric injury
- Rectal injury
- Fistulae
40
When should an oophrectomy be considered when performing a hysterectomy?
- Decision to remove the ovaries will be largely dictated by whether the woman menopausal or not
- In patients with dysmenorrhoea, the decision to perform an oophorectomy should be carefully considered because there are some common non-gynaecological causes of cyclical pain (e.g. IBS)
- A 3-month trial of GnRH analogues to suppress ovarian function before surgery should be carried out to confirm that oophorectomy will alleviate the pain
41
What are the main groups of young women you would consider an oophrectomy when doing an hysterectomy?
- Debilitating premenstrual syndrome
- Severe endometriosis
- IMPORTANT: oophorectomy in young women is likely to require immediate systemic HRT
42
Describe the pre-assessment of a hysterectomy
- Patients usually present to pre-assessment clinic up to 2 weeks before the operation
- All patients will have a:
- FBC
- Group and save
- If > 50 years or known cardiac/renal/respiratory problems will have:
- U&E
- LFTs
- Creatinine
- CXR
- ECG
- Risk of thromboembolism will be assessed (plans for post-operative thromboprophylaxis can be made)
- COCP should be STOPPED 4 weeks before the operation and alternative contraception should be used
- HRT should also be stopped
- LMWH may be given if HRT is to be continued
- All women should be mobilised early after surgery
- All women should be given thromboembolic stockings (TEDS) and kept hydrated
- LMWH is given based on the risk assessment
43
Describe thromboprophylaxis in a hysterectomy
- LOW risk: surgery < 30 mins without risk factors
- MODERATE risk
- Use TEDS and LMWH
- Surgery > 30 mins, high BMI, varicose veins, sepsis, immobility, comorbidity
- HIGH risk
- Use TEDS and LMWH for 5 days or until mobile
- Cancer, prolonged surgery, previous thromboembolic event, thrombophilia or > 3 moderate risk factors
44
What is a Pfannenstiel incision?
- Transversely, two finger breaths above the pubic symphysis
- Strong when repaired with low risk of herniation and dehiscence
- Not very painful (limited to one or two dermatomes)
- Cosmetically attractive (lower than the underwear line)
- Cannot be easily extended or made larger
- If extension is required, an inverted T incision is usually performed
- Surgical access limited to pelvic organs
- Used for uncomplicated gynaecological procedures
- Below the arcuate line so there is NO posterior rectus sheath
45
What is a midline incision?
- Vertically from pubic symphysis up to umbilicus
- Less strong: prone to herniation and dehiscence
- Cosmetically unattractive
- Can easily be extended to around the umbilicus up to the xiphisternum
- Gives excellent surgical access
- Useful if significant surgical difficulty is anticipated (e.g. adhesions, large fibroids, ovarian cysts)
- More post operative pain
- Increases risk of respiratory infection due to limited breathing and coughing effort
46
Evaluate hysterectomy operations
- Vaginal incisions have a low morbidity (almost no pain)
- However, sometimes adhesion bands can form which interfere with intercourse
- Laparoscopic surgery is also associated with low post-operative pain, better cosmetic outcomes and quicker discharge from hospital
47
What are indications for a hysteroscopy?
- Postmenopausal bleeding
- Irregular menstruation (IMB, PCB)
- Persistent heavy menstrual bleeding
- Persistent discharge
- Suspected uterine malformations
- Suspected Asherman's syndrome
- Essure hysteroscopic sterilisation
- Operating hysterectomy can also be used to resect fibroids, polyps and uterine septums
48
What are complications of a hysteroscopy?
- Perforation of the uterus
- Cervical damage (if dilatation is needed)
- Ascending infection (if infection present)
49
What is a laparoscopy?
- Allows visualisation of the peritoneal cavity
- Involves insertion of a needle into a suitable puncture point in the umbilicus
- Insufflation of the abdominal cavity allows larger instruments to be inserted
- Operative laparoscopy can be done to perform ovarian cystectomy and oophorectomy and to treat endometriosis with cautery or laser
50
What are indications for a laparoscopy?
- Suspected ectopic pregnancy
- Ovarian cyst accident and acute pelvic pain
- Undiagnosed pelvic pain
- Tubal patency testing
- Sterilisation
51
What are complications of a laparoscopy?
- UNCOMMON
- Damage to bowel and major blood vessels
- Incisional hernia
52
What are indications for cytoscopy?
- Haematuria
- Recurrent UTI
- Sterile pyuria
- Short history of irritative symptoms
- Suspected bladder abnormality (e.g. diverticulum, stones, fistula)
- Assessment of bladder neck
53
What are complications of a cytoscopy?
- UTI
| - Bladder perforation (RARE)
