Gynaeoncology Flashcards
What is the different pathology of ovarian tumours?
Epithelial
Germ cell tumours
Ovarian stromal tumours
Mets eg, Krukenberg tumours.
Tumours are either invasive or borderline.
Two types of epithelial ovarian cancer
- High grade serous
- Arises from surface epithelium of ovary and mullerian inclusion cysts (low grade serous, endometroid, clear cell)
How does ovarian cancer spread?
Direct extension (transcoelemic),
Exfoliation into peritoneal cavity,
Lymphatic invasion
Risk factors for ovarian CA?
Smoking,
Low parity,
Oral contracpetive,
Infertility,
Tubal ligation,
Early menarche,
Late menopause
What genes are linked to ovarian cancer?
BRCA1
BRCA2
Lynch syndrome
Other undiscovered genes
BRCA genes have a 30% lifetime risk of ovarian cancer.
What are features which suggest genetic mutations?
Early onset of breast CA (<50y),
Male breast cancer,
Ashkenazi jews,
Bilateral breast cancers,
Multiple genetically related family memebrs with cancer
What is the risk reducing surgery for ovarian cancer?
Prophylactic bilateral salpingo-oopherectomy. Important to remove entire ovary and fallopian tube!
What is the presentation of ovarian cancer?
Vague and non specific
Altered bowel habit,
Abdominal pain/bloating,
Early setiaty,
Difficulty eating,
Urinary/pelvic symptoms
Signs - Abdo distention, upper abdo mass, pleural effusion, nodules on PV examination and paraneoplastic syndrome
What are the investigations for ovarian cancer?
Initial: Ultrasound and CA125. Then calculate the risk of malignancy index.
If RMI is high then do CT. Used to determine initial treatment plan
How do you calculate RMI?
Ultrasound score,
Menopausal status,
CA125 level
If RMI > 200 then high suspicion so get CT and referral to MDT
How can you confirm diagnosis of ovarian cancer?
Cytology of pleural effusion or ascitic fluid.
Histology from biopsy either percutaneous under guidence or laparoscopic
Staging
Stage 1 - confined to ovaries.
Stage 2 - On surface of pelvic orgnans.
Stage 3 - Mets out of pelvis + retroperitoneal nodes.
Stage 4 - distant mets
Treatment of ovarian cancer?
All ovarian cancer will come back at some stage.
Surgery - midline laparotomy with total abdominal hysterectomy, BSO, washings, omentectomy +/- any other abdominal organs containing disease.
Chemotherapy - either neo/adjuvant.
Fertility conserving surgery
Describe features of chemotherapy used in ovarian cancer and other treatments used.
- IV chemo either NACT or adjuvant. 1st line is carboplatin with paclitaxel.
- Intraperitoneal chemotherapy
- Biological agents - bevacizumab (in patients with residual disease)
- Hormonal therapy - tamoxifen/aromatase inhibitors
- PARPi inhibitors - for BRCA
What is the presentation of endometrial cancers
PMB,
PCB,
IMB,
Altered menstrual pattern,
Persistent vaginal discharge.
what are the different pathological types of endometrial cancer?
Adenocarcinoma is the most common. Type 1 associated with oestrogen excess, type 2 is not associated with oestrogen excess.
Sarcomas - derived from muscle layer. Leiomyosarcoma is most common
Uterine carcinosarcoma
What is the precursor for endometrial cancer?
Atypical endometrial hyperplasia
What are the risk factors for endometrial cancer?
Obesity,
Physical inactivity,
HRT,
Diabetes,
Metabolic syndrome,
Tamoxifen,
Nullparity,
Longer menstrual lifespan,
Lynch syndrome type II.
How do you diagnose Lynch syndrome?
Amsterdam criteria:
Colorectal CA in 3+ relatives,
Involves at least two generations,
One case above age 50,
FAP excluded
How can you reduce the risk of endometrial cancer?
Reduce BMI
Avoid diabetes,
Parity and COCP use protective,
TVS and biopsy,
Progesterone prophylaxis?
What is the staging of ovarian cancer?
Stage 1 - Tumour confined to uterus
2 - Cervical stromal invasion but not beyond uterus.
3 - Tumour invasion outside of uterus
Stage 4 - Metastasis.
What are the investigations for endometrial cancer?
Bloods
Imaging - Transvaginal scan to measure endometrial thickness, if thick then biopsy (pipelle or hysteroscopy)
When to biopsy endometrial tissue?
If thickness > 3mm and not HRT useres.
If thickness > 5mm and HRT user.
Hyseroscopy/biopsy if using tamoxifen
Endometrialcancer: What is the treatment for early disease?
Total hysterectomy, BSO and washings.
Examine all peritoneal surfaces,
Lymphadenectomy
May need additional chemorads
What is the treatment for advanced disease?
Surgery, chemo, radiotherapy, hormonal treatment.
If inoperable then chemo/rads and/or hormonal therapy.
Describe features of radiotherapy in endometrial cancer
Either external beam, or brachytherapy.
Side effects - Proctitis, cystitis, lethargy and skin changes.
What are the risk factors for cervical cancer?
HPV,
Smoking,
Early first episode of sexual intercourse,
COCP use,
Multiple sexual partners,
Immunosuppression
What strains does the Gardisal vaccine protect against?
HPV 6, 11, 16 and 18.
What is the cervical screening programme?
Smears every 3 years for women aged 25-49
Smears > 50y is every 5 years
More based on HPV status now
Describe anatomy of cervix
Endocervix is columnar epithelium and ectocervix is squamous cell. Where this change happens is called the transformation zone.
What are the ix for an abnormal looking cervix?
Do not do smear. Do biopsy!
Either punch biopsy or large loop excision of transformation zone (LLETZ). A LLETZ is both treatment and biopsy
Describe features of colposcopy
Done if abnormal smear result of suspicious symptoms/appearance.
Uses a binocular microscope and examination with acetic acid and/or lugols iodine.
If abnormal on colposcopy then either do biopsy or go ahead and treat first.
Describe features of cervical intraepithelial neoplasia
CIN 1 - low grade and should resolve on their own.
CIN2 or 3 - High grade and therefore treatment is offered.
Treatment - excisional. most commonly via LLETZ.
Then continue to follow up, if + for HPV then more follow up
What are the most common types of cervical cancer types?
Adenocarcinoma
Adenosquamous carcinoma
What is the presentation of cervical cancer?
Unschedualed vaginal bleeding,
Offensive vaginal discharge,
Obstructive renal failure,
Supraclavicular node
Can also be asymptomatic
Staging of cervical cancer
Stage 1 - confined to cervix
Stage 2 - Spread to vagina and parametrium
Stage 3 - SPread within pelvis,
Stage 4 - Mets
What is the management of cervical cancer?
Surgery - fertility sparing, simple or radical surgery
Chemotherapy - cisplatin
Radiotherapy
If advanced disease then pallative care, chemorads
Fertility conserving surgery for cervical ca
LLETZ,
Trachelectomy - will probably need IVF and then C-section
simple vs total hysterectomy
Simple - only uterus and cervix. Used for 1A1 and 1A2 staging.
Radicle - Uterus, cervix and parts of vagina. Used in 1B1 and 2A staging
RFs for vulva cancer?
Smoking,
HPV,
Immunosuppression,
Lichen sclerosis
Pathological types of vulval cancers?
90% squamous cell carcinoma,
Others: Adenocarcinoma, melanoma, BCC, sarcoma
What is the precursors to vulval cacner?
Vulval intraepithelial neoplasia 1,2 and 3
VIN 2/3 - Usual, warty, basaloid.
What is the presentation of VIN?
Pruritis,
Pain,
Ulceration,
Thickened white areas,
Lump/wart,
Asymptomatic
Where is the commonest sites of VIN?
Labia majora, labia minora, posterior courchette
How do you diagnose and manage high grade VIN?
Biopsy - incisional or exision.
Management - Observation or excision, ablation either with laser or chemical (imiquimod)
Signs and symptoms of vulvar cancer?
Symptoms - lump, pain, bleeding, discharge, swollen leg, groin lump.
Signs - Mass, ulceration, colour changes, elevation and irregular surface, inguinal lymphadenopathy and lower limb lymphoedema
How do you diagnose vulval cancer?
Biopsy - incisional (prefered) or excisional.
Investigate locoregional lymphnodes with US, CT or MRI
What is the management of vulval cancer?
Surgical - WLE or vulvectomy (triple excision). Do sentinal lymph node biopsy, if negative then no need to preform lymphadenectomy
What are the complications of lemphadenectomy?
Delayed wound healing, infection, wound breakdown, lymphoedema, recurrent infection.
