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Obstetrics & Gynaecology > Malignancy > Flashcards

Malignancy Flashcards

1
Q

What is the commonest type of gynae malignancy?

A

Endometrial cancer

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2
Q

What is the epidemiology of endometrial cancer?

A

Presents in post-menopausal women- rare below the age of 30

Most over the age of 60

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3
Q

Does endometrial cancer tend to present early or late?

A

Early and usually confused as being benign?

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4
Q

What are the two subtypes of endometrial carcinoma? (clue oestrogen and non-oestrogen dependent)

A

Type 1- oestrogeon dependent- associated with obesity- usually non-aggressive- adenocarcinoma

Type 2- not oestrogeon dependent- not associated with obesity- worse prognosis- adenosquamoscarcinoma

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5
Q

What are the risk factors for endometrial carcinoma

clue anything which causes unopposed oestrogeon action

A

Nulliparity
Late menopause
PCOS with prolonged amenorrhoea
Obesity (androgens are peripherally converted to oestrogeon)
Tamoxifen (in the uterus is a breast agonist but in breast is oestrogeon anatagonist)
Ovarian granulosa cell tumours (secrete oestrogeon)
Hypertension, Diabetes
Lynch II sydnrome

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6
Q

What is the premalignant disease of the uterus?

A

Endometrial hyperplasia with atypia

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7
Q

Explain the process of endometrial hyperplasia with atypica/cystic hyperplasia?

Management?

A
  • Oestrogeon stimulation causes proliferation-hyperplasia-enlargement of glandular cells (cystic changes)
  • If oestrogeon stimulation continue-proliferation-cells change into atypical cells- pre-malignant. Atypical hyperplasia may exist with carinoma elsewhere in the cavity
  • Hysterectomy or preserved fertility then progestegons (IUS/ continuous oral) with 6 monthly hysteroscopy with endometrial biopsies
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8
Q

What are the clinical features of endometrial carcinoma?

Findings on bimanual pelvic examination?

A
  • Postmenopausal bleeding
  • If premenopausal- recent onset menorrhagia, intermenstrual bleeding, menstrual irregularities
  • Pelvis is often normal. May have atrophic vaginitis
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9
Q

Explain how endometrial carcinoma is spread according to the FIGO stages, and the lymphatic spread?

A 
Stage 1a- endometrium 
Stage 1b- Myometrium 
Stage 2- Cervix 
Stage 3a- ovary 
Stage 3b- upper vagina 
Stage 4- bowl and bladder

Lymphatic spread: pelvis and the paraortic lymph nodes

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10
Q

What are the investigations for endometrial carcinoma?

A
  1. Transvaginal ultrasound- assess thickness of endometrium
  2. Hysteroscopy with endometrial biopsy, or pipelle for biopsy- makes diagnosis
  3. MRI- if spread suspected
  4. CXR- to check for pulmonary spread
  5. FBC, U+E’s, glucose, renal function tests, ECG
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11
Q

When can you conduct staging of endometrial carcinoma?

A

Staging can only done following hysterectomy

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12
Q

What percentage of individuals present with stage 1 endometrial disease (ie confined to the endometrium)

A

75%

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13
Q

What is the main management of endometrial carcinoma?

A

Hysterectomy with salpingoopherectomy
Adjuvant radiotherapy can be used after hysterectomy Chemotherapy - reserved for high risk early stage disease (lymphatic spread) and advanced disease

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14
Q

When is external beam radiotherapy used in endometrial carcinoma?

A

Lymph node spread
Deep myometrial invasions
Poor tumour grade or histology (ie adeunoquamous carcinoma)
Stage 2- involving cervix

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15
Q

Where and when is endometrial carcinoma most likely to recur and what is treatment?

A

At the vaginal vault in the first three years

Management with vaginal vault prolapse- better chance of working if radiotherapy not used before

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16
Q

What is the premalignant condition of the cervix called?

A

Cervical intraepithelial neoplasia/ cervical dysplasia

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17
Q

What is the pathology of CIN, explain what are the features of dyskaryotic cells?

A

CIN is the presence of atypical (dyskaryotic cells) within the squamos epithelium (transformation zone squamos in vagina, columnar in cervix)

Dyskaryotic cells characterised by hyperchromatic nuclei

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18
Q

What are the three histological grades of CIN? (clue extent of presence in epithelium)

A

CIN 1: Atypical cells in lower epithelium: may regress or progress to other CIN stages
CIN 2: Atypical cells in lower two thirds of epithelium. A third will develop cervical carcinoma
CIN 3: Atypical cells found throughout the epithelium- carcinoma in situ. A third will develop cervical carcinoma

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19
Q

Epidemiology of CIN, and aetiology/RF:

A

Epidemiology- peaks 25-29

Aetiology: Human papillomavirus 16.18. 31. 33- most 16 & 18 in UK 
Risk factors: 
- multiple sexual partners 
- STD's 
- multiparity 
- previous CIN
-oral contraceptive use 
- Smoking- causes persistent HPV 
- Immunosuppression- HIV, long term steroids use- results in early progression of CIN to malignancy
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20
Q

CIN diagnosed using cervical smear? What does smear look at, and what is the screening schedule in the UK?

A

Smear looks at cellular changes and either, mild, moderate or severe dyskaryosis: dyskaryosis indicates CIN

25-49: every 3 years
50-64: every 5 years
<64: only if abnormal, or not had a smear since 50

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21
Q

What would you do next if a cervical smear showed a low grade dyskaryosis

A

Check for high risk HPV ie 16 & 18

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22
Q

Which CIN patients are referred for colposcopy?

A
  • mild dyskaryosis but high risk HPV
  • Moderate/severe dyskaryosis
  • Presence of abnormal columnar cells (cervical glandular intraepithelial neoplasia): indicates adenocarcinoma of cervix or endometrium
23
Q

What is the treatment for CIN?

A
  • Loop excision of the transformation zone- sample is sent for histological analysis
  • Or coloposcopy with biopsy- histological analysis- then LETS
24
Q

What is the epidemiology of cervical carcinoma?

A

Two peaks of incidence:

  • 30
  • 80
25
Q

What is the difference between cervical carcinoma and CIN?

A

Cervical carcinoma the cells breath the basement membrane

26
Q

What are the pathological subtypes of cervical carcinoma? Which ones have a worse prognosis?

A

90% have squamos carcinoma
10% have adenocarcinoma- carcinoma of the columnar epithelial cells
Adenocarcinomas have a worse prognosis

27
Q

Is cervical carcinoma hereditary?

Aetiological factors?

A

Not hereditary

HPV, Immunosuprpression (ie renal transplant, HIV,)- causes persistent infection and faster progression from CIN to cervical carcinoma

28
Q

What are the clinical features of cervical carcinoma?

A

Occult carcinoma- asymptomatic diagnosis made via LETZ or biopsy

Post-coital bleeding 
Post-menopausal bleeding 
Offensive vaginal discharge- intermitten or continuous
Haematuria, Rectal bleeding 
Uraemia (urea in blood)
29
Q

What are examination findings for cervical cancer?

A
  • Ulcer or visible mass

- Early disease no change

30
Q

What is the spread and staging of cervical cancer according to FIGO staging?

A
  • Cervix-vagina-pelvic sidewalls- parametrium

Stage 1- cervix
Stage 2- two thirds of upper vagina
Stage 3- lower third of vagina or pelvic sidewalls
Stage 4- Invades bladder, rectum, and mets

31
Q

What is the lymphatic spread of cervical cancer?

A

Mets via regional lymph nodes then paraaortic lymph nodes

Lymph node spread is an early feature!!

32
Q

What are the investigations for cervical cancer?

A
  1. Coloposcopy with biopsy or pipelle biopsy- histological analysis- makes diagnosis
  2. Rectal and vaginal examination under GA- assess spread of tumour
  3. CT/MRI of abdomen to assess spread
  4. Cytoscopy to assess spread into bladder
  5. Fitness for surgery: FBC, glucose, U &E’s, ECG
33
Q

What is the management of cervical cancer?
Stage 1a
Stage 1-2 (fertility and not preserving fertility)
Stage 2b, or lymph node spread

A

Stage 1a- Cone biopsy or simple hysterectomy in older women

Stage 1-2
Fertility- Radical trachelectomy (remove cervix, upper vagina and cervical suture prevent preterm birth)

Not fertility- Lymph node sampling via laproscopic lymphoadenectomy if negative then radical abdominal hysterectomy

Stage 2b/lymph node spread
Chemoradiotherapy (external beam and cisplatin)

34
Q

What are the complications of a cone biopsy?

A

Preterm birth

Post-op haemorrhage

35
Q

What is removed in a radical abdominal hysterectomy, and what structure is left in place in young women in treatment of cervical carcinoma

A
  • Uterus, parametrium, upper third of vagina, and pelvic node clearance
  • In young women leave ovary behind
36
Q

What is the epidemiology of ovarian carcinoma?

A

> 50-65 years old
Postmenopausal]

Most women present in stage 3a

37
Q

What is the aetiology/risk factors for ovarian carcinoma?

A

Prolonged oestrogeon expsoure, or ovulation induction

  • Obesity, nulliparity, early menarche and late menopause, HRT therapy, clomifene
  • 1st degree relative with ovarian cancer
  • BRCA1 and 2 genes
  • Asbestos expsosure, talcum powder
  • ENDOMETRIOSIS
38
Q

Pathological subtypes of ovarian carcinoma?

A

Ovarian epithelial tumours- 90%- older women
Ovarian germ cell tumours- teratomas- present in 35- rapidly expanding abdo mass causing pain
Sex cord tumours (eg granulosa)- 5%
Metastatic tumours- breast, uterus or cervix

39
Q

Clinical features of ovarian carcinoma?

A
  • Asymptomatic
  • IBS like symptoms- ABC
  • weight loss, fatigue, anorexia, depression
  • urinary frequency/urgency
  • bowel obstruction
  • Ascites- third may have pleural effusion
40
Q

If someone with ovarian carcinoma present with abdominal, pelvic, or back pain. What does this suggest?

A
  • Ovarian rupture, cysts or infection
41
Q

What is the lymphatic spread of ovarian carcinoma, and ovarian mets?

A
  • Pelvic and paraaortic lymph nodes

- pelvic and abdominal peritoneum

42
Q

FIGO stages of ovarian carcinoma?

A

Stage 1- ovaries
Stage 2- >1 ovaries and pelvic extension ie fallopian tubs and cervix
Stage 3- peritoneal mets and lymph nodes
Stage 4- LIVER METS

43
Q

If women presenting with ascites or pelvic abdo mass with suspected ovarian carcinoma, what would you do?

A

Refer urgently to gynaecology, I think they don’t need ovarian tests

44
Q

What are indications for conducting ovarian gynae tests?

A

> 50 and presented 12 times over the past 12 months with- early satiety, persistent bloating, pain, urgency or urinary frequency

Unexplained weight loss, and fatigue

45
Q

What is the calculation for the Risk malignancy index, and when do you refer to gynae oncological specialist?

A

Ultrasound score X Menopausal score X Ca125 levels

If >250 then refer to gynaecology oncologist

46
Q

What are the investigations for ovarian carcinoma

A
  1. CA125 > 35 IU then
  2. Pelvic and abdominal ultrasound
  3. CT/MRI of abdomen and pelvis to stage disease
47
Q

What is the epidemiology of vulval cancer

  • Pathological subtype
  • Aetiology (Clue is a dermatological condition)
A
  • Very rare- mostly in lederly and posmenopausal women
  • Squamos cell carcinoma
  • Associated wtih lichen sclerosis, where they may have premalignant vulval intraepithelial neoplasia) and HPV
48
Q

What is the spread of vulval cancer and which lymph nodes does it spread to?

A
  • spreads to perineal structures eg vagina, anus, upper urethra
  • Mostly involves the inguino-femoral lymph nodes
  • Severe stage mets to pelvic lymph nodes
49
Q

What are the clinical features of vulvar cancer?

A
  • Begins as nodule or ulcer with sloughed base and raised edges, may complain of persistent lump
  • vulval itching for many years or months
  • vulval soreness or bleeding
  • Pain on passing urine (urethral involvement)
50
Q

Management of vulval cancer?

A

Simple vulvectomy with inguinofemoral lymphoadenectomy

Radical vulvectomy with inguinal, femoral and pelvic lymph nodes

51
Q

What is vaginal cancer and what are its features?

A

Very rare
Mostly metastatic cancer, then squamos and then adenocarcinoma
Present with vaginal or bloody discharge

52
Q

How do you treat vaginal cancer?

A

Stage 1 and II- radical hysterectomy and radiotherapy

Severe disease- radiotherapy

53
Q

What is the treatment for ovarian carcinoma according to stages?

A

Laparatomy with total hysterectomy, partial oopherectomy and omentectomy
If stages 2-4: surgery and neoadjuvant chemotherapy

Obstetrics & Gynaecology (16 decks)

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