O&G: Gynae cancers Flashcards
Cervical cancer
who does it tend to affect
younger women, peaking in the reproductive years
Cervical cancer
what is the most common type
- squamous cell carcinoma
- then adenocarcinoma
Cervical cancer
what is is strongly associated with
human papillomavirus
Cervical cancer
at what age are people vaccinated against certain strains of HPV to reduce risk of cervical cancer
children aged 12-13y
Cervical cancer
how is HPV transmitted
primarily a STI
Cervical cancer
what types of HPV are responsible for around 70% of cervical cancers
type 16 and 18
Cervical cancer
what is the trx for infection with HPV
none, most cases resolve spontaneously within 2y
Cervical cancer
how does HPV promote the development of cancer
HPV produces proteins E6 and E7
which inhibit P53 and pRb tumour suppressor genes respectively
Cervical cancer
risk factors
increased risk of catching HPV:
- early sexual activity
- increased number of sexual partners
- sexual partners who have more partners
- not using condoms
non-engagement with cervical screening
- smoking
- HIV
- COCP use>5y
- increased number of full term pregnancies
- FH
- Exposure to diethylstilbestrol during fetal development (was previously used to prevent miscarriages before 1971)
Cervical cancer
presentation
- asymptomatic
- abnormal vaginal bleeding
- vaginal discharge
- pelvic pain
- dyspareunia
Cervical cancer
appearances on speculum exam that may suggest cervical cancer
- ulceration
- inflammation
- bleeding
- visible tumour
Cervical cancer
speculum exam may suggest cervical cancer. What next?
urgent cancer referral for colposcopy
Cervical cancer
what is Cervical intraepithelial neoplasia (CIN)
a grading system for the level of dysplasia (premalignant change) in the cells of the cervix
CIN is diagnosed at colposcopy (not with cervical screening)
Cervical cancer
CIN I grade
- mild dysplasia
- affecting 1/3 the thickness of the epithelial layer
- likely to return to normal without treatment
Cervical cancer
CIN II grade
- moderate dysplasia
- affecting 2/3 the thickness of the epithelial layer
- likely to progress to cancer if untreated
Cervical cancer
CIN III grade
- severe dysplasia
- very likely to progress to cancer if untreated
- aka cervical carcinoma in situ
Cervical cancer
screening: what does microscope examination look for
precancerous changes (dyskaryosis)
Cervical cancer
screening: what are samples initially tested for before cells are examined
high-risk HPV
if HPV test is -ve, the cells are not examined, the smear is considered negative, and the woman is returned to the routine screening program.
Cervical cancer
how often are women screened
- every 3y aged 25-49
- every 5y aged 50-64
Cervical cancer
how often are women with HIV screened
annually
Cervical cancer
can women over 65 request a smear if they have not had one since aged 50
yes
Cervical cancer
if pregnant and due a routine smear, what should they do
wait until 12 weeks post-partum
Cervical cancer
what organisms are often discovered in women with an intrauterine device (coil).
Actinomyces-like organisms
Cervical cancer
smear result: inadequate sample
what next
repeat the smear after at least three months
Cervical cancer
smear result: HPV negative
what next
continue routine screening
Cervical cancer
smear result: HPV positive with normal cytology
what next
repeat the HPV test after 12 months
Cervical cancer
smear result: HPV positive with abnormal cytology
what next
refer for colposcopy
Cervical cancer
what does colposcopy involve
inserting speculum and using colposcope to magnify cervix
Cervical cancer
colposcopy: what does the stain, acetic acid do
causes abnormal cells to appear white: acetowhite
because CIN and cervical cancer cells have more nuclear material
Cervical cancer
colposcopy: what does the stain, Schiller’s iodine test do
Iodine will stain healthy cells a brown colour. Abnormal areas will not stain.
Cervical cancer
colposcopy: how to get a tissue sample
punch biopsy or large loop excision of the transformational zone
Cervical cancer
what is the large loop excision of the transformation zone (LLETZ) procedure aka
a loop biopsy
Cervical cancer
what does a LLETZ involve
single diathermy to remove abnormal epithelial tissue on the cervix
The electrical current cauterises the tissue and stops bleeding.
Cervical cancer
what may LLETZ increase the risk of
preterm labour
Cervical cancer
what is a cone biopsy for
trx for cervical intraepithelial neoplasia (CIN)
and very early-stage cervical cancer.
Cervical cancer
what is involved in a cone biopsy
Surgeon removes a cone-shaped piece of the cervix using a scalpel.
This sample is sent for histology to assess for malignancy.
Cervical cancer
main risks of cone biopsy
- pain
- bleeding
- infection
- scar formation with stenosis of the cervix
- increased risk of miscarriage and premature labour
Cervical cancer
stage 1
Confined to the cervix
Cervical cancer
stage 2
Invades the uterus or upper 2/3 of the vagina
Cervical cancer
stage 3
Invades the pelvic wall or lower 1/3 of the vagina
Cervical cancer
stage 4
Invades the bladder, rectum or beyond the pelvis
Cervical cancer
mnx for CIN and early-stage 1A
LLETZ or cone biopsy
Cervical cancer
mnx for stage 1B-2A
- radical hysterectomy
- removal of local lymph nodes with chemo and radio
Cervical cancer
mnx for stage 2B - 4A
Chemotherapy and radiotherapy
Cervical cancer
mnx for stage 4B
combination of surgery, radiotherapy, chemotherapy and palliative care
Cervical cancer
what is pelvic exenteration
used in advanced cervical cancer
removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum
Cervical cancer
what is Bevacizumab (Avastin)
a monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer
Cervical cancer
how does Bevacizumab (Avastin) work
It targets vascular endothelial growth factor A (VEGF-A), which is responsible for the development of new blood vessels.
Therefore, it reduces the development of new blood vessels.
Cervical cancer
what is the current NHS HPV vaccine
gardaso;
Cervical cancer
which strains does the HPV vaccine protect against
6 + 11: genital warts
16 + 18: cervical cancer
Endometrial Cancer
what type is the most common
adenocarcioma
Endometrial Cancer
what does it mean by oestrogen-dependent cancer
oestrogen stimulates the growth of endometrial cancer cells.
Endometrial Cancer
woman presenting with postmenopausal bleeding. What is it
endometrial cancer until proven otherwise
Endometrial Cancer
key RFs
obesity + diabetes
Endometrial Cancer
what is endometrial hyperplasia
a precancerous condition involving thickening of the endometrium.
Endometrial Cancer
what are 2 types of endometrial hyperplasia to be aware of
- Hyperplasia without atypia
- Atypical hyperplasia
Endometrial Cancer
how may endometrial hyperplasia be treated
by a specialist using progestogens, with either:
- IU system (mirena)
- Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
Endometrial Cancer
RFs
exposure to unopposed oestrogen:
- increased age
- earlier onset menstruation
- late menopause
- oestrogen only HRT
- no or fewer pregnancies
- obesity
- PCOS
- tamoxifen
Endometrial Cancer
why do women with PCOS have more exposure to unopposed oestrogen
less likely to ovulate and form a corpus luteum.
so progesterone not produced and the endometrial lining has more exposure to unopposed oestrogen.
Endometrial Cancer
why do obese women have more exposure to unopposed oestrogen
adipose tissue contains aromatase which converts testosterone into oestrogen
Endometrial Cancer
what effect does tamoxifen have on breast tissue and the endometrium
an anti-oestrogenic effect on breast tissue
but an oestrogenic effect on the endometrium
Endometrial Cancer
why may T2 DM increase the risk
increased production of insulin.
Insulin may stimulate the endometrial cells and increase the risk of endometrial hyperplasia and cancer.
Endometrial Cancer
protective factors
- COCP
- mirena coil
- increased pregnancies
- cigarette smoking
Endometrial Cancer
why is smoking a protective factor
- Oestrogen may be metabolised differently in smokers
- Smokers tend to have less adipose tissue and aromatase enzyme
- Smoking destroys oocytes (eggs), resulting in an earlier menopause
Endometrial Cancer
the number 1 presenting sx
postmenopausal bleeding
Endometrial Cancer
presentation
- postmenopausal bleeding
- Postcoital bleeding
- Intermenstrual bleeding
- Unusually heavy menstrual bleeding
- Abnormal vaginal discharge
- Haematuria
- Anaemia
- Raised platelet count
Endometrial Cancer
what is the
referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer
Postmenopausal bleeding (more than 12 months after the last menstrual period)
Endometrial Cancer
NICE recommends referral for a transvaginal ultrasound in women over 55 years with?
- Unexplained vaginal discharge
- Visible haematuria
- plus raised platelets, anaemia or elevated glucose levels
Endometrial Cancer
3 inx to diagnose and exclude endometrial cancer
- TVUS for endometrial thickness
- pipelle biopsy
- hysteroscopy
Endometrial Cancer
what is a normal endometrial thickness
<4mm
Endometrial Cancer
when may you discharge pt following inx
- endometrial thickness <4mm
- normal pipette biopsy
Endometrial Cancer
stage 1
Confined to the uterus
Endometrial Cancer
stage 2
Invades the cervix
Endometrial Cancer
stage 3
Invades the ovaries, fallopian tubes, vagina or lymph nodes
Endometrial Cancer
stage 4
Invades bladder, rectum or beyond the pelvis
Endometrial Cancer
mnx for stage 1 and 2
total abdominal hysterectomy with bilateral salpingo-oophorectomy
aka TAH and BSO
(removal of uterus, cervix and adnexa).
Endometrial Cancer
mnx stage 3 and 4
- radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
- radio and chemotherapy
- Progesterone may be used as a hormonal treatment to slow the progression of the cancer
Ovarian Cancer
types
- Epithelial Cell Tumours
- Dermoid Cysts / Germ Cell Tumours
- Sex Cord-Stromal Tumours
- Metastasis
Ovarian Cancer
which is the most common type
Epithelial Cell Tumours
Ovarian Cancer
what are the subtypes of epithelial cell tumours
- serous tumours (most common)
- endometrioid carcinomas
- clear cell tumours
- mucinous tumours
- undifferentiated tumours
Ovarian Cancer
what are Dermoid Cysts / Germ Cell Tumours
benign ovarian tumours.
They are teratomas, meaning they come from the germ cells.
may contain various tissue types, such as skin, teeth, hair and bone.
Ovarian Cancer
what are Dermoid Cysts / Germ Cell Tumours associated with
ovarian torsion
Ovarian Cancer
what may Dermoid Cysts / Germ Cell Tumours cause
raised α-FP and hCG
Ovarian Cancer
what are sex cord-stromal tumours
rare tumours, that can be benign or malignant.
They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles)
Ovarian Cancer
types of Sex Cord-Stromal Tumours
Sertoli–Leydig cell tumours
granulosa cell tumours.
Ovarian Cancer
what is a Krukenberg tumour
a metastasis in the ovary
usually from a GI tract cancer, particularly the stomach
Ovarian Cancer
on histology, what will Krukenberg tumours show
“signet-ring’’
Ovarian Cancer
RFs
- Age (peaks age 60)
- BRCA1 and BRCA2 genes
- Increased number of ovulations
- Obesity
- Smoking
- Recurrent use of clomifene
increased ovulations:
- Early-onset of periods
- Late menopause
- No pregnancies
Ovarian Cancer
protective factors
less lifetime ovulations:
- COCP
- breastfeeding
- pregnancy
Ovarian Cancer
presentation
non specific:
- Abdo bloating
- Early satiety
- Loss of appetite
- Pelvic pain
- Urinary symptoms (frequency / urgency)
- Weight loss
- Abdominal or pelvic mass
- Ascites
Ovarian Cancer
why may it present with hip or groin pain
ovarian mass may press on the obturator nerve and cause referred hip or groin pain.
Ovarian Cancer
when should you refer directly on a 2 week wait referral
if a physical examination reveals:
- Ascites
- Pelvic mass (unless clearly due to fibroids)
- Abdominal mass
Ovarian Cancer
inital investigations
- CA125 blood test (>35 IU/mL is significant)
- Pelvic ultrasound
Ovarian Cancer
what is the risk of malignancy index (RMI)
estimates the risk of an ovarian mass being malignant, taking account of three things:
- Menopausal status
- Ultrasound findings
- CA125 level
Ovarian Cancer
secondary care inx
- CT
- histology
- paracentesis (ascitic tap)
Ovarian Cancer
which women need tumour markers for a possible germ cell tumour (α-FP + HCG)
women <40y with a complex ovarian mass
Ovarian Cancer
causes of a raised CA125
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infection
- Liver disease
- Pregnancy
Ovarian Cancer
stage 1
Confined to the ovary
Ovarian Cancer
stage 2
Spread past the ovary but inside the pelvis
Ovarian Cancer
stage 3
Spread past the pelvis but inside the abdomen
Ovarian Cancer
stage 4
Spread outside the abdomen (distant metastasis)
Ovarian Cancer
mnx
surgery + chemo
Vulval Cancer
what is the most common
squamous cell carcinoma
less common: malignant melanomas
Vulval Cancer
RFs
- > 75y
- immunosuppression
- HPV
- Lichen sclerosus
Vulval Cancer
what is Vulval intraepithelial neoplasia (VIN)
a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer
Vulval Cancer
what is High grade squamous intraepithelial lesion
a type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years.
Vulval Cancer
what is Differentiated VIN
an alternative type of VIN associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years).
Vulval Cancer
what is required to diagnose VIN
a biopsy
Vulval Cancer
trx options
- Watch and wait with close follow up
- Wide local excision (surgery) to remove the lesion
- Imiquimod cream
- Laser ablation
Vulval Cancer
presentation
- Vulval lump
- Ulceration
- Bleeding
- Pain
- Itching
- Lymphadenopathy in the groin
Vulval Cancer
which part of the vulva does it typically affect
labia majora, giving an appearance of:
- Irregular mass
- Fungating lesion
- Ulceration
- Bleeding
Vulval Cancer
Establishing the diagnosis and staging involves:
- Biopsy of the lesion
- Sentinel node biopsy to demonstrate lymph node spread
- Further imaging for staging (e.g. CT abdomen and pelvis)
Vulval Cancer
mnx
- wide local excision to remove the cancer
- Groin lymph node dissection
- Chemotherapy
- Radiotherapy
Ovarian cancer
features to look out for on the USS (as part of the RMI)
1 point for each:
- multiocular cysts
- solid area
- metastases
- ascites
- bilateral lesions
To what regional lymph nodes is her ovarian tumour most likely to spread initially?
para-aortic nodes
The main lymphatic drainage of the ovary is to the para-aortic nodes.
