Obs&Gyn: Gyn malignancies Flashcards
Cervical screening programme
- 25-49 years: 3-yearly screening
- 50-64 years: 5-yearly screening
*cervical screening cannot be offered to women over 64
Cervical screening in pregnancy
Cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears
Possible results of the cervical screen
Grades of CIN
CIN is a precancerous lesion. They are graded histologically as:
- CIN 1 – 1/3 thickness affected (can revert to normal in 10-23 months)
- CIN 2 – 2/3 thickness
- CIN 3 – Full thickness (carcinoma in situ)
Management of Cervical Intraepithelial Neoplasia (CIN)
- Cold coagulation in CIN 1
- Follow up according to NHS cervical screening
guidelines
•LLETZ (Large Loop Excision of Transformation zone → performed mostly under local anaesthesia
to confirm diagnosis and treat)
HPV vaccine
Gardasil → protects against HPV 6, 11, 16 & 18
- all 12- and 13-year-olds (girls AND boys) in school Year 8 will be offered the human papillomavirus (HPV) vaccine
- given as 2 doses - girls have the second dose between 6-24 months after the first, depending on local policy
- HPV vaccination should also be offered to men who have sex with men under the age of 45 to protect against anal, throat and penile cancers
Common subtypes of HPV that are linked to a disease
- 6 & 11: causes genital warts
- 16 & 18: linked to a variety of cancers, most notably cervical cancer
Risk factors predisposing to cervical cancer
- HPV serotypes 16,18 & 33
- smoking
- HIV
- early first intercourse, many sexual partners
- high parity
- lower socioeconomic status
- combined oral contraceptive pill
Symptoms of cervical cancer
- Intermenstrual bleeding/post- coital bleeding
- Vaginal discharge
- Pelvic pain (advanced disease)
- Abnormal looking cervix
- Pelvic vein thrombosis causing a swollen leg
Types of cervical cancer
- Squamous cell carcinoma (85%)
- Adenocarcinoma
- Rare forms: malignant melanoma, sarcoma
Investigations in cervical cancer
- Colposcopy – cervical biopsy
- Cystoscopy and sigmoidoscopy
- Bloods: FBC, U&E, LFTs
- MRI pelvis, CT abdomen and Chest
- Clinical staging :FIGO
- Cone biopsy
Management of cervical cancer
- Wertheim’s Hysterectomy/ aka radical hysterectomy
- Radiotherapy
Risk factors for endometrial cancer
- obesity
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen (addition of a progestogen to oestrogen reduces this risk)
- diabetes mellitus
- tamoxifen
- polycystic ovarian syndrome
- hereditary non-polyposis colorectal carcinoma
Symptoms of endometrial cancer
- postmenopausal bleeding is the classic symptom
- premenopausal women may have a change intermenstrual bleeding
- pain and discharge are unusual features
Ix in endometrial cancer
- Ultrasound (endometrial thickness)
- Hysteroscopy / Dilatation & Curettage
- MRI of abdomen and pelvis
- Chest X ray
- Bloods-FBC,U&E and LFT
Who should we investigate for endometrial cancer?
- women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
- first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
- hysteroscopy with endometrial biopsy
Management of endometrial cancer
- localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
- Patients with high-risk disease may have post-operative radiotherapy
- progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
Risk factors for ovarian cancer
- family history: mutations of the BRCA1 or the BRCA2 gene or HPNCC
- many ovulations: early menarche, late menopause, nulliparity
Symptoms of ovarian cancer
Clinical features are notoriously vague
- abdominal distension and bloating
- abdominal and pelvic pain
- urinary symptoms e.g. Urgency
- early satiety
- diarrhoea
Investigation of ovarian cancer
-
CA125
- CA125 test is done initially → endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
- if the CA125 is raised (35 IU/mL or greater) → urgent ultrasound scan of the abdomen and pelvis should be ordered
*a CA125 should not be used for screening for ovarian cancer in asymptomatic women
- ultrasound
- Diagnosis is difficult and usually involves diagnostic laparotomy
Types of ovarian cancers
- Epithelial → serous, mucinous, endometrioid
- Sex cord stromal →granulosa cell
- Malignant germ cell tumours → dysgerminoma, immature teratoma
- Metastatic tumours
Management of ovarian cancer
- MDT discussion for plan of management including calculation of risk of malignancy index (risk of malignancy of a cyst)
- Surgery (Hysterectomy and bilateral salpingo-ophorectomy , omentectomy) and surgical FIGO staging
- Chemotherapy ( i.e. Carboplatin)
- Monitor response clinically with regular follow up; tumour marker (CA125, CEA, CA19-9 )
- Palliative: drainage of ascites
Vulval intraepithelial neoplasia
- what’s that
- presentation
- Ix
- management
- Premalignant lesion of the vulva
- Presents as visible lesion, pain or pruritus
- Investigations : vulvoscopy and biopsy
- Treatment is local excision
- Long term follow up
Presentation of vulval carcinoma
Vulval:
- itching
- irritation
- pain
- bleeding
Development of vulval carcinoma
- Can develop from lichen schlerosus, VIN ,lichen planus and Paget`s disease
- Lesions can be exophytic mass or ulcerative
- Spreads locally and can embolise to the inguinal lymph nodes
Treatment of vulval cell carcinoma
- Wide local excision (early disease)
- Radiotherapy to protect sphincter function
- Radical vulvectomy with inguinal node dissection
Types of vaginal carcinoma
- Usually secondary from malignancies elsewhere (endometrium, cervix, vulva, colon, rectum)
- Usually squamous cell carcinomas
- Adenocarcinoma (9%)
Treatment of vaginal carcinoma
Most treated with chemo and radiotherapy
What’s uterine sarcoma?
Aggressive tumours arising from the myometrium of the uterus
Types of uterine sarcomas
- Leiomyosarcoma
- Endometrial stromal sarcoma
- Mixed mullerian tumours
Investigations and management of uterine sarcomas
- Staging is surgico-pathological
- Ultrasound scan shows vascular mass in the myometrium
- MRI and CT Chest
- Surgery is the mainstay of treatment
Origin of fallopian tube cancer
- 90% papillary serous adenocarcinoma
- Arise from the endosalpinx
- Transition from benign to malignant of tubal mucosa
- Ovaries and endometrium are normal or contain smaller tumours
Presentation of fallopian tube cancer
- vaginal bleeding
- pain
- discharge
Investigations of fallopian tube cancers
- Tubal cystic mass on ultrasound
- Diagnosed at laparotomy-FIGO staging
Management of fallopian tube cancers
- Surgical TAH and BSO along with omentectomy and removal of lymph nodes
- Chemotherapy
Risk of malignancy index
What’s HPV triage?
- Smear
- Tested for HPV
a. If negative → not anything else, routine smear in 3 years
b. If positive → test for dyskariosis: - if borderline/mild → smear in 1 year; if severe → colposcopy
* After 1 year → if negative routine recall if still positive →see for dyscariosis and so on
If 3 positive HPV smears → colposcopy anyway (regardless of grade of dyscariosis)
Total abdominal hysterectomy vs radical
- radical take out also the top part of vagina + part of abdominal wall
Figo staging for gyn cancers
What’s a omental cake?
Omentum is full of cancer (usually from ovarian ca)
What value on the Risk of Malignancy Index do we worry about?
250 and over → high risk of ovarian ca
Possible causes of post-coital bleed
- infection
- ectropion
- cancer
- trauma
Triple swap
- endocervical for chlamydia and gonorrhoea
- high vaginal swab → general infection e.g. trush
Management of endometrial hyperplasia
- simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
- atypia: hysterectomy is usually advised
