Oncogynae Flashcards
What is vaginal cancer?
Very rare
Upper 1/3rd of post vaginal wall most common site
HPV related, metastatic from uterus/ vulva.
Sx of vaginal cancer?
Vaginal bleeding
Leukoplakia
Vaginal ulceration with contact bleeding
Malodorous discharge
Urinary freq
Types of vaginal ca?
SCC: most, usually 2° to cervical SCC
Adenocarcinoma: rare, vaginal clear cell, 2° to vaginal adenosis (glandular columnar epithelium within upper 2/3rd of vaginal wall. Younger women DES exposure IU.
Pelvic exam, colposcopy, biopsy
Sarcoma botyoides: embryonal rhabdomyosarcoma, paed carcinoma <4, highly malignant. Mutilytic grape like form, chemoradiotherapy. Pleomorphic spindle shaped cells. Desmin pos.
What is Paget disease of the vulva?
Adenocarcinoma in situ
Eczematoid lesions (raised well demarcated, erythematous patches with white scaring, crusting + ulcerations) Local pruritis
Low risk <15% of invasive paget disease/ invasive adenocarcinoma
What is vulval ca?
Most SCC, some BBC, melanomas, paget disease of vulva.
Most >65
RF: HPV, vulval, IS, intraepithelial neoplasia, lichen sclerosis, smoking.
Precursor: vulval intraepithelial neoplasia, HPV associated disease
Sx of vulval ca?
Lump/ulcer: visible on labial majora
Inguinal lymphadenopathy
Irritation, itching, burning sensation
Bleeding
Red, black, white patches of discoloration
Dysuria, dyspareunia
Investigations for vulval ca?
Biopsy: staged based on depth of lesion + involvement of neighbouring surgical structures
Pelvic exam + colposcopy
What is cervical ca?
Around 50% of cases of cervical cancer occur in women under the age of 45 years
incidence rates for cervical cancer in the UK are highest in people aged 25-29 years, according to Cancer Research UK.
It may be divided into:
squamous cell cancer (80%)
adenocarcinoma (20%)
Features of cervical ca?
may be detected during routine cervical cancer screening
abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
vaginal discharge
RF’s for cervical ca?
smoking, HIV, early 1st intercourse, many sexual partners, high parity, ↓socioeconomic, COCP.
HPV 16, 18, 13: common infection in sexually active people, most clear, dysplastic changes, can turn cancerous.
Produce oncogenes E6 inhibits p53 tumour suppressor
E7 inhibits RB suppressor gene. Infected cells > development of koilocytes (large nucleus, irrgeg nuclear membrane, nucleus stains darker than normal, perinuclear halo).
Sx of cervical ca?
Abnormal vaginal bleeding: postcoital, intermenstrual or PMB irregular/ heavy vaginal bleeding.
Dyspareunia
Lower back pain/ pelvic pain
Vaginal discharge: watery, mucoid, purulent
Haematuria, haematochezia.
Complications of cervical cancer Tx?
Surgery/ biopsy: ↑ risk of preterm birth in future
Radiotherapy: ovarian failure, fibrosis of bowel/skin/bladder/ vagina.
Screening for cervical ca?
25-49: 3 yrly
50-64: 5 yrly
HPV 1st: test for high-risk strains of HPV. Cytological exam only performed if pos.
Sample inadequate: repeat in 3mnths, if 2 consecutive samples > colposcopy
Treatment of cervical ca?
1A: local excision, simple hysterectomy + pelvic lymphadenectomy if larger. For pts wanting fertility, cone biopsy with neg margins.
All other stges: chemo + radiotherapy (brachytherapy or external beam). Cisplatin.
Recurrent: chemoradiation or surgery
What is endometrial ca?
classically seen in post-menopausal women but around 25% of cases occur before the menopause
usually carries a good prognosis due to early detection
Commonest gynae Ca in UK, adenocarcinoma
RF’s for endometrial ca?
obesity
nulliparity
early menarche
late menopause
unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
diabetes mellitus
tamoxifen
polycystic ovarian syndrome
hereditary non-polyposis colorectal
carcinoma
Features of endometrial ca?
postmenopausal bleeding is the classic symptom - why most women present with stage 1
premenopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features
Dyspareunia
Pelvic cramping
Uterine mass, fixed uterus or adnexal mass indicating extra-uterine disease.
WL
Investigation for endometrial ca?
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
CT scan - mets
Pap smear: may identify atypical glandular cells on cervical cytology, prompt endometrial sampling.
FBC: anaemia
Protective factors for endometrial ca?
combined oral contraceptive pill
smoking
Management of endometrial ca?
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
high-risk disease may have post-op radiotherapy, brachytherapy, chemotherapy
progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
Types of endometrial ca?
Endometroid: ↑oest, endometrial hyperplasia, intraepithelial neoplasia > adenocarcinoma. PIK3CA, CTNNB1, PTEN, ARID1A, KRAS.
Nonendometriod: oest independent, arising from endometrial atrophy/ polyp. Tp53 mutation.
Clear cell: hopnail cells, very aggressive.
serous: p53, after radiotherapy for cervical Ca.
What is endometrial hyperplasia?
defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
Types: simple complex simple atypical complex atypical
Features:
abnormal vaginal bleeding e.g. intermenstrual
Management:
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
What is ovarian ca?
fifth most common malignancy in females.
peak age of incidence is 60 years
generally carries a poor prognosis due to late diagnosis.
around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas (unilocular, bilat, psammoma bodies)
Subtypes of epithelial:
> mucinous - multiloculated, unilat, lining ot tall columnar epithelial cells, Pseudomyxoma peritonei. Huge cystic masses.
Brenner/transitional - unilat, solid grey or yellow appearance resemble bladder epithelium, associated with endometriosis.
Clear cell: large epithelial cells, clear cytoplasm. Endometroid carcinoma of ovaries
interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers
RF’s for ovarian ca?
family history: mutations of the BRCA1 or the BRCA2 gene, Lynch syndrome
many ovulations*: early menarche, late menopause, nulliparity
PCOS
Smoking
Obesity
Endometriosis
Protective factors for ovarian ca?
COCP
multiple pregnancies
Breastfeeding
Investigations for ovarian ca?
2ww if physical examination reveals ascites, pelvic mass (unless clearly due to fibroids), abdominal mass
CA125
- NICE recommends a CA125 test is done initially if Sx of possible ovarian ca (change in bowels, bloating, early satiety, pelvic pain,WL, urinary freq/urg).
- Endometriosis, menstruation, benign ovarian cysts, pregnancy and other conditions may also raise the CA125 level (disease irritating peritoneum)
- if the CA125 is raised (35 IU/mL or greater) then an 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
biopsy + fine needle aspiration not routinely recommended as can disseminate tumour cells into peritoneal cavity.
histology - using CT guided biopsy, laparoscopy, laparotomy
paracentesis
women under 40 with complex ovarian mass require AFP and hCG for possible germ cell tumour
Management of ovarian ca?
gynaecology oncology MDT
usually a combination of surgery and platinum-based chemotherapy
Surgery: removal of ovaries, uterus + omentum, lymphadenectomy, total hysterectomy, appendectomy
Fertility sparing: preserve uterus, contralat ovary + fallopian tube. Cone biopsy with neg margins.
Bevacizumab: monoclonal antibody targets VEGF
Prognosis of ovarian ca?
80% of women have advanced disease at presentation
the all stage 5-year survival is 46%
Features of ovarian ca?
Vague
Large pelvic mass: bloating, distension, early satiety, persistent pelvic pain, nausea, change in bowel habit (diarrhoea), ↑urinary freq, dyspepsia.
Abdo, pelvic, lower back pain.
Ascites: disseminated disease, scattering grains of rice that seep fluid.
Pleural effusion
Dysmenorrhoea
Sister Mary Joseph node (umbilical met)
Dyspareunia
Breast tenderness.
Referred pain to groin: obstruction of obturator nerve.
What are different types of ovarian ca?
Epithelial - serous, endometroid, clear cell, mucinous, undifferentiated
Dermoid cyst/germ cell tumours - teratomas (arise from neuroectoderm usually malig.), yolk sac (endodermal sinus tumour. Most common germ cell tumour in children. V aggressive. Schiller Duval bodies), associated with ovarian torsion, caused raises AFP, LDH and hCG
Sex-cord stromal tumours - rare, benign or malignant, arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles), types include Sertoli-Leydig and granulosa cell tumours
Metastatic - Krukenberg from GI, likely spreads by lymphatics, involves both ovaries, mucin-secreting signet ring cells.
What is the Risk of Malignancy Index (RMI) for Ovarian Cancer?
predicts risk that an adnexal mass is malignant.
takes into account:
Menopausal status X Ultrasound findings X CA125 level
USS (multilocular cyst, solid areas, mets, ascites, bilat lesions) 1 feature 1 point, 2+ features 3 points. Premenopausal 1, postmenopausal 3.
> 250 refer.
International Federation of Gynaecology and Obstetrics (FIGO) staging system for ovarian ca?
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
