Oncogynaecology Flashcards
Presentation / diagnosis of benign ovarian cysts?
Pelvic/abdominal mass (DDx: uterine/Fallopian/urinary tract/bowel tumour, pregnancy), or symptoms (e.g. pain, pressure on bowel/bladder), or incidentally on USS.
• Acute pain: torsion of ovarian cyst or rupture/haemorrhage into cyst.
Examination may elicit pelvic/abdominal mass separate from uterus.
Investigations:
- TVUSS or abdominal USS
- CT or MRI
- Tumour markers
- Pregnancy test to exclude pregnancy
- Inflammatory markers (e.g. CRP, WCC) important if DDx includes appendicitis or tubo-ovarian abscess.
How do ovarian cysts vary with age? (when is each most likely)
- Functional cysts: young girls, adolescents + reproductive years
- Germ cell tumours: more common in young women (peak incidence early 20s)
- Benign epithelial tumours: more commonly in older women
How are ovarian cysts classified?
Functional: Follicular cysts, corpus luteal cysts, theca luteal cysts
Inflammatory: tubo-ovarian abscess, endometrioma
Germ cell: benign teratoma
Epithelial: serous cystadenoma, mucinous cystadenoma, Brenner tumour
Sex cord stromal: fibroma, thecoma
Other cysts occasionally presenting as ovarian tumours: fimbrial cysts, paratubal cysts, other uncommon embryologically derived cysts e.g. cysts of Morgani
Follicular cysts - aetiology, diagnosis and management?
Aetiology unknown but risk ↑ by oral contraceptive pill.
USS: >3cm (normal ovulatory follicles up to 2.5cm), rarely >10cm + appear as simple unilocular cysts on USS.
Management: observe with sequential USS (if asymptomatic), laparoscopic cystectomy if symptomatic.
Corpus luteal cysts - aetiology, diagnosis and management?
- Occur following ovulation + may present with pain due to rupture and/or haemorrhage: typically late in menstrual cycle.
- Management: expectant with analgesia (occasionally surgery to wash out pelvis + perform ovarian cystectomy)
Theca luteal cysts - aetiology, diagnosis and management?
Associated with pregnancy, particularly multiple pregnancy (often diagnosed incidentally at routine USS)
Most resolve spontaneously in pregnancy
Inflammatory cysts - aetiology, diagnosis and management?
Most common in young women + usually associated with PID. Occasionally, can develop from other infective causes e.g. appendicitis, diverticular disease.
Inflammatory mass or abscess may involve tube, ovary + bowel.
Dx: PID diagnosis + inflammatory markers helpful.
Treatment: Abx, surgical drainage or excision (definitive surgery usually deferred until after acute infection due to risk of systemic infection and difficulty with inflamed tissue)
Endometrioma - aetiology, diagnosis and management?
(chocolate cysts): altered blood within the ovary (endometrial tissue). May reach 10cm and have ‘ground glass’ appearance on USS.
Management: offer laparoscopic ovarian cystectomy to improve chance of spontaneous pregnancy and reduce recurrence (but take into account ovarian reserve).
Germ cell tumours - aetiology, diagnosis and management?
Most common ovarian tumours in young women (peak incidence early 20s, >50% ovarian tumours in this group).
Dermoid cyst (cystic teratoma) are most common form (80% appear during reproductive life). They are a combination of all tissue types (mesenchymal, epithelial + stromal) & ~10% of dermoid cysts can be bilateral. Any mature tissue type may be present e.g. hair, muscle, cartilage, bone, teeth.
Risk of malignant transformation is <2%.
Dx: may be incidental but ~15% present with torsion (cuts off supply to ovarian tissue, acute onset of pain & nausea). MRI useful for diagnosis due to high fat content.
Tx: Usually surgical excision, but torsion may require complete oophorectomy. If ovary is viable, cystectomy can be performed (often laparoscopically).
Epithelial tumours - aetiology, diagnosis and management?
need to add more
Benign epithelial tumours increase with age + most common in perimenopausal women.
Serous cystadenomas (most common): o 20-30% of benign tumours in women <40 o Typically unilocular & rarely involve opposite ovary.
Mucinous cystadenomas
o Large multiloculated cysts
o Bilateral in 10% of cases
Brenner tumours
o Small tumours found incidentally within the ovary
o May secrete oestrogen
Sex cord stromal tumours - aetiology, diagnosis and management?
need to add more
Ovarian fibroma (most common): o Solid tumours composed of stromal cells o Present in older women often with torsion (due to heaviness of ovary) o Occasionally present with MEIG syndrome (pleural effusion, ascites & ovarian fibroma) – pleural effusion often resolves following removal of fibroma
Thecoma
o Benign oestrogen-secreting tumours
o Often present post-menopause with manifestations of excess oestrogen e.g. PMB
o May induce an endometrial carcinoma
Endometrial cancer - aetiology / risk factors?
Most common gynae cancer in UK; 4th most common cancer in women in UK.
- 75% occur in postmenopausal women
- Incidence increases from 50 years old (<5% are <50), mean age 61
Risk factors: majority due to excessive unopposed oestrogen
- Obesity
- PCOS (continuous anovulation)
- Early menarche, late menopause
- Nulliparity
- Unopposed exogenous oestrogen HRT
- Tamoxifen (oestrogen antagonist for adjuvant Rx in breast CA but mild oestrogenic effect on endometrium)
- Genetic predisposition: Hereditary non-polyposis colorectal cancer (HNPCC) i.e. Lynch type 2 syndrome - rare (<5% of all endometrial cancers) - strong FHx of bowel, endometrial & gastric cancer, usually premenopausal, lifetime risk 40-60% with HNPCC
Protective: parity, OCP, smoking, exercise, aspirin, coffee
Pathology of endometrial cancer?
Endometrial hyperplasia: caused by excessive proliferation of the endometrium (largely from prolonged oestrogen stimulation).
- Simple or complex without atypia usually benign and can be treated with progesterone
- Hyperplasia with cellular atypia is pre-malignant, up to 50% of women with atypia shown to have endometrial carcinoma in subsequent hysterectomy specimen
Subtypes of endometrial cancer?
Majority (80%) are Type 1 (endometrial adenocarcinoma)
o Sub-grades 1 (low grade), 2, 3 (aggressive)
o Usually occurs in pre and peri-menopausal women
o May be preceded by premalignant atypical endometrial hyperplasia (EH)
o Associated with lower grade / favourable prognosis
o Associated with oestrogen exposure
o 75% endometrioid adenocarcinoma, 5% mucinous adenocarcinoma
Others are Type 2 tumours (much worse) including:
o Serous (5-10%)
o Clear cell (1-5%)
o Mucinous, mixed, squamous cell, transitional cell
o Non-endometrioid histology
Uterine sarcoma (<5%): tumours arising from myometrium & connective tissues of the uterus
- Rare diagnosis with an aggressive course and poor prognosis
- 2% leiomyosarcoma
Presentation of endometrial cancer?
- PMB: vaginal bleeding 18 months after last period: only 10% with PMB have endometrial cancer
- Watery vaginal discharge
- Heavy erratic bleeding in a pre-menopausal woman
- Glandular (endometrial) abnormalities on cervical smear
- Atrophic vaginitis: low oestrogen > inflamed skin of vagina
Ix for endometrial cancer?
2 week rapid referral from GP for suspected malignancies
- TVUSS (endometrial thickness <4mm normal)
- Endometrial biopsy: pipelle taken as an outpatient, endometrial curettage (full thickness biopsy) in theatre
- Hysteroscopy: awake in clinic or asleep as day-case operation
Staging for endometrial cancer?
Surgical staging main means of assessing whether adjuvant radiotherapy required
- Histology assesses grade & stage of the tumour
- Imaging can be done pre-operatively: MRI looks for myometrial invasion, cervical involvement, lymph node status, metastatic. CXR for metastatic disease.
- Pre-op evaluation helps to determine if lymph node removal is required and whether there will be a role for chemotherapy
- Stage 1: confined to uterus
- Stage 2: involves cervix
- Stage 3: spread to adnexal structures or lymph nodes
- Stage 4: spread to bowel, bladder distant metastases
Tx endometrial cancer?
Surgical (total hysterectomy + BSO +/- lymphadenectomy)- open, laparoscopic or robotic
Radiotherapy: adjuvant f high recurrence risk, primary if unfit for surgery
Chemotherapy for metastatic disease
Recurrence treated with radiotherapy, surgery or progestogens
Prognosis of endometrial cancer?
Most present stage 1 + therefore have good survival (75% overall survival at 5 years)
Survival related to stage at presentation and grade of tumour- generally ‘curable’ as obvious symptoms lead to early presentation
Aetiology of ovarian cancer? (how common)
Lifetime risk 1 in 70
70% present with advanced diagnosis
UK (2008): 5th most common cancer in women.
now thought to arise in fallopian tubes (incessant ovulation and cytokine release?) > primary peritoneal carcinoma
Risk factors for ovarian cancer?
Theory of incessant ovulation: therefore increasing age, early menarche, late menopause, delayed child bearing / nulliparity, HRT >5 years, fertility drugs (e.g. clomiphene).
Other risk factors: BRCA (BRCA1 > BRAC2 for ovarian), IUDs (but oral contraceptive reduces risk), endometriosis, cigarette smoking (mucinous tumours only), obesity, diabetes + sedentary life (especially in young), infertility, previous cancer treatment, being tall (unsure why), asbestos exposure
Protective factors for ovarian cancer?
COCP, breast feeding, hysterectomy, salpingectomy, bilateral salpingo-oopherectomy, tubal sterilisation
Genetics of ovarian cancer?
~20% ovarian carcinomas are hereditary
Lifetime risk by age 70: 63% BRCA1, 27% BRCA2, 10-12% HNPCC, background 1.4% (1 in 70)
Prophylactic surgery: salpino-oophorectomy +/- hysterectomy. Lifetime reduction of peritoneal cancer (1% persists).
Types of ovarian TUMOUR?
- Epithelial (60-70%):
- 90% are malignant: serous (serious!),
- mucinous, clear cell, endometrioid, undifferentiated. - Germ cell (20-30%):
- 3% malignant
- age <20, 70% malignant - Ovarian sex cord stromal tumour cells (8% of ovarian tumours)
- Metastatic secondary tumours: breast, stomach, large bowel, uterus
Note: tumours not always cancer (serous / mucinous cystadenoma, dermoid (teratoma), fibroma / fibrothecoma, endometrioma, Brenner tumour)
