Oncology

Question 1

what is the pathophysiology of post-menopausal bleeds?

Answer 1

• vaginal atrophy
• endometrial atrophy
• endometrial hyperplasia
• malignancy: endometrial, cervical cancer, ovarian tumours, vaginal cancer
• HRT
• polyps, fibroids
• anticoagulant and bleeding disorders

Question 1

what is considered postmenopausal bleeding?

Answer 1

• more than 12m after last menstrual period in those not recieving hormone therapy
• HRT woman considered postmenopausal if more than 6m after menstruation stopped

Question 2

what is the referral pathway for post-menopausal bleeds?

Answer 2

women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer

*women on HRT with postmenopausal bleeding still need to be investigated

Question 3

how’s postmenopausal bleeds investigated?

Answer 3

• transvaginal ultrasound is the investigation of choice
  
  • the endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is <5mm
• Biopsy of the endometrium, obtained via hysteroscopy or pipelle

Question 4

how is postmenopausal bleeds managed?

Answer 4

• hormonal therapy for atrophy
• surgical for polyps and malignancies
• supportive like topical oestrogen, HRT
• dilatation and curettage is performed to remove the excess endometrial tissue

Question 5

what are some risk factors of cervical cancer?

Answer 5

• HPV
• young age of first intercourse
• multiple sex partners
• exposure as no barrier contraception
• smoking
• long term COCP
• immunosuppression
• HPV vaccine lack
• no compliance with screening

Question 6

what is the pathogenesis of cervical cancer?

Answer 6

• commonly HPV 16 & 18
• produces E6 & E7 which suppress products of p53 tumour suppressor gene in keratinocytes
• infection common in late teens and early twenties and lasts 8m
• vaccine expected to prevent most cases

Question 7

what is cervical intraepithelial neoplasia? how is it managed?

Answer 7

🤰🏽 pre-malignant condition occurring at transformational zone, asymptomatic, caused by HPV

• histological diagnosis
• tx: excisional large loop excision of transformation zone, cryocautery, diathermy, followup

Question 8

what are the 4 stages of cervical cancer?

Answer 8

• 1 - confined to cervix
• 2 - beyond cervix but not pelvic wall or lower 1/3 of vagina
• 3 - pelvic spread, reaches side wall or lower 1/3 of vagina may cause hydronephrosis
• 4 - distant mets

Question 9

what is the management of cervical malignancy?

Answer 9

• microinvasive carcinoma - conservative, if fertility an issue cone biopsy then hysterectomy
• clinical lesions - radical hysterectomy, chemoradio
• beyond stage 2 - chemoradio
• postop radio - LN involvement
• recurrent disease - radio, chemo, palliative, exenteration

Question 10

when does cervical screening start?

Answer 10

• first invitation at 25
• 3 yearly to 25-50
• 5 yearly from 50-65
• after 65 only selected few

Question 11

what does cervical screening involve?

Answer 11

• cytology
  
  • transformation zone of cervix cell collected
  • detect dyskaryosis as mild/ moderate or severe
• colposcopy
  
  • low power binocular microscopy of cervix to look for signs of CIN or Ca

Question 12

what is the cervical protective vaccine offered?

Answer 12

• covers Gardasil 6,11,16,18 and cervarix 16 & 18
• 3 injections over 6m, ideally prior to SI, 5 years protection, still need smears as some not covered

Question 13

what are some risk factors of endometrial cancers?

Answer 13

• obesity
• early menarche and late menopause
• nulliparity
• PCOS
• unopposed oestrogen
• tamoxifen
• previous breast or ovarian cancer
• BRCA 1/2
• endometrial polyps
• DM
• Parkinson’s

Question 14

what lowers the risk of endometrial cancer?

Answer 14

• continuous combined HRT
• COCP
• smoking
• physical activity
• coffee, tea

Question 15

how does endometrial cancer commonly present?

Answer 15

• pre-menopausal
  
  • prolonged, frequent vaginal bleeding and intermenstrual bleeding
• post-menopausal
  
  • post-menopausal bleeding, less commonly blood stained, watery or purulent vaginal discharge

Question 16

what is the pathophysiology of endometrial cancer?

Answer 16

• pre-malignant endometrial hyperplasia:malignancy co-exists with 25-50% of cases and 20% will develop Ca within 10 years
• type 1 - endometrial adenocarcinoma
• type 2 - papillary cerous, clear cell or caricnosarcoma

Question 17

how is endometrial cancers staged?

Answer 17

FIGO Staging - 5 year survival decreases as stages increase

• stage 1 - limited to myometrium
• stage 2 - cervical spread
• stage 3 - uterine serosa, ovaries, tubes, vagina, pelvic, para-aortic lymph nodes
• stage 4 - bladder or bowel involvement with distant mets

Question 18

how do you diagnose and investigate endometrial cancer?

Answer 18

*one stop postmenopausal bleeding clinic - history, exam, FBC, transvaginal USS, hysteroscopy, endometrial biopsy

• tissue sampling by pipelle biopsy
• hysteroscopy
• transvaginal USS
• bloods, imaging etc

Question 19

how is endometrial cancer managed?

Answer 19

*age, fitness, patient preference taken into account

• 80% surgery with total hysterectomy PLUS bilateral salpingo-oophorectomy with peritoneal washing
• progestagens or primary radiotherapy
• adjuvant radiotherapy if high recurrence risk with external bram and brachytherapy
• advanced disease, inoperable or unfit for surgery with chemo, radio, hormones (aromatase inhibitors), palliative

Question 20

what is the pathology of ovarian carcinoma?

Answer 20

• around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
• interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancer

Question 21

what are some risk factors for ovarian cancers?

Answer 21

• obesity
• nulliparity
• early menarche, late menopause
• unopposed oestrogen HRT
• family history
• BRCA 1/2
• endometriosis

Question 22

what factors lower risk of endometrial cancers?

Answer 22

• COCP
• pregnancy
• breastfeeding
• hysterectomy
• oophorectomy
• sterilisation
• ?statin

Question 23

how might ovarian cancers present?

Answer 23

non specific
- abdominal swelling
- pain
- anorexia
- N+V
- weight loss
- vaginal bleeding
- bowel sx

Question 24

how is ovarian cancers investigated?

Answer 24

• pelvic exam
• USS
• FBC, U&E, LFT
• CA125
• CXR
• CT CAP - mets
• cytology for ascitic tap
• surgical exploration
• histopathology

Question 25

how are ovarian cancers staged?

Answer 25

• stage 1 - limited to ovaries
• stage 2 - spread to pelvic organs
• stage 3 - peritoneal disease and lymph nodes
• stage 4 - distant mets, liver and lungs

Question 26

how is ovarian cancer managed?

Answer 26

• epithelial cancer
  
  • surgery + chemo
  • staging laparotomy hysterectomy and bilateral salpingoophorectomy plus debulking
  • platinum and taxane
• non-epithelial
  
  • conservative surgery and chemo as chemo sensitive in young
• recurrent
  
  • palliative

Question 27

what is Vulvar intraepithelial neoplasia (VIN)?

Answer 27

• pre-malignant condition can resolve spontaneously or can progress to vulval cancer
• can be asymptomatic
• can present with itching, burning, pain

Question 28

how is Vulvar intraepithelial neoplasia (VIN) managed?

Answer 28

conservative antihistamine, medical imiquimod, surgical excision

Question 29

what are some risk factors for valvular carcinoma?

Answer 29

• HPV
• HSV type 2
• smoking
• immunosuppression
• chronic vulvar irritation
• conditions such as lichen sclerosis

Question 30

what is the pathology of valvular cancers?

Answer 30

• rare
• elderly
• usually SCC - HpV or chronic skin disease caused

Question 31

how are valvular cancers managed?

Answer 31

• surgery (anatomical considerations)
• radiotherapy or chemo
• overall 5 year survival rate 75%