Pelvic Masses Flashcards
What are the two main strains of HPV associated with cervical cancer?
HPV 16 and 18
What increases risk of CIN?
more sexual partners and sex from a young age
prolonged use of COCP
smoking
CIN is a precursor to?
squamous cell carcinoma of the cervix
What percentage of cervical cancers are SCC?
90%
What is the aim of cervical screening?
to catch CIN before it becomes cancer
In scotland who is cervical screening done in?
those with a cervix should be screened every 5 years from age 25-65 years
Who may voluntarily withdraw of cervical screening?
never had any intimate contact men or women, if wont benefit e.g. terminally ill, unable to give adequate sample e.g. FGM, women with physical or learning disability that may make giving a sample distressing
Describe what is done with a smear test?
first it is tested for HPV, if negative nothing further is done, if positive look at the cytology
If a smear is negative what happens?
recall in 5 years
If a smear is positive HPV but negative cytology what happens?
recall in 12 months, only colposcopy if 3 consecutive samples are HPV positive
If smear is positive, and cytology is positive for low grade what is done?
seen for colposcopy within 8 weeks
If smear is positive for HPV, and cytology is positive and high grade what is done?
seen for colposcopy within 4 weeks
What happens if
If smear is positive for HPV, and glandular abnormality is seen or there is suspicion of invasion?
seen within 2 weeks
Describe colposcopy?
this allows the cervix to be examined in more detail through the use of a speculum and microscope
the squamocolumnar junction must be visualised
abnormal epithelium contains more protein and less glycogen than normal epithelium meaning when acetic acid is applied they appear white in colour and easily identifiable
can then take punch biopsy for histopathology
Describe treatment for CIN?
CIN 1: conservative management for 2 years
CIN 2 and 3: treatment in the form of excision or ablation
Describe presentation of cervical cancer?
may be asymptomatic in early stages post coital bleeding inter-menstrual bleeding menorrhagia pelvic pain offensive vaginal discharve in advanced disease: backache, leg pain, haematuria, weight loss, anaemia, changes in bowel habit
Describe stages of cervical cancer?
1: just in cervix (although A2 and B risk of lymph nodes involvement)
2: spread to adjacent organs e.g. vagina or uterus
3: involvement of pelvic wall
4: distant metastases or involvement of the bladder or rectum
Treatment of cervical cancer recurrences?
most recurrences are only suitable for palliative care
Describe the HPV vaccine?
this is for age 12-13 now given to boys as well as girls, in two doses six months apart
currently using quadrivalent vaccine covering 16,18,6 and 11
offers about 70% protection
nanovalent vaccine exists but not used in Uk yet
Most uterine malignancies arise from _____
the endometrium- most commonly adenocarcinoma
What is considered to increase risk of endometrial malignancy? What does this then mean?
high levels of oestrogen are considered to increase risk
factors that may increase oestrogen include: PCOS, late menopause, nulliparity, obesity, unopposed oestrogen, HRT, tamoxifen, oestrogen secreting tumours
interestingly evidence of endometrial cancer is lower in women who have used the COCP
Presentation of endometrial carcinoma?
AUB is principle symptom
post menopausal bleeding!
less commonly vaginal discharge
pain is rare in early disease
Post menopausal bleeding is ____
malignancy until proven otherwise
Investigations for endometrial carcinoma?
TV US is usually first line and in post menopausal women can measure endometrial thickness, smooth regular endometrium < 4 mm makes malignancy unlikely
endometrial biopsy
D and C
hysteroscopy allows visualisation of the uterine cavity, enabling biopsy/ curettage to be done
Treatment of endometrial carcinoma?
main stay of treatment is surgical: hysterectomy and bilateral oophorectomy laparoscopically, lymphadenectomy may be advised in some cases
if there is spread beyond the uterus treatment is tailored to the individual
radiotherapy be used as an adjuvant to prevent recurrence
radiotherapy or high dose progesterones can also be used in those unsuitable for surgery
in widespread disease chemo may be considered
Prognosis of endometrial carcinoma?
most have a good prognosis with no recurrence
Risk factors for fibroids?
age, obesity, afro carribbean ethnicity, nulliparity
Symptoms of fibroids?
heavy and/ or painful periods, abdo pain, lower back pain, urinary frequency, constipation, dyspareunia
Treatment of fibroids?
symptom relief: mirena coil, tranexamic acid, NSAIDs, COCP, progesterone pill days 5-26
to shrink fibroids: GnRH analogues or ullipristal acetate
surgery to remove uterus or fibroids if very bad (myomectomy, hysterectomy and uterine artery embolisation)
What is the peak age of ovarian cancer?
75- mainly occurs in the elderly
Risk factors for ovarian cancer?
number of times ovulated is biggest risk factor therefore…
COCP decreases risk
Breast feeding decreases risk
nulliparity increases risk
5-10% of cases have a genetic predisposition so FH increases risk
HNPCC and BRCA1 and 2 are implicated
endometriosis may increase risk
Presentation of ovarian cancer?
may be asymptomatic and often presents late as symptoms are non-specific
bloating, early satiety, abdo pain or swelling, constipation and menstrual changes
most patients complain of abdo distension which may be due to ascites or mass
In any women with new onset IBS over 50 ______
must think of ovarian cancer
What is the RMI?
Risk of malignancy index for ovarian cancer
= USS score x menopausal score x Ca125
Suspicious USS findings for ovarian cancer include?
complex mass with solid and cystic area, multi loculated, thick septations, associated ascites, bilateral disease
Describe some markers for ovarian cancer?
Ca125 is raised in 80% ovarian cancers but also raised in many other conditions so it’s better for monitoring progression as opposed to making a diagnosis
Carcino-embryonic antigen (CEA) may be raised in ovarian cancer esp in mucinous tumours
65% of germ cell tumours produce raised hCG and AFP
Management of ovarian tumours?
treatment for benign tumours is excision and drainage
epithelial tumours get combo of chemo and surgery
may do conservative management if want to preserve fertility and only remove one ovary, if unfit for surgery may just do chemo
non epithelial tumours are often sensitive to chemo, often more important to preserve fertility as patients are younger
Prognosis of ovarian cancers?
5 year survival is 40%
germ cell tumours have higher survival at 75%
What is endometriosis?
condition where there are deposits of endometrium outside the uterine cavity
this tissue undergoes cyclical changes and will breakdown and bleed at the time of menstruation
Presentation of endometriosis?
pelvic pain severe period pain affecting QOL dyspareunia pain on urination or defaecation during period heavy periods nausea, constipation and diarrhoea infertility
Investigations for endometriosis?
abdo US, TV US
dont need MRI unless deep endometriosis
may do diagnostic laparoscopy
Management of endometriosis?
analgesics- NSAIDs, paracetamol, neuromodulators
Hormonal- COP, progesterone, GnRH analogues (not good long term), IUS Mirena
Surgery
Explain the different types of fibroid?
- Most common are intramural fibroids which lie within the myometrium
- Subserosal fibroids are located on the serosal outer surface and extend outwards, they deform the normal contour of the uterus
- Submucosal fibroids develop near the inner surface of the endometrium and extend into the endometrial cavity either causing a distortion of the cavity or filling the cavity if they are pedunculated
