9 - Gynaecological Cancer Flashcards
What is the most common gynaeological cancer?
Endometrial!! (then ovarian)
Strongly linked to obesity
What histological type of cancer occurs in the vulva and what are some risk factors for this?
Squamous Cell Carcinoma (rarely malignant melanoma)
- Advanced age (particularly over 75 years)
- Immunosuppression
- Human papillomavirus (HPV) infection
- Lichen sclerosus
What is VIN and the different types of this?
Vulval intraepithelial neoplasia is a premalignant condition that can precede vulval cancer
- High grade squamous intraepithelial lesion: associated with HPV, occurs in younger women aged 35 – 50 years.
- Differentiated VIN: associated with lichen sclerosus and typically occurs in older women aged 50 – 60 years
How is VIN diagnosed and treated?
Dx: Biopsy
Mx:
- Watch and wait with close followup
- Wide local excision
- Imiquimod cream
- Laser ablation
How may vulval cancer present?
Often found incidentally when catheterising dementia patients
- Vulval lump
- Ulceration
- Bleeding
- Pain
- Itching
- Lymphadenopathy in the groin
What part of the vulva does cancer tend to affect?
Labia Majora
- Irregular mass
- Fungating lesion
- Ulceration
- Bleeding
How do you deal with suspected vulval cancer?
Urgent 2 week referal
- Biopsy lesion
- Sentinel node biopsy
- Imaging for staging e.g CT
How is vulval cancer staged and managed?
International Federation of Gynaecology and Obstetrics (FIGO)
- Radical wide local excision
- Groin lymph node dissection
- If advanced radiotherapy +/- chemotherapy
What is the histology of endometrial cancer and what makes you think of endometrial cancer?
Adenocarcinoma
Any women with PMB is endometrial cancer until proven otherwise
Obesity and Diabetes are risk factors as oestrogen dependent tumour
What is endometrial hyperplasia and how is it managed?
Precancerous condition of the endometrium where it thickens. Can progress or return to normal
Two types: Hyperplasia without atypia OR atypical hyperplasia
_Mx:_ Progestogens e.g Mirena IUS Coil or Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
What are the risk factors for endometrial cancer?
Exposure to unopposed oestrogen (lack of progesterone) stimulates endometrial cells, increases the risk of endometrial hyperplasia and cancer
- Increased age
- Earlier onset of menstruation
- Late menopause
- Oestrogen only HRT
- No or fewer pregnancies
- Obesity
- PCOS
- Tamoxifen
- T2DM
What genetic syndrome increases risk of endometrial cancer?
Lynch Syndrome
Most type I endometriosis carcinomas are due to this
Also risk of colorectal cancer
Why do the following increase the risk of endometrial cancer?
- PCOS
- Obesity
- Tamoxifen
- T2DM
PCOS: unopposed oestrogen as less likely to ovulate so won’t produce a corpus luteum that usually produces the progesterone. Also the insulin resistance
Obesity: adipose tissue contains aromatase that converts androgens into oestrogen so more adipose tissue more oestrogen
Tamoxifen: SERM that is anti-oestrogen on breast tissue but oestrogenic on endometrial tissue
T2DM: More insulin is produced and insulin promotes endometrial hyperplasia
What medication is a must for people with PCOS?
They need progestogen to oppose oestrogen
- IUS Mirena Coil OR
- COCP OR
- Cyclical progestogens
What are some protective factors against endometrial cancer?
- Combined contraceptive pill
- Mirena coil
- Increased pregnancies
- Cigarette smoking
Why is smoking protective against endometrial cancer?
- Oestrogen may be metabolised differently in smokers
- Smokers tend to be leaner, meaning they have less adipose tissue and aromatase enzyme
- Smoking destroys oocytes (eggs), resulting in an earlier menopause
What are some symptoms and signs of endometrial cancer?
Symptoms
- POST MENOPAUSAL BLEEDING
- Abnormal uterine bleeding: intermenstrual, frequent, heavy or prolonged
- Constitutional symptoms: weight loss, anorexia, lethargy, anaemia
Signs
- Physical examination: typically normal (fixed, hard uterus suggests advanced disease)
- Cervical evaluation: may see abnormal tissue on speculum examination
What are the referral criteria for endometrial cancer?
2-week-wait urgent:
- Postmenopausal bleeding (more than 12 months after the last menstrual period)
Refer for ultrasound in women over 55 years with:
- Unexplained vaginal discharge
- Visible haematuria plus raised platelets, anaemia, elevated glucose levels or haematuria
What investigations need to be done if endometrial cancer is suspected?
- Abdominal, pelvic and speculum examination
- Transvaginal ultrasound: look at endometrial thickness, normal is <4mm post menopause
- Pipelle Biopsy: highly sensitive
- Hysteroscopy with endometrial biopsy
What happens in a Pipelle biopsy and which women can have this over a hysteroscopy biopsy?
Speculum examination and insert a thin tube through the cervix into the uterus. This small tube fills with a sample of endometrial tissue
Quicker and less invasive in lower-risk women
If high risk or unable to tolerate pipelle biopsy (e.g cervical stenosis/discomfort) then send for hysteroscopy but will need anaesthesia
What other investigations can be done to stage endometrial cancer?
- MRI pelvis
- CT to look for metasases
- Blood tests
Must be done in all high risk women
How is endometrial cancer staged?
International Federation of Gynaecology and Obstetrics (FIGO)
- Stage 1: Confined to the uterus
- Stage 2: Invades the cervix
- Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
- Stage 4: Invades bladder, rectum or beyond the pelvis
What is the treatment for endometrial cancer?
- If stage 1 or 2 then total abdominal hysterectomy with bilateral salpingo-oophorectomy, (TAH and BSO)
- A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
- Chemoradiotherapy to shrink tumour before surgery
- Progesterone may be used as a hormonal treatment to slow the progression of the cancer. Can be fertility sparing but risky
What is the prognosis with endometrial cancer?
5 year survival of 75%
Post menopausal bleeding should make you think of endometrial cancer. What are some other differentials for PMB?
How should endometrial hyperplasia be managed?
Hyperplasia without atypia: Mirena IUS and surveillance biopsies
Atypical hyperplasia: high rate of progression to cancer so TAB and BSO
Where do most cervical cancers occur and which age do they tend to affect?
Transformation zone
Peak from 25-29 then again in 80s
What is the pathophysiology of cervical cancer?
70% are squamous cell, 15% are adenocarcinomas, 15% mixed
Progression from Cervical Intraepithelial Neoplasia (CIN) over the course of around 10-20 years
99.7% of this cancer contains HPV!!!!!!
What are the common sites of metastases for cervical cancer?
- Bowel
- Bone
- Liver
- Lung
What HPV strains are in the vaccine?
6, 11, 16, 18
What are some risk factors for cervical cancer?
HPV!
- Smoking
- Long term COCP use (>8 years)
- Immunosuppression (e.g HIV)
- FHx
- High parity (number of births at full term > 5)
What are the clinical features of cervical cancer?
- Usually asymptomatic and found on screening
- Intermenstrual bleeding
- Post-coital bleeding
- Blood stained foul smelling discharge
- Haematuria if advanced
What clinical examinations should you do for suspected cervical cancer?
Speculum: look for bleeding, discharge, ulceration
Bimanual: assess for pelvic mass
Abdo: assess for hydronephrosis, hepatomegaly, rectal bleeding, mass on PR
What investigations should you do if you suspect a patient has cervical cancer?
Never do smear unless screening!!!!!
Smear only detects pre-malignant CIN
Might always want CT CAP for metastases
Pre menopausal:
- Test for chlamydia: if positive treat and if symptoms persist refer for colposcopy and biopsy. If negative send for colposcopy and biopst
Post-Menopausal
- URGENT colposcopy and biopsy
What is a colposcopy?
Colposcope produced magnified view of cervix.
Acetic acid stain: abnormal cells appear white (acetowhite). Suggest CIN or cancer
Schiller’s iodine test: iodine solution will stain healthy cells a brown colour. Abnormal areas will not stain.
Punch biopsy or large loop excision of the transformational zone can be performed based on results of above during colposcopy
What is the staging system for cervical cancer?
FIGO
- Stage 0 - Carcinoma in situ
- Stage 1 - Confined to cervix
- Stage 2 - Beyond cervix, involves vagina but not lower ⅓. No pelvic side wall
- Stage 3 - Extends to pelvic side wall/involves lower ⅓ of vagina/hydronephrosis
- Stage 4 - Extends to bladder or rectum or metastases
How is cervical cancer managed?
- CIN and early-stage 1A: LLETZ or cone biopsy
- Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
- Stage 2B – 4A: Chemotherapy and radiotherapy
- Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care. Pelvic exenteration and Bevacizumab (Avastin)
What is Large Loop Excision of the Transformation Zone (LLETZ) and what are some complications of this?
Loop biopsy done under local anaesthetic during a colposcopy.
Diathermy removes abnormal epithelial tissue on the cervix. The electrical current cauterises the tissue and stops bleeding
Bleeding and abnormal discharge can occur for several weeks following.
Intercourse and tampon use should be avoided after the procedure to reduce the risk of infection.
May increase the risk of preterm labour.
What is a cone biopsy and some complications of this?
Treatment for CIN and very early-stage cervical cancer.
Need general anaesthetic. Surgeon removes cone-shaped piece of the cervix using a scalpel. Sample is sent for histology to assess for malignancy.
Complications
- Pain
- Bleeding
- Infection
- Scar formation with stenosis of the cervix
- Increased risk of miscarriage and premature labour
Who is offered a smear for cervical cancer screening?
Women and Transgender men aged 24.5-64
25-50 every 3 years
50-64 every 5 years
What is CIN and the different types of this?
Grading system for the level of dysplasia
CIN is diagnosed at colposcopy (not with cervical screening). The grades are:
- CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
- CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
- CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ.
If hrHPV is found on a smear then cytology is performed. What are some results that can come from cytology and how should management be directed from this?
IF SUSPICIOUS COLPOSCOPY REFERRAL IN 2-6 WEEKS!!!!!!!!!!!!
- Inadequate (repeat 3/12)
- Normal
- Borderline changes
- Low-grade dyskaryosis
- High-grade dyskaryosis (moderate)
- High-grade dyskaryosis (severe)
- Possible invasive squamous cell carcinoma
- Possible glandular neoplasia
What are some reasons to delay a smear?
- Currently menstruating
- Abnormal vaginal discharge / pelvic infection
- Less than 12 weeks postnatal
- Less than 12 weeks after a termination of pregnancy or miscarriage
Which women need additional screening for cervical cancer?
- HIV
- Renal failure with dialysis
- Organ transplant
- Daughters of women exposed to diethylstilbestrol (DES) as risk of risk of clear cell adenocarcinoma affecting the vagina and cervix
How can ovarian cancer be classified?
METASTASES!!!
Epithelial
- Serous: most common, originate from fallopian tube epithelium.
- Endometrioid: Related to endometriosis. Some have concomitant endometrial cancer
- Clear cell: often associated with endometriosis. Complications include paraneoplastic hypercalcaemia and thrombosis (e.g. DVT)
- Mucinous
- Transitional cell
- Undifferentiated
Non-Epithelial
- Germ cell tumours: In patients younger than 35. Associated with torsion
- Sex cord and stromal tumours
- Carcinosarcoma
- Small cell cancer
What is a Kruckenberg tumour?
Metastasis in the ovary, usually from a GI cancers like stomach
Signet Ring histology
What are some risk factors for ovarian cancer?
- Increased age
- Genetics (BRCA1 and BRCA2)
- FHx
- Lynch Syndrome
- Smoking
- Obesity
- Endometriosis?
- Asbestos
- Nulliparity
- Early menarche
- Late menopause
- HRT
How may ovarian cancer present?
- Abdominal bloating
- Early satiety
- Loss of appetite
- Pelvic pain
- Urinary symptoms (frequency / urgency)
- Weight loss
- Abdominal or pelvic mass
- Ascites
- Hip/Groin pain (mass pushing on obturator nerve)
What is the referral criteria for a 2 week wait for ovarian cancer?
- Ascites and/or
- A pelvic or abdominal mass (which is not obviously uterine fibroids)
What investigations should you do for ovarian cancer?
USS and CA125 to calculate RMI
AFP and hCG if <40 years old to see if germ cell tumour
CT scan, Histology, Paracentesis (ascitic tap) for staging
What is the RMI cut off score for ovarian cancer?
Specialist MDT NICE advise >250, with other patients being managed at local centres.
How is ovarian cancer staged?
FIGO
How is ovarian cancer managed?
Surgery and Chemotherapy
Surgery: macroscopic resection or optimal cytoreduction
Chemotherapy: Carboplatin monotherapy or Carboplatin & Paclitaxel
What is the prognosis with ovarian cancer?
Poor as often presents at late stages as few symptoms in early stages
How can you tell the difference between mucinous and serous cystadenocarcinoma?
What are some of the different types of ovarian cancer?
