9 - Gynaecological Cancer Flashcards
(70 cards)
1
Q
What is the most common gynaeological cancer?
A
Endometrial!! (then ovarian)
Strongly linked to obesity
2
Q
What histological type of cancer occurs in the vulva and what are some risk factors for this?
A
Squamous Cell Carcinoma (rarely malignant melanoma)
- Advanced age (particularly over 75 years)
- Immunosuppression
- Human papillomavirus (HPV) infection
- Lichen sclerosus
3
Q
What is VIN and the different types of this?
A
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
4
Q
How is VIN diagnosed and treated?
A
Dx: Biopsy
Mx:
- Watch and wait with close followup
- Wide local excision
- Imiquimod cream
- Laser ablation
5
Q
How may vulval cancer present?
A
Often found incidentally when catheterising dementia patients
- Vulval lump
- Ulceration
- Bleeding
- Pain
- Itching
- Lymphadenopathy in the groin
6
Q
What part of the vulva does cancer tend to affect?
A
Labia Majora
- Irregular mass
- Fungating lesion
- Ulceration
- Bleeding
7
Q
How do you deal with suspected vulval cancer?
A
Urgent 2 week referal
- Biopsy lesion
- Sentinel node biopsy
- Imaging for staging e.g CT
8
Q
How is vulval cancer staged and managed?
A
International Federation of Gynaecology and Obstetrics (FIGO)
- Radical wide local excision
- Groin lymph node dissection
- If advanced radiotherapy +/- chemotherapy
9
Q
What is the histology of endometrial cancer and what makes you think of endometrial cancer?
A
Adenocarcinoma
Any women with PMB is endometrial cancer until proven otherwise
Obesity and Diabetes are risk factors as oestrogen dependent tumour
10
Q
What is endometrial hyperplasia and how is it managed?
A
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)
11
Q
What are the risk factors for endometrial cancer?
A
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
12
Q
What genetic syndrome increases risk of endometrial cancer?
A
Lynch Syndrome
Most type I endometriosis carcinomas are due to this
Also risk of colorectal cancer
13
Q
Why do the following increase the risk of endometrial cancer?
- PCOS
- Obesity
- Tamoxifen
- T2DM
A
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
14
Q
What medication is a must for people with PCOS?
A
They need progestogen to oppose oestrogen
- IUS Mirena Coil OR
- COCP OR
- Cyclical progestogens
15
Q
What are some protective factors against endometrial cancer?
A
- Combined contraceptive pill
- Mirena coil
- Increased pregnancies
- Cigarette smoking
16
Q
Why is smoking protective against endometrial cancer?
A
- 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
17
Q
What are some symptoms and signs of endometrial cancer?
A
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
18
Q
What are the referral criteria for endometrial cancer?
A
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
19
Q
What investigations need to be done if endometrial cancer is suspected?
A
- Abdominal, pelvic and speculum examination
- Transvaginal ultrasound: look at endometrial thickness, normal is <4mm post menopause
- Pipelle Biopsy: highly sensitive
- Hysteroscopy with endometrial biopsy
20
Q
What happens in a Pipelle biopsy and which women can have this over a hysteroscopy biopsy?
A
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
21
Q
What other investigations can be done to stage endometrial cancer?
A
- MRI pelvis
- CT to look for metasases
- Blood tests
Must be done in all high risk women
22
Q
How is endometrial cancer staged?
A
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
23
Q
What is the treatment for endometrial cancer?
A
- 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
24
Q
What is the prognosis with endometrial cancer?
A
5 year survival of 75%
25
Post menopausal bleeding should make you think of endometrial cancer. What are some other differentials for PMB?
26
How should endometrial hyperplasia be managed?
**Hyperplasia without atypia**: Mirena IUS and surveillance biopsies
**Atypical hyperplasia:** high rate of progression to cancer so TAH and BSO
27
Where do most cervical cancers occur and which age do they tend to affect?
Transformation zone
Peak from 25-29 then again in 80s
28
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**!!!!!!
29
What are the common sites of metastases for cervical cancer?
* Bowel
* Bone
* Liver
* Lung
30
How does HPV cause cervical cancer?
High risk is 16 and 18
***P53*** and ***pRb*** are ***tumour suppressor genes***.
HPV produces two proteins (***E6*** and ***E7***) that ***inhibit*** these ***tumour suppressor genes***
The ***E6 protein*** inhibits ***p53***, and the ***E7 protein*** inhibits ***pRb***.
Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.
31
What HPV strains are in the vaccine?
6, 11, 16, 18
32
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)
33
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
34
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
35
When taking a history for suspected cervical cancer what should you include?
***When you are performing a history in your exams and considering cancer, always ask about risk factors to show your examiners you are assessing that patient’s risk of having cancer.***
***Ask about attendance to smears, number of sexual partners, family history and smoking***
36
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
37
What is a colposcopy?
Colposcope produced magnified view of cervix.
## Footnote
***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
38
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
39
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)***
40
How are patients followed up after cervical cancer?
Reviewed every 4/12 for first 2 years then ever 6-12 months for next 3 years
After radiotherapy cervical smear testing is no longer valid
41
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***.
42
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
43
How can cervical cancer be prevented?
* HPV Vaccine (aged 12-13 2 doses)
* Screening
* Safe sex with condoms
44
CIN is a precursor for SCC of the cervix. What is CGIN?
Cervical glandular intraepithelial neoplasia
This is a non-invasive lesion that can develop into adenocarcinoma of the cervix
45
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
46
How is cervical screening carried out?
Speculum examination and collection of ***cells from transformation zone*** of cervix using a small brush.
The cells are deposited from the brush into a preservation fluid. (***liquid-based cytology)***.
Samples are initially tested for ***high-risk HPV*** before the cells are examined. If the HPV test is negative the cells are not examined, the smear is considered negative, and the woman is returned to the routine screening program.
47
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***.
48
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**
49
Apart from dyskaryosis, what else can be tested for on a smear test?
Infections such as ***bacterial vaginosis***, ***candidiasis*** and ***trichomoniasis***
***Actinomyces-like organisms*** are often discovered in women with an IUD (coil).
If symptomatic (e.g. pelvic pain or abnormal bleeding), remove IUD
50
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**
51
Do women still need smears after a hysterectomy?
**Subtotal hysterectomy:** YES
**Total hysterectomy:** depending on the presence of CIN because of the risk of developing vaginal intraepithelial neoplasia. This involves taking vault cytology from the top of the vagina at specified time intervals.
52
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
53
How do you treat people based on their CIN status?
**CIN 1:** repeat review at 12 months.
**CIN 2:** may resolve but risk of cancer so remove
**CIN 3:** removal is always advised
Surgical management options include knife cone biopsy, laser conisation, large loop excision of the transformation zone (LLETZ)
54
What are some conditions associated with an increased risk of gynaecological cancer?
* CIN
* Endometrial hyperplasia
* Lichen Sclerosus
55
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**
56
What are some tumour markers for ovarian cancer?
* CA125
* Germ Cell: AFP and HCG
57
What is a Kruckenberg tumour?
**Metastasis** in the ovary, usually from a GI cancers like **stomach**
**Signet Ring** histology
58
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**
59
What are some protective factors against ovarian cancer?
* Increased number of pregnancies
* COCP
* Breastfeeding
60
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)
61
How may someone present acutely due to ovarian cancer?
* Breathless due to malignant pleural effusion
* Bowel obstruction due to metastases and adhesions
* Paraneoplastic hypercalcaemia
* DVT
* Ovarian torsion
62
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)
63
What cancers is CA125 raised in?
Over 35 is raised
**Malignant:** Ovarian, pancreas, breast, lung, colon and endometrium
**Benign:** endometriosis, liver disease, pelvic inflammatory disease and during the first trimester of pregnancy
64
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
65
What is the RMI cut off score for ovarian cancer?
Specialist MDT NICE advise \>250, with other patients being managed at local centres.
66
How is ovarian cancer staged?
FIGO
67
How is ovarian cancer managed?
Surgery and Chemotherapy
**_Surgery:_** macroscopic resection or optimal cytoreduction
**Chemotherapy:** Carboplatin monotherapy or Carboplatin & Paclitaxel
68
What is the prognosis with ovarian cancer?
Poor as often presents at late stages as few symptoms in early stages
69
How can you tell the difference between mucinous and serous cystadenocarcinoma?
70
What are some of the different types of ovarian cancer?
