Gynae Cancer

Question 1

What is endometrial cancer?

Answer 1

The majority are adenocarcinomas and are related to excessive exposure to unopposed oestrogen.

Question 2

What age group does endometrial cancer effect?

Answer 2

Postmenopausal women

Investigate all postmenopausal bleeding to rule out endometrial cancer

Question 3

What are the risk factors of endometrial cancer?

Answer 3

Obesity, T2DM, hypertension (peripheral oestrogen)
Nulliparity (pregnancy associated with high progesterone)
Early menarche and late menopause
Anovulatory cycles e.g. PCOS (no corpus luteum)
Oestrogen-only HRT
Breast cancer (similar lifestyle factors + tamoxifen use)
Genetic predisposition - HNPCC (Lynch II syndrome) increases chance of ovarian, endometrial and colorectal cancer

Question 4

What are the protective factors for endometrial cancer?

Answer 4

COCP use

Parity

Question 5

What is the presentation of endometrial cancer?

Answer 5

PMB

Heavy/irregular uterine bleeding or abnormal smear or discharge and pyometra in pre-menopausal women

Question 6

How is endometrial cancer diagnosed?

Answer 6

TVS - endometrial thickness >4mm (if under no need for further tests)
Then hysteroscopy and biopsy
CT/MRI to stage pre-operatively

Question 7

Describe the staging of endometrial cancer.

Answer 7

I - in the body of the uterus
II - in the body and cervix
III - beyond the uterus, but remaining in the pelvis e.g. vagina, ovary, pelvic lymph nodes
IV - beyond the pelvis e.g. bowel and bladder

Question 8

What is the treatment for endometrial cancer?

Answer 8

Total hysterectomy with bilateral salpingo-oophorectomy and peritoneal washings
Advanced disease - high dose progesterone and external beam radiotherapy

Question 9

What are group does cervical cancer affect?

Answer 9

30-39 and over 70

Question 10

What are the risk factors for cervical cancer?

Answer 10

Persistent high-risk HPV infection
Smoking
Multiple partners
Oral contraceptive (due to decrease in barrier contraceptive use)
Immunocompromised (HIV, immunosuppressants, organ transplantation)

Question 11

What are the signs and symptoms of cervical cancer?

Answer 11

Abnormal cervical smear
Post-coital/post-menopausal bleeding
Watery vaginal discharge
Incidental finding on treatment of CIN
Features of advanced disease: heavy vaginal bleeding, weight loss, vesicovaginal fistula, bowel disturbance, ureteric obstruction, pain

Question 12

What are the investigations for cervical cancer?

Answer 12

FBC, U&Es, LFTs
Colposcopy and punch biopsy
CT and MRI for staging

Question 13

Describe the stages of cervical cancer.

Answer 13

Stage I: confined to the cervix
Stage II: involves the upper 2/3 of the vagina
Stage III: involves the lower 1/3 of the vagina
Stage IV: involves the bladder/rectum

Question 14

What is the treatment for cervical cancer?

Answer 14

Local excision (fertility-sparing) or hysterectomy
Chemoradiotherapy
Lymphadenectomy

Question 15

What is the peak age of onset for ovarian cancer?

Answer 15

75-84Y

Question 16

What are the risk factors for ovarian cancer?

Answer 16

Nulliparity
Early menarche/late menopause
BRCA1/BRCA2 gene mutations
HNPCC (Lynch II syndrome)

Question 17

What are the protective factors for ovarian cancer?

Answer 17

COCP
Pregnancy
Breast feeding

Question 18

What is the presentation of ovarian cancer?

Answer 18

Very vague presentation leading to late presentation and higher mortality
Abdo/pelvic pain
Weight loss, early satiety
Vaginal bleeding
Fatigue
Urinary symptoms 
Change in bowel habit
Mass felt per abdomen

Question 19

What are the investigations for ovarian cancer?

Answer 19

FBC, U&Es, LFTs
CA125
Chest X-ray looking for mets/pleural effusion - needed for staging
CT CAP - to find mets
MRI - shows ovarian mass in more detail and distinguishes from benign mass
Can send samples of ascites and pleural effusion off for cytology

Question 20

Describe the staging of ovarian cancer.

Answer 20

Stage I: limited to one or both ovaries
Stage II: limited to the pelvis
Stage III: limited to the abdomen
Stage IV: distant mets

Question 21

What is the treatment for ovarian cancer?

Answer 21

Full staging laparotomy
Removal of all cancer
Chemotherapy wit platinum-based agents

Question 22

What is the pre-invasive form of cervical cancer called?

Answer 22

CIN (cervical intra-epithelial neoplasia)

Question 23

Which viruses are CIN associated with?

Answer 23

Ocogenic HPV 16,18, 31 and 33

Question 24

What are the types of CIN and what are the differences between them?

Answer 24

CIN I affects the lower basal 1/3 of the cervical epithelium and 60% regress within 2 years.
CIN II affects 1/3 - 2/3 of the cervical epithelium
CIN III affects 2/3 to the full thickness of the cervical epithelium
CIN II and III are less likely to regress and more likely to progress to invasive squamous cell carcinoma

Question 25

What is the function of the smear test?

Answer 25

It collects cervical cells for microscopy to identify dyskaryosis which indicates CIN.

Question 26

How often are cervical smears conducted?

Answer 26

3 yearly for women between 25 and 50
And then 5 yearly until the age of 64
Annually for women who are HIV positive

Question 27

What is the management for different types of abnormal smear?

Answer 27

Borderline/mild dyskaryosis
- sample tested for HPV
- if negative back to routine recall
- if positive referred for routine colposcopy
Moderate/severe dyskaryosis or suspected invasive cancer
- refer for urgent colposcopy (within 2 weeks)
Inadequate
- repeat smear
- if 3 inadequate samples - refer for routine colposcopy

Question 28

What are the complications of LLETZ?

Answer 28

Haemorrhage
Infection
Small chance of cervical incompetence and premature delivery
- increased risk with multiple procedures/biopsy depth over 1cm
Cervical stenosis
Vasovagal episodes
Anxiety