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Gynaecological Cancer Flashcards

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1
Q

What cancers may present with abnormal vaginal bleeding or discharge?

A

Cervical
Ovarian

Uterine
Vaginal

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2
Q

What cancers may present with abnormal vaginal bleeding or discharge?

A

Cervical
Ovarian

Uterine
Vaginal

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3
Q

What cancers may present with pelvic pain or pressure?

A

Ovarian
Uterine

Vulvar

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4
Q

What cancers present with abdominal pain and bloating?

A

Ovarian

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5
Q

What cancers present with change in bowel habits?

A

Ovarian

Vaginal

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6
Q

What cancers present with itching or burning of the vulva?

A

Vulvar

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7
Q

What cancers present with changes in vulva colour or skin?

A

Vulvar

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8
Q

When does cervical cancer most commonly affect women?

A

25-34yo

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9
Q

Histologically, what type of cancer can cervical cancer be?

A

70% squamous
15% adenocarcinoma

15% mixed

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10
Q

What is squamous cell cervical cancer commonly associated with?

A

99.7% contain HPV DNA

HPV 16 and 18

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11
Q

How do HPV16 and 18 cause cervical cancer?

A

HPV 16 produce E6 oncogene - inhibit p53 (tumour suppressor)

HPV 18 produce E7 oncogene - inhibit RB (tumour suppressor)

Uncontrolled cervical epithelium division

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12
Q

What is CIN?

A

Cervical intraepithelial neoplasia - dysplasia of the cervical epithelium

Can progress to cancer over 10-20 years

Most cases don’t progresses and spontaneously regress

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13
Q

What risk factors are associated with cervical cancer?

A

Persistent HPV infection
Smoking

Other STD’s
>8 years COCP use
Immunodeficiency
Early first intercourse

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14
Q

How does cervical cancer present?

A

Majority asymptomatic - picked up on screening

!!Abnormal vaginal bleeding
!!Discharge

Dyspareunia
Pelvic pain
Weight loss
Symptoms of invasion - loin pain, haematuria, oedema, rectal bleeding, radiculopathy

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15
Q

How would you investigate suspected cervical cancer in a woman pre-menopause?

A

Chlamydia screen

Positive - treat
Negative - colposcopy and biopsy

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16
Q

How would you investigate suspected cervical cancer in a woman post-menopause?

A

Urgent colposcopy and biopsy

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17
Q

How is cervical cancer staged?

A

I - Only in cervical tissue
II - Spread to upper 2/3 vagina or other tissue next to cervix

III - Spread tor issues on side of pelvic and/or lower 1/3 vagina
IV - Spread to bladder or rectum or beyond pelvis

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18
Q

Where does cervical cancer metastasise to?

A

Lung
Liver

Bone
Bowel

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19
Q

Briefly, how is cervical cancer managed surgically?

A

Preserve fertility - radical trachelectomy

Stage 1: Laparoscopic hysterectomy + cervical lymphadenectomy
Stage 2: radical hysterectomy
Stage 4: pelvic exenteration

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20
Q

What is a trachelectomy?

A

Removal of the uterine cervix

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21
Q

What other management options are there for cervical cancer?

A

Radiotherapy - external beam or brachytherapy

Chemotherapy - chemoradiation gold standard for stage Ib to III

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22
Q

What is a Lletz biopsy and what are the complications?

A

Transformation zone is removed with diathermy

Scarring and stenosis
Pyometra (uterus infection)
Cervical incompetence = PROM

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23
Q

When are women screened for cervical cancer?

What happens to screening if a women becomes pregnant?

A

25-49 yo = 3 yearly screening

50-64 yo = 5 yearly screening

Delay in pregnancy until 3 months post partum

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24
Q

How is cervical cancer screened?

When in the cycle is it best to do this?

A

Smear - brush rotated at squamo-columnar junction

Liquid based cytology to analyse fluid collected

Best to take mid cycle

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25
What is a smear poor at picking up?
Adenocarcinomas
26
How are smear results categorised?
Borderline or mild dyskaryosis Moderate dyskaryosis - CIN II Severe dyskaryosis - CIN III Suspected invasive cancer Glandular neoplasia Inadequate
27
What is done if a smear comes back as HPV negative?
Return to normal recall
28
What is done if a smear comes back as HPV positive?
Cytology is done on the sample: abnormal (including borderline dyskaryosis) = 2wk colposcopy normal = yearly smear
29
A women returns a year later for a smear as she is HPV positive... what now? A women returns for the third year in a row due to being HPV positive... what now?
HPV -ve = return to normal 3 yearly HPV +ve but cytology still normal = yearly HPV -ve = return to normal 3 yearly HPV +ve but cytology still normal = colposcopy
30
What should be done if a smear is inadequate?
Repeat smear If persistent (3 inadequate samples) - colposcopy assessment
31
What can the risk factors of cervical cancer be categorised into?
Those that increase the risk of catching HPV Later detection of precancerous and cancerous changes - not engaging in screening Other risk factors
32
How can CIN be diagnosed?
With colposcopy not with cervical screening
33
How can CIN be diagnosed?
With colposcopy not with cervical screening
34
What cancers may present with pelvic pain or pressure?
Ovarian Uterine Vulvar
35
What cancers present with abdominal pain and bloating?
Ovarian
36
What cancers present with change in bowel habits?
Ovarian | Vaginal
37
What cancers present with itching or burning of the vulva?
Vulvar
38
What cancers present with changes in vulva colour or skin?
Vulvar
39
When does cervical cancer most commonly affect women?
25-34yo
40
Histologically, what type of cancer can cervical cancer be?
70% squamous 15% adenocarcinoma 15% mixed
41
What is squamous cell cervical cancer commonly associated with?
99.7% contain HPV DNA HPV 16 and 18
42
How do HPV16 and 18 cause cervical cancer?
HPV 16 produce E6 oncogene - inhibit p53 (tumour suppressor) HPV 18 produce E7 oncogene - inhibit RB (tumour suppressor) Uncontrolled cervical epithelium division
43
What is CIN?
Cervical intraepithelial neoplasia - dysplasia of the cervical epithelium Can progress to cancer over 10-20 years Most cases don't progresses and spontaneously regress
44
What risk factors are associated with cervical cancer?
Persistent HPV infection Smoking Other STD's >8 years COCP use Immunodeficiency Early first intercourse
45
How does cervical cancer present?
Majority asymptomatic - picked up on screening !!Abnormal vaginal bleeding !!Discharge Dyspareunia Pelvic pain Weight loss Symptoms of invasion - loin pain, haematuria, oedema, rectal bleeding, radiculopathy
46
How would you investigate suspected cervical cancer in a woman pre-menopause?
Chlamydia screen Positive - treat Negative - colposcopy and biopsy
47
How would you investigate suspected cervical cancer in a woman post-menopause?
Urgent colposcopy and biopsy
48
How is cervical cancer staged?
I - Only in cervical tissue II - Spread to upper 2/3 vagina or other tissue next to cervix III - Spread tor issues on side of pelvic and/or lower 1/3 vagina IV - Spread to bladder or rectum or beyond pelvis
49
Where does cervical cancer metastasise to?
Lung Liver Bone Bowel
50
Briefly, how is cervical cancer managed surgically?
Preserve fertility - radical trachelectomy Stage 1: Laparoscopic hysterectomy + cervical lymphadenectomy Stage 2: radical hysterectomy Stage 4: pelvic exenteration
51
What is a trachelectomy?
Removal of the uterine cervix
52
What other management options are there for cervical cancer?
Radiotherapy - external beam or brachytherapy Chemotherapy - chemoradiation gold standard for stage Ib to III
53
What is a Lletz biopsy and what are the complications?
Transformation zone is removed with diathermy Scarring and stenosis Pyometra (uterus infection) Cervical incompetence = PROM
54
When are women screened for cervical cancer? What happens to screening if a women becomes pregnant?
25-49 yo = 3 yearly screening 50-64 yo = 5 yearly screening Delay in pregnancy until 3 months post partum
55
How is cervical cancer screened? When in the cycle is it best to do this?
Smear - brush rotated at squamo-columnar junction Liquid based cytology to analyse fluid collected Best to take mid cycle
56
How is stage 2 endometrial cancer managed?
Radical hysterectomy + pelvic lymphadenectomy + radiotherapy
57
How are smear results categorised?
Borderline or mild dyskaryosis Moderate dyskaryosis - CIN II Severe dyskaryosis - CIN III Suspected invasive cancer Glandular neoplasia Inadequate
58
What is done if a smear comes back as HPV negative?
Return to normal recall
59
What is done if a smear comes back as HPV positive?
Cytology is done on the sample: abnormal (including borderline dyskaryosis) = 2wk colposcopy normal = yearly smear
60
A women returns a year later for a smear as she is HPV positive... what now? A women returns for the third year in a row due to being HPV positive... what now?
HPV -ve = return to normal 3 yearly HPV +ve but cytology still normal = yearly HPV -ve = return to normal 3 yearly HPV +ve but cytology still normal = colposcopy
61
What should be done if a smear is inadequate?
Repeat smear If persistent (3 inadequate samples) - colposcopy assessment
62
What can the risk factors of cervical cancer be categorised into?
Those that increase the risk of catching HPV Later detection of precancerous and cancerous changes - not engaging in screening Other risk factors
63
What appearances on colposcopy may suggest cervical cancer?
Ulceration Inflammation Bleeding Visible tumour
64
How can CIN be diagnosed?
With colposcopy not with cervical screening
65
What are the stages of CIN?
CIN 1 - mild dysplasia, affecting 1/3 thickness of epithelial layer CIN 2 - moderate, affecting 2/3, likely to progress to cancer if untreated CIN 3 - severe, very likely to become cancer if untreated
66
What is dyskaryosis?
Found on smear results - cells examined under microscope for precancerous changes
67
How are smears tested?
Initially tested for high risk HPV, if HPV test negative then the cells are not examined and smear considered negative.
68
What are notable exceptions to the smear program?
Women with HIV screened annually Women over 65 can request one if not had one since 50 Women with previous CIN may require additional testing Immunocompromised additional Pregnancy women should wait 12 weeks post partum
69
What are the outcomes of smear cytology results?
``` Inadequate Normal Borderline changes Low grade dyskaryosis High grade dyskaryosis Possible invasive squamous cell carcinoma Possible glandular neoplasia ```
70
When should smears be repeated based on results?
Inadequate sample - repeat after at least three months HPV negative - continue routine screening HPV positive with normal cytology - repeat HPV test after 12 months HPV positive with abnormal cytology - refer for colposcopy
71
What tests can be performed on colposcopy?
Acetic acid causes abnormal cells to appear white, if there are cells with an increased nuclear to cytoplasmic ratio Abnormal cells will not stain with Schiller's iodine test Punch biopsy or loop excision can be performed
72
What is LLETZ?
Large loop excision of the transformation zone Removes abnormal tissue on the cervix Procedure can increase risk of preterm labour
73
What is a cone biopsy?
Treatment for CIN and very early stage cervical cancer | Done under GA, cone shaped piece of cervix removed using scalpel
74
What are the main risks of cone biopsy?
Pain Bleeding Infection Scar formation with stenosis of the cervix Increased risk of miscarriage and premature labour
75
What is the management of cervical cancer?
CIN and early stage 1A - LLETZ or cone biopsy 1B - 2A radical hysterectomy and removal of local lymph nodes with chemo and radio 2B - 4A chemotherapy and radiotherapy 4B - combination of surgery, radiotherapy, chemo, palliative care
76
What investigation is done in secondary care for patients referred with a raised CA125 and abnormal USS?
CT abdo-pelvis to look at extent of disease Laparotomy for histology Paracentesis can be used to test ascitic fluid for cancer cells
77
What are the risk factors for ovarian cancer?
Increased ovulation - null parity, early menarche, late menopause Increasing age Oestrogen only HRT Obesity Genetics - BRCA 1/2, Lynch syndrome
78
What are the protective factors against ovarian cancer?
Reduced ovulations - multiparity - breastfeeding - COCP
79
When is the HPV vaccine given?
Boys and girls, ideally before they become sexually active
80
What is the peak age of endometrial cancer?
65-75 years old
81
What is the most common type of endometrial cancer?
Adenocarcinoma
82
What is happening to the incidence of endometrial cancer?
Rising - possibly due to obesity
83
What is the pathophysiology of endometrial cancer?
Most due to unopposed oestrogen stimulating endometrium No protective effects of progesterone
84
What risk factors are associated with endometrial cancer?
OESTROGEN ``` Anovulation - Early menarche and late menopause - Low parity - PCOS - HRT - oestrogen alone - Tamoxifen Increasing age Obesity HNPCC - Lynch syndrome ```
85
How does endometrial cancer present?
Post-menopausal bleeding Clear/white vaginal discharge Pre-menopausal - abnormal bleeding, pelvic pain and dyspareunia
86
Describe the staging of endometrial cancer
1 - confined to uterine body 2 - extend to cervix but not beyond uterus 3 - extend beyond uterus but confined to pelvis 4 - Involved bladder or bowel or metastasis
87
What is the presentation of ovarian cancer?
``` Non specific symptoms Have a low threshold Abdominal bloating Early satiety Loss of appetite Pelvic pain Urinary symptoms Weight loss Abdominal or pelvic mass Ascites ``` Ovarian mass may press on obturator nerve causing referred hip or groin pain
88
How is stage 2 endometrial cancer managed?
Radical hysterectomy + pelvic lymphadenectomy + radiotherapy
89
How are stage 3/4 endometrial cancer managed?
Maximal debulking + chemo + radio May palliate
90
What is the difference between a total and radical hysterectomy?
Total: uterus + cervix removed Radical: uterus + cervix + parametrium + top part of vagina removed
91
What can be protective against endometrial cancer?
COCP Smoking Mirena coil Increased pregnancies
92
What is endometrial hyperplasia?
Thickening of uterine cavity due to too much oestrogen with too little progesterone
93
How is endometrial hyperplasia managed?
Hyperplasia without atypia - progesterone (Mirena coil) + surveillance biopsies Intrauterine system e.g. Mirena, or continuous oral progestogens e.g. levonorgestrel Atypical hyperplasia - as stage 1 - total hysterectomy + bilateral salpingo-oophorectomy + peritoneal washing High risk of becoming malignant
94
Why is smoking protective against endometrial cancer in postmenopausal women?
Not protective against other oestrogen dependent cancers Anti oestrogenic in endometrial cancer - oestrogen may be metabolised differently by smokers, smokers tend to be leaner meaning less adipose tissue and aromatase, smoking destroys oocytes resulting in earlier menopause
95
What is the referral criteria for endometrial cancer?
Postmenopausal bleeding - red flag symptom - 2WW Also recommends TVUSS in women over 55 years with unexplained vaginal discharge, or visible haematuria plus raised platelets, anaemia or elevated glucose levels
96
What are the investigations for endometrial cancer?
TVUSS for endometrial thickness, less than 4mm in postmenopause Pipelle biopsy highly sensitive Hysteroscopy with biopsy
97
What are the stages of endometrial cancer?
1 - confined to the uterus 2 - invades the cervix 3 - invades ovaries, fallopian tubes, vagina or lymph nodes 4 - invades bladder, rectum or beyond pelvis
98
What is the management of endometrial cancer?
Treatment for stage 1 or 2 is total abdominal hysterectomy with bilateral salpingo-oophorectomy TAHBSO - uterus, cervix and adnexa Radical hysterectomy also removing pelvic lymph nodes, surrounding tissues and top of vagina Radiotherapy, chemotherapy Progesterone to slow progression
99
What is the peak age women get ovarian cancer?
60 years old
100
How can ovarian cancer be classified?
Epithelial - 90% Germ cell Sex cord stromal
101
What are the types of epithelial ovarian cancers?
Serous, mucinous, endometriod etc. Arise from surface epithelium due to irritation during ovulation
102
What are germ cell ovarian tumour? How do they present?
Tumours arising from embryonic germ cells of gonad Present in younger patients as rapidly enlarging abdominal mass
103
What do sex-cord stroll ovarian cancers arise from?
Connective tissue cells
104
How do ovarian cancers present?
Vague - 58% present in stage 3 or 4 ``` Persistent bloating Early satiety/loss of appetite Pelvic or abdominal pain Urinary frequency or urgency Vaginal bleeding ```
105
What must be done in women >50yo with a new onset of IBS?
Ovarian cancer testing - can present similarly
106
How is ovarian cancer investigated in primary care?
CA125 >35 = USS USS abdo/pelvis abnormal = secondary care USS abdo/pelvis normal = safety netting CA125 <35 = safety netting
107
What other tests can be done in <40yo in primary care for suspected ovarian cancer? Why?
AFP Beta HCG Raised levels suggest alternate tumours
108
What investigation is done in secondary care for patients referred with a raised CA125 and abnormal USS?
CT abdo-pelvis to look at extent of disease | Laparotomy for histology
109
What are the risk factors for ovarian cancer?
Increased ovulation - null parity, early menarche, late menopause Increasing age Oestrogen only HRT Obesity Genetics - BRCA 1/2, Lynch syndrome
110
What are the protective factors against ovarian cancer?
Reduced ovulations - multiparity - breastfeeding - COCP
111
What is important to know about CA125?
Reduced specificity in premenopausal women Also raised due to: - Endometriosis, benign ovarian cysts, menstruation, pregnancy - Diverticulitis, cirrhosis - Other malignancies (bladder, breast, liver, lung)
112
What is RMI (ovarian cancer)? | How is it calculated?
Score to calculate risk of malignancy in those with suspected ovarian cancer M x U x CA125 Menopause: pre = 1, post = 3 USS score: 1 feature = 1 , >1 feature = 3 If score >250: specialist MDT
113
What features on USS of ovaries cause concern?
Multilocular cyst Solid areas Metastasis Ascites Bilateral lesions
114
Describe the staging of ovarian cancer
FIGO system I - one or both ovaries only II - spread to other pelvic organs III - spread to peritoneum or lymph nodes IV - spread to distant organs - lung/liver
115
What is the management for ovarian cancer?
Combination of surgery and chemo Laparotomy - tumour debunking Hysterectomy, salpingo-oophorectomy and infra colic omentectomy
116
How is ovarian cancer followed up?
5 year CA125 monitoring
117
What is a Krukenberg tumour?
A metastasis in the ovary, usually from a gastrointestinal tract cancer. Signet ring on histology
118
What are protective factors in ovarian cancer?
Factors which stop ovulation or reduce the number of lifetime ovulations e.g. Combined contraceptive pill Breastfeeding Pregnancy
119
When should 2WW be referred for ovarian cancer?
If feels ascites, pelvic mass (unless due to fibroids) or abdominal mass on examination Carry out further investigations before referral e.g. CA125
120
What is the staging of ovarian cancer?
1 - confined to ovary 2 - spread past ovary but inside pelvis 3 - spread past pelvis but inside abdomen 4 - spread outside abdomen - distant mets
121
What is the epidemiology of vulval cancer?
Very rare cancer 90% squamous Mostly >75yo Less commonly they can be malignant melanomas
122
How do vulval cancers present?
May be an incidental finding e.g. catheterisation in a patient with dementia Lump Ulceration + bleeding Pruritus Pain Lymphadenopathy in the groin Vulval cancer most frequently affects the lavia majora - giving it an appearance of irregular mass, fungating lesion, ulceration, bleeding
123
When would you refer someone to gynae under 2 week wait for suspected vulval cancer?
Lump | Ulceration + bleeding
124
Where do vulval cancers affect?
Labia majora - 50% Labia minora - 20% Clitoris and bartholin's glands - infrequent
125
What are the risk factors for vulval cancer?
VIN HPV Lichen sclerosus
126
How is vulval cancer diagnosed?
Examination and biopsy
127
Where do vulval cancers spread?
Inguinal and femoral lymph nodes
128
How are vulval cancers managed?
Surgical - radical or wide local resection Senitel lymph node biopsy +- groin node dissection Reconstructive surgery often performed Biopsy of the lesion, sentinel lymph node biopsy, further imaging for staging e.g. CT abdomen and pelvis
129
What is VIN?
Premalignant state that occurs spontaneously or due to pre-existing vulval disorder such as lichen sclerosis Affects the squamous epithelium of the skin that can precede vulval cancer High grade squamous intraepithelial lesion is a type of VIN associated with HPV Typically occurs between 35-50 Differentiated VIN is associated with lichen sclerosus, 50-60 years of age
130
How does VIN present?
Itching | Plaque like white patches
131
How is VIN diagnosed?
Biopsy - confirm not invasive cancer
132
How is VIN managed?
Laser therapy | Wide local excision
133
What are some complications of a Lletz biopsy (for suspected cervical cancer)
Scarring = cervical stenosis Cervical incompetence Infection and pyometra

Obstetrics and Gynaecology (11 decks)

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