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gynaecological cancers DONE Flashcards

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1
Q

what is endometrial hyperplasia

A

thickening of the inner lining of the womb (uterus)

excess of the hormone oestrogen not balanced by progestrone hormone

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2
Q

what are the two types of endometrial hyperplasia

A

hyperplasia without atypia. In this type, the lining of the womb is thicker, as more cells have been produced. The cells are all normal, however, and are very unlikely to ever change to cancer. Over time, the overgrowth of cells may stop on its own, or may need treatment to do so.

Atypical hyperplasia. In this type, the cells are not normal (they are said to be atypical). This type of hyperplasia is more likely to become cancerous over time if not treated.

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3
Q

Sx of endometrial hyperplasia

A 
red flags
above 55
vaginal bleeding which is different to your usual pattern. 
PMB
 vaginal discharge

inbetween their periods

heavier or irregular

HRT you may get bleeding

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4
Q

causes of endometrial hyperplasia

A 
overweight
diabetic
HRT
no children
PCOS
tumour of the ovary
tamoxifen
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5
Q

tests for endometrial hyperplasia

A

US scan - exclude other causes such as polyps or cysts

after menopause lining is thin usually

endometrial biopsy

hysteroscopy

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6
Q

Mx for endometrial hyperplasia without atypia

A

nothing and repeat biopsy

IUS is the best treatment releases progestorn which thins the lining of the women.

stays in at least for 6 months but for upo 5 years

repeat sampling in 3-4 months

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7
Q

when may hysterectomy endometrial hyperplasia without atypia be required

A

The hormone treatments are not working after 6-12 months.

The condition comes back after treatment.

You go on to develop atypical hyperplasia.

You prefer to have an operation than to take regular medication or have an IUS

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8
Q

Mx for atypical endometrial hyperplasia

A

total hysterectomy with bilateral salpingo-oophorectomy

menopause - removal of ovaries and fallopian tubes may be suggested

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9
Q

most common gynaecological cancer

A

endometrial

Rare before the age of 35
Peak age group 64 – 74
Declines after 80
Commoner in western world

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10
Q

high risk factors for endometrial cancer

A 
Obesity
Early menarche-late menopause
Nulliparity
PCOS
Unopposed oestrogen
Tamoxifen
Previous breast or ovarian cancer
BRCA 1/2
Endometrial polyps
Diabetes
Parkinson’s

all result in excess oestrogen

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11
Q

risk factors that reduce endometrial cancer

A 
Continuous combined HRT
Combined oral contraceptive pill
Smoking
Physical activity
Coffee
Tea
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12
Q

presentation of endometrial cancer

A

Pre-menopausal (1% risk)
Prolonged, frequent vaginal bleeding
Intermenstrual bleeding

Postmenopausal
Postmenopausal Bleeding (PMB) (10% risk)
Less commonly blood stained, watery or purulent vaginal discharge
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13
Q

pathology of endometrial hyperplasia

A

Pre-malignant condition
Classification simple, complex, atypical
With atypical, malignancy co-exists in 25-50% of cases, and 20% will develop Ca within 10 years.
Treatment with progestagens/ surgery

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14
Q

classification of endometrial adenocarcinoma

A

TYPE 1 (80%): Endometrial Adenocarcinoma

TYPE 2 (20%):

Papillary Serous
Clear cell Carcinosarcoma

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15
Q

endometrial FIGO staging

A

1A - confined to cervix - <7mm wide
1B - confined to cervix - >7mm

2 - Cervical spread NOT TO PELVIC WALL

3 - Uterine serosa
Ovaries / Tubes Vagina
Pelvic / Para-aortic Lymph Nodes to pelvic wall

4 - Bladder / bowel involvement
Distant metastases

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16
Q

diagnostic tests for endometrial cancer

A

Endometrial sampling by Pipelle or (less commonly) D&C - dilataion and caradarch

Hysteroscopy: gold standard to assess uterine cavity
Transvaginal Ultrasound: useful for investigation of PMB, use >5mm cut off for endometrial thickness

1) women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
2) first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
3) hysteroscopy with endometrial biopsy

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17
Q

other Ix for endometrial cancer

A
  • Metastases rare at presentation in Type 1 cancers
  • Intraperitoneal, lung, bone, brain
  • FBC, U&E, LFT
  • CT chest/abdo/pelvis
  • MRI Pelvis
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18
Q

preferref Mx for endometrial cancer and factors influencing it

A

Surgical treatment is the preferred treatment option where possible.

Factors influencing primary treatment are stage, age & fitness for surgery, patient preference

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19
Q

surgical Mx for endometrial cancer

A

Hysterectomy PLUS bilateral salpingo-oophorectomy, peritoneal washings
Laparoscopic / Open

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20
Q

non-surgical alternatives for endometrial cancer

A

Progestagens

Primary Radiotherapy

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21
Q

adjuvant radiotherapy if high risk of recurrence of endometrial cancer

A

External beam

Brachytherapy

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22
Q

advanced disease/inoperatble disease/ unfit for surgery for endometrial cancer

A

Chemotherapy
Radiotherapy
Hormones
Palliative Care

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23
Q

what will happen at one stop postmenopausal bleeding

A

History & Examination
FBC
Transvaginal ultrasound
Hysteroscopy and endometrial biopsy

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24
Q

epidemiology of ovarian cancer

A
  • Second commonest gynae cancer in the UK
  • Incidence is rising
  • Lifetime risk 1:50
  • Peak age 70-74 years, occurs predominantly in 5th, 6th and 7th decade
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25
pathology of ovarian cancer
``` cystadenocarcinoma - commonest histological subtype surface epithelium - most common serous - mucinous endmetriod - clear cell brenner tumpurs ``` germ cells - dysgerminoma - teratoma - yolk sac - choriocarcinoma stroma - granulosa - theca - sertoli-leydig krukenberg tumour from stomach or breast cancer
26
which types of ovarian cells can be benign/malignant
serous mucinous teratoma
27
high risk factors for ovarian cancer
1. Genetic - FH of ovarian cancer - BRCA 1/2 HNPCC 2. Environmental - asbestos exposure - talcum powder use 3. physical - Obesity 4. Hormonal - Nulliparity - Early Menarche - Late Menopause - Unopposed Oestrogen HRT 5. Medical Hx - Endometriosis / cysts
28
risk factors that reduce ovarian cancer
``` Combined oral contraceptive pill Pregnancy Breastfeeding Hysterectomy Oophorectomy Sterilisation ? Statins ```
29
ovarian cancer presentation
not specific - abdominal swelling - pain - anorexia - N/V - weight loss - vaginal bleeding - bowel Sx adenocarcinoma cells and a complex pelvic mass
30
Ovarian cancer diagnosis and work up
CA125 - baseline Pelvic examination Ultrasound FBC, U&E, LFT (CXR) - staging CT to assess peritoneal, omental and retroperitoneal disease Cytology of ascitic tap Surgical exploration Histopathology
31
ovarian cancer staging
 1 - Limited to ovary / ovaries 2 - Spread to pelvic organs 3 - Spread to rest of peritoneal cavity Omentum Positive Lymph nodes 4 - Distant metastatsis Liver parenchyma Lung
32
epithelial ovarian cancer Tx
Surgery + chemotherapy Staging laparotomy, TAH PLUS BSO and debulking Platinum (Cisplatin, carboplatin) and Taxane (paclitaxel) In women of reproductive age, where the tumour is confined to one ovary, ophorectomy only may be considered
33
non-epithelial ovarian tumours Tx
often occur in young women and can be extremely chemo-sensitive (e.g. germ cell). Often treated with combination of ‘conservative’ surgery and chemo
34
Tx if recurrent ovarian tumours
palliative chemotherapy
35
factors that increase risk of cervical cancer
- HPV - Young age at first intercourse - Multiple sex partners  - Exposure (no barrier contraception)  - Smoking  - Long term use of COCP - Immunosuppression/HIV Non compliance with cervical screening
36
factors that may reduce cervical cancer
HPV vaccine Cervical screening compliance
37
which HPV types increase risk of cervical cancer
16, 18
38
what is HPV
HPV (esp subtypes 16 & 18): produce proteins (E6&7) which suppress the products of ‘p53’ tumour suppressor gene in keratinocytes Most women will be infected at some time HPV infection is common in late teens and early twenties Infection lasts on average 8 months
39
history of HPV
Asymptomatic | Can be cleared or persist or cause CIN
40
CIN history
Asymptomatic | Can regress, persist or progress to cancer
41
what is CIN
Pre-malignant condition Occurs at the TZ Asymptomatic
42
diagnosis of cervical cancer
histological
43
cervical presentation
PCB PMB IMB Blood stained vaginal discharge In very advanced disease: Fistulae, renal failure, nerve root pain, lower limb oedema
44
staging of cervical cancer
1 Confined to cervix A Microinvasive (depth<5 mm/width<7mm) B Clinical lesion 2 Beyond cervix but not pelvic side wall or lower 1/3 of vagina A Upper 1/3 Vagina B Parametrium 3 Pelvic spread, reaches side wall or lower 1/3 of vagina A Lower 1/3 of vagina, hydronephrosis B Extends to pelvic side wall, hydronephrosis 4 Distant spread A Invades adjacent organs (bladder/bowel) B Distant sites
45
Mx for cervical cancer
Microinvasive carcinoma: can be more conservative. If fertility is an issue, then cone biopsy can be used. Once family is complete, hysterectomy is appropriate. Clinical Lesions (1b - 2a): Wertheim’s radical hysterectomy or chemoradiotherapy (survival same) 3. Clinical lesions beyond stage 2a: Chemoradiotherapy 4. Postoperative radiotherapy: with lymph node involvement 5. Recurrent disease: Radiotherapy, chemotherapy, exenteration, palliative care
46
surgical complications of cervical cancer Mx
Surgery: ``` Infection VTE Haemorrhage Vesicovaginal fistula Bladder dysfunction Lymphocyst formation Short vagina ```
47
radiotheraphy complications of cervical cancer
``` Vaginal dryness Vaginal stenosis Radiation cystitis Radiation proctitis Loss of ovarian function ```
48
Principles of cervical screening
The condition should be an important health problem. There should be a treatment for the condition. Facilities for diagnosis and treatment should be available. There should be a latent stage of the disease. There should be a test or examination for the condition. The test should be acceptable to the population. The natural history of the disease should be adequately understood. There should be an agreed policy on whom to treat. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
49
cervical smear frequency
First invitation age 25 3 yearly from 25 to 50 5 yearly from 50 – 65 After 65 selected patients only
50
cervical cytology
Cells collected from cervix (transformation zone) and exfoliated morphology examined Liquid based cytology- UK
51
classification of cytology
``` Normal Inadequate Borderline Mild Dyskaryosis Moderate Dyskaryosis Severe Dyskaryosis Possible Invasion ```
52
what is colposcopy
- Low-power binocular microscopy of cervix To look for features suggestive of CIN or invasion - --- abnormal vascular pattern (mosaicism, punctation) - --- abnormal staining of the tissue (aceto-white, brown iodine)
53
Mx for CIN
See-and-treat concept Excisional: LLETZ (large loop excision of the transformation zone), cold knife cone Destructive: cryocautery, diathermy, laser vaporisation (less common in UK) Following colposcopy, follow up depends on results, but may be 6 monthly, yearly for 10 years, or routine recall
54
what vaccination is given preveneting cervical cancer
Gardasil: 6,11,16,18 Cervarix:16 & 18 3 injections over 6 months Ideally prior to SI 5 years protection Still need smears (HPV 31, 45 & others)
55
how does vulval cancer look
ulcerated lesion or raised in labia or clitoris
56
what is VIN vulval intraepithelial neoplasia presentation Mx
Pre malignant condition - Can resolve spontaneously - Can progress to vulval cancer Can be asymptomatic Can present with itching/burning/pain Treatment Conservative: Antihistamine Medical: Imiquimod Surgical: Excision
57
risk factors for VIN
``` Herpes Simplex Virus Type 2 Smoking Immunosuppression Chronic vulvar irritation Conditions such as Lichen Sclerosus ```
58
vulval cancer cell type
SCC caused by HPV
59
Meig's syndrome three features
a benign ovarian tumour ascites pleural effusion
60
what is serous cystadenoma
benign Most common benign ovarian tumour, often bilateral Cyst lined by ciliated cells (similar to Fallopian tube)
61
what is serous cystadenocarcinoma
malignant Often bilateral Psammoma bodies seen (collection of calcium)
62
what is mucinous cystadenoma
benign Cyst lined by mucous-secreting epithelium (similar to endocervix)
63
what is mucinous cystadenocarcinoma
malignant May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause)
64
what is brenner tumour
Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have 'coffee bean' nuclei. benign
65
what is teratoma Ix
``` Mature teratoma (dermoid cyst) - most common: benign Immature teratoma: malignant ``` Ix - AFP, LDH, hCG Account for 90% of germ cell tumours Contain a combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue
66
what is dysgerminoma
malignant Most common malignant germ cell tumour Histological appearance similar to that of testicular seminoma Associated with Turner's syndrome Typically secrete hCG and LDH
67
what is yolk sac tumour
malignant secrete AFP Schiller-Duval bodies on histology are pathognomonic
68
what is choriocarcinoma
malignant estational trophoblastic disease Typically have increased hCG levels Often characterised by early haematogenous spread to the lungs
69
what is granulosa cell tumour
malignant Produces oestrogen leading to precocious puberty if in children or endometrial hyperplasia in adults. Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)
70
what is sertoli-leydig tumour
benign Produces androgens → masculinizing effects Associated with Peutz-Jegher syndrome
71
what is fibroma
benign Associated with Meigs' syndrome (ascites, pleural effusion) Solid tumour consisting of bundles of spindle-shaped fibroblasts Typically occur around the menopause, classically causing a pulling sensation in the pelvis
72
what is krukenberg tumour
malignant Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma
73
if a woman is pregnant but she is due for cervical smear what should u do
3 months post-partum
74
for ovarian cancer if it spread lymphatically where will it go first and its haematological where will it go first
lymphatically - para-aortic lymph nodes | haematological - liver
75
epidemiology of ovarian cancer
leading cause of death from gynaecological cancer most common in the postmenopausal group
76
what investigations are done to assess ascites
- ascitic tap for cytology
77
exudative causes of ascites
malignant infiltration peritoneum pancreatitis abdominal TB
78
transudative causes of ascites
cardiac failure hypoalbuminaemia hepatic cirrhosis renal failure
79
cervical screening interpretation HRPV +VE HRPV -VE
-ve -> routine recall +ve -> cytology cytology abnormal -> colposcopy cytology normal -> repeat test if the repeat test is now hrHPV -ve → return to normal recall if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later: If hrHPV -ve at 24 months → return to normal recall if hrHPV +ve at 24 months → colposcopy sample inadequate - repeat within 3 months - > if two consecutive inadequate samples then → colposcopy
80
why may be a cervical sample be inadequate
Was taken but the cervix was not fully visualized. Was taken in an inappropriate manner (for example, using an unapproved device). Contains insufficient cells. Contains an obscuring element (for example lubricant, inflammation, or blood). Is incorrectly labelled.
81
role of a colposcopy chemicals used
look for abnormal changes pre cancerous CIN cancer acetic acid - abnormal areas turn white (ACETOWHITE) iodine solution - normal tissue outside of cervis stains brown
82
epidemiology of endometrial cancer
``` Commonest gynaecological cancer in UK Incidence is rising Rare before the age of 35 Peak age group 64 – 74 Declines after 80 Commoner in western world ```
83
epidemiology of cervical cancer
Worldwide - in some areas commonest cancer in women UK 3rd commonest gynae cancer 80% of cervical cancer occurs in developing world 5% lifetime risk in some regions Incidence declined by 40% with cervical screening Bimodal age distribution (30s and 80s) More common in low socio-economic groups 2/3 are squamous & ca 15% are adenocarcinoma
84
symptoms of lichen slerosis
```  Itch  Soreness  Dyspareunia if introital narrowing  Urinary symptoms  Other symptoms, e.g. constipation, can occur if there is peri-anal involvement  Can be asymptomatic, but this is rare ```
85
signs of lichen sclrosus
 Pale, white atrophic areas affecting the vulva  Purpura (ecchymosis) is common  Fissuring  Erosions, but blistering is very rare  Hyperkeratosis can occur  Changes may be localised or in a ‘figure of eight’ distribution including the perianal area  Loss of architecture may be manifest as loss of the labia minora and/or midline fusion. The clitoral hood may be sealed over the clitoris so that it is buried
86
complications of lichen sclerosus
 Development of squamous cell carcinoma  Development of clitoral pseudo cyst  Sexual dysfunction  Dysaesthesia
87
Mx of lichen sclerosus
ultra potent steroids
88
DDx of PMB
``` incomplete cessation of menses cervical cancer ovarian cancer cervical poly endometrial polyp atrophic vaginitis ```
89
Risks of hysterectomy w bilateral salpingo-oopherectomy
damage to urethra, ureters, bowel thromboembolism stress incontinence risk of herniation through scat site
90
other gynae conditions requiring hysterectomy
``` severe endometriosis fibroids other gynae cancers menorrhagia PID w chronic pain ```

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