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cOGtext > Gynaecological Oncology > Flashcards

Gynaecological Oncology Flashcards

1
Q

What is the most common uterine malignancy?

A

Endometrial adenocarcinoma

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2
Q

High levels of estrogen increase risk of endometrial malignancy - what factors increase estrogen levels in the body?

A 
Polycystic ovarian syndrome (PCOS)
Early menarche/late menopause
Nulliparity
Obesity
Unopposed estrogen HRT
Tamoxifen
Oestrogen-secreting tumours (granulose/theca cell ovarian tumours)
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3
Q

What is the principle symptom of endometrial malignancy?

A

Abnormal uterine bleeding (commonly postmenopausal)

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4
Q

What is the first line investigation for suspected endometrial cancer?

A

Transvaginal ultrasound

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5
Q

What finding on transvaginal ultrasound would raised suspicion of malignancy?

A

Endometrial thickness >4mm

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6
Q

What investigation/s should be carried out after a finding of thickened endometrium?

A

Hysteroscopy + endometrial biopsy +/- dilatation and curettage

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7
Q

What are the histological findings of endometrial hyperplasia?

A

Increased number of endometrial cells

Increase in the gland-to-stromal ratio

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8
Q

What are the different types of endometrial hyperplasia and what is the recommended treatment?

A

Simple/complex - progesterone treatment (e.g. Mirena)

Atypical - risk of progression to malignancy - hysterectomy recommended

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9
Q

What are some histological appearances of endometrial carcinoma?

A

Purely glandular
Areas of squamous differentiation
Papillary
Clear cell pattern

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10
Q

How does endometrial Ca commonly spread?

A

Usually direct into myometrium and cervix

Haematogenous or lymphatic spread can occur

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11
Q

What is the aetiology of type I endometrial cancer?

A 
Most common (80% of all endometrial Ca)
Usually diagnosed shortly after the menopause
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12
Q

What are the pathophysiological features of Type I endometrial cancer?

A

Endometrioid

  • estrogen dependent
  • atypical hyperplasia is a precursor
  • microsatellite instability (Lynch syndrome)
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13
Q

What is the aetiology of type II endometrial cancer?

A

Older women

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14
Q

What are the pathophysiological features of Type II endometrial cancer?

A

Serous and clear cell

  • not associated with unopposed estrogen
  • TP53 mutation
  • common extrauterine spread
  • poor prognosis
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15
Q

What is a common presentation of endometrial sarcoma?

A

Lung or ovarian metastasis

Locally aggressive and metastasizes early

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16
Q

Define carcinosarcoma?

A

Mixed tumours with malignant epithelial and stromal elements

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17
Q

What staging system is used in endometrial cancer?

A

International Federation of Gynaecology and Obstetrics (FIGO) scheme

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18
Q

What is the mainstay of treatment for endometrial cancer?

A

Surgical - hysterectomy and bilateral salpingo-oophorectomy

+/- lymphadenectomy

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19
Q

What treatment is available for endometrial Ca in patients not fit for surgery?

A

Radiotherapy

High dose progestogens

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20
Q

What is the most common uterine sarcoma and how does it present?

A

Leiomyosarcoma

Women >50 years old
Abnormal vaginal bleeding, palpable pelvic mass, pelvic pain

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21
Q

What is the most common type of primary ovarian tumour?

A

Epithelial tumours (70% of cases)

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22
Q

The number of times a women ovulates is the main risk factor for ovarian Ca. What factors influence this?

A

Parity (multiparity reduces risk)
Breastfeeding reduces risk
COCP reduces risk

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23
Q

What genetic conditions are associated with ovarian cancer?

A

HNPCC (Lynch syndrome)

BRCA1/BRCA2

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24
Q

How are epithelial ovarian tumours classified?

A

Benign
Borderline (malignant characteristics with no stromal invasion)
Malignant

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25
Q

What is the most common ovarian cancer?

A

Serous carcinoma

26
Q

What are precursor lesions for serous carcinomas?

A

Serous tubal intraepithelial carcinoma (STIC) –> high grade serous carcinoma

Serous borderline tumour –> low grade serous carcinoma

27
Q

What are the features of mucinous ovarian tumours?

A 
Often benign (unilateral) but can be malignant (bilateral)
Contain mucinous fluid
28
Q

What are the features of endometrioid ovarian tumours?

A

Usually malignant but present early
30% of women will also have a primary tumour in endometrium
Associated with Lynch syndrome

29
Q

What are the features of clear cell ovarian tumours?

A

Almost all malignant
Associated with endometriosis
Associated with Lynch syndrome

30
Q

What are the features of urothelial-like ovarian tumours?

A

Rarely malignant

Transitional type epithelium

31
Q

What are the features of granulosa cell ovarian tumours?

A

Low grade but potentially malignant
75% secrete sex hormones - can cause precocious pseudopuberty and/or abnormal bleeding
Call-Exner bodies (coffee bean nuclei and gland-like spaces)

32
Q

What are the features of thecoma/fibroma ovarian tumours?

A

Usually benign
Contain theca cells or fibroblastic-type cells
May produce estrogen
Can cause Meigs syndrome

33
Q

What are the features of sertoli/leydig cell ovarian tumours?

A

Very rare
Young women
Unilateral
Can be androgenic

34
Q

What are the features of teratoma ovarian tumours?

A

Most common germ cell tumour
Usually benign
Mature teratomas may contain hair/teeth/epithelium/sebum - ‘dermoid cyst’

35
Q

What are the features of dysgerminoma ovarian tumours?

A

Most common malignant germ cell tumour
Associated with gonadoblastoma in gonadal dysgenesis
hCG may be increased

36
Q

What are the features of endodermal sinus/yolk sac ovarian tumours?

A

Usually present with sudden pelvic mass
hCG normal
Alpha-fetoprotein increased

37
Q

What are the features of choriocarcinoma ovarian tumours?

A

Secrete hCG - precocious pseudopuberty

Poor prognosis

38
Q

How do ovarian cancers normally spread?

A

Trans-coelomically

  • tumour seeds into peritoneal cavity
  • death can result from intestinal blockage and cachexia
  • para-aortic node metastases are common finding
39
Q

How does ovarian cancer typically present?

A

Late
GI complications/bowel obstruction
Abdominal distention

40
Q

What is the risk of malignancy index (RMI) made up of?

A

USS score
Menopausal score
CA125

41
Q

What are suspicious USS findings of ovarian cancer?

A 
Complex mass with solid + cystic area
Multi-loculated
Thick septations
Associated ascites
Bilateral disease
42
Q

CA125 is raised in 80% of ovarian cancers. What are other causes for it being raised?

A 
Endometriosis
Peritonitis
Pregnancy
Pancreatitis
Ascites
43
Q

What is the typical treatment for epithelial ovarian cancer?

A

Chemotherapy + surgery

+/- fertility preservation

44
Q

What are risk factors for cervical neoplasia?

A 
Multiple sexual partners
Starting intercourse at younger age
Intercourse without barrier protection
COCP
Smoking
45
Q

What types of HPV are closely linked to the development of cervical neoplasia?

A

16 and 18

46
Q

What are the preinvasive phases of cervical/endocervical cancer?

A

Cervical intraepithelial neoplasia –> squamous cervical cancer

Cervical glandular intraepithelial neoplasia –> endocervical adenocarcinoma

47
Q

What are features of endocervical adenocarcinoma?

A

Harder to detect by screening
Worse prognosis than squamous

Risk factors:
Later onset of sexual activity, smoking, HPB (particularly HPV18, higher SE class)

48
Q

Who is recommended to have cervical screening and how often?

A

Anyone with a cervix aged 25-65 every 5 years

49
Q

Define the ‘transformation zone’?

A

The area where the columnar epithelium of the endocervix meets the squamous epithelium of the ectocervix

The area targeted during a cervical smear test

50
Q

What test is carried out at a cervical smear?

A

HPV test

Cytology is investigated only after a positive HPV result

51
Q

How is CIN classified?

A

I-III

CIN I: dyskaryosis (abnormal cells) in a third of the basal epithelium
CIN II: abnormal cells have extended into middle third
CIN III: abnormal cells span full thickness of epithelium

52
Q

What is the purpose of colposcopy?

A

Allows the cervix to be examined in more detail and the squamocolumnar junction visualised

+/- biopsy/treatment

53
Q

Why is acetic acid applied during colposcopy?

A

Abnormal epithelium contains more protein and less glycogen

When acetic acid is applied, abnormal epithelium appears white

54
Q

What is the risk of progression of CIN III to invasive disease?

A

30% over 5-20 years

55
Q

What is the treatment for high grade CIN?

A

Excision at colposcopy or after biopsy

Usually done by large loop excision of the transformational zone (LLETZ)

Ablation is alternative option

56
Q

What is the typical presentation of cervical cancer?

A 
Post-coital bleeding
Intermenstrual bleeding
Menorrhagia
Pelvic pain
Offensive vaginal discharge

Often asymptomatic

57
Q

How does cervical cancer typically spread?

A

Spread to adjacent structures - parametrium, upper vagina, pelvic sidewall, bladder, rectum

Lymphatic spread usually results in metastases to the pelvic and para-aortic nodes

58
Q

How is cervical cancer staged?

A

Based on clinical examination and confirmed by histological biopsy (does not include imaging results)

59
Q

What is the management of cervical cancer?

A

Stage 1A1 - local excision
Stage 1A2 - simple hysterectomy + pelvic lymphadenectomy

Stage IB-IIA - Radical hysterectomy + pelvic lymphadenectomy OR radical radiotherapy +/- cisplatin

Stage IIB-IV - Radical radiotherapy + cisplatin chemotherapy

60
Q

What are the side effects of radiotherapy to the cervix?

A

Cystitis
Diarrhoea
Fibrosis which can cause vaginal stenosis
Sexual dysfunction

cOGtext (11 decks)

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