Gynaecological Oncology

Question 1

2 types of cervical cancer

Answer 1

Squamous cell carcinoma – about 70-80% of cases of cervical cancer.
Cervical adenocarcinoma – about 10% of cases of cervical cancer.

Question 2

2 peaks for cervical cancer incidence age groups

Answer 2

30-39 and over 70s.

Question 3

5 symptoms of cervical cancer (early)

Answer 3

Postcoital and/or postmenopausal bleeding
Intermenstrual bleeding
Watery vaginal discharge/ blood stained vaginal discharge
Pelvic pain
Dyspareunia

Question 4

7 symptoms of cervical cancer (advanced)

Answer 4

Postcoital and/or postmenopausal bleeding
Intermenstrual bleeding
Watery vaginal discharge/ blood stained vaginal discharge
Pelvic pain
Dyspareunia

Question 5

3 methods of examining cervix

Answer 5

colposcopy, bimanual examination, speculum examination

Question 6

what can be seen on Colposcopy for cervical cancer

Answer 6

: shows an irregular cervical surface, abnormal vessels and a dense uptake of acetic acid.

Question 7

signs of cervical cancer to look for on Bimanual examination:

Answer 7

cervix feels roughened and hard. If disease is advanced, there is loss of the fornices and the cervix is fixed.

Question 8

signs of cervical cancer Speculum examination:

Answer 8

shows and irregular mass that will often bleed on contact. Cervix may appear inflamed or friable and bleed on contact (this is most commonly caused by chlamydia though). There may be a visible ulcerating or fungating lesion. There may be serosanguineous discharge.

Question 9

An urgent referral to gynaecology (2ww pathway) should be arranged for post-menopausal women who:

Answer 9

Have not received HRT and have vaginal bleeding.

Have persistent or unexplained vaginal bleeding after cessation of HRT for 6 weeks.

Question 10

Referral to gynaecology or GUM should be arranged for premenopausal women who have:

Answer 10

Persistent intermenstrual bleeding, post-coital bleeding or blood stained vaginal discharge, AND
Infection has been excluded or treated, but the bleeding has continued for 6-8 weeks post treatment, or a polyp, ectropion, cervicitis or warts are present.

Question 11

Define stage I cervical cancer stages (Ia and Ib)

Answer 11

Stage I: tumours are confined to the cervix.
Ia: microscopic
Ib: macroscopic

Question 12

Define stage II cervical cancer stages (a and b)

Answer 12

tumours have extended locally to the upper 2/3 of the vagina.
IIb: if have spread to parametria (fibrous and fatty connective tissue that surrounds the uterus).

Question 13

Define stage III cervical cancer stages (a and b)

Answer 13

Stage IIIa: tumours have spread to lower third of the vagina.
IIIb: tumour spread to the pelvic wall.

Question 14

Define stage IV cervical cancer stages (a and b)

Answer 14

Stage IV: tumour spread to bladder or rectum.

IVb: if there is spread to distant organs.

Question 15

Treatment for stage Ia (1 and 2) cervical cancer

Answer 15

Stage Ia1 (<3mm depth): local excision (fertility sparing) or hysterectomy. 
Stage Ia2 (<5mm depth) and Ib1 (<4cm diameter): lymphadenectomy and if node negative, proceed to Wertheim’s hysterectomy.

Question 16

Treatment stage Ib2 and early stage II cervical cancer

Answer 16

Stage Ib2 (>4cm diameter) and early IIa: chemoradiotherapy. If negative lymph nodes, consider Wertheim’s hysterectomy.

Question 17

Treatment >stage IIb cervical cancer

Answer 17

> stage IIb: combination chemoradiotherapy.

Question 18

Treatment stage IVb cervical cancer

Answer 18

Stage IVb: chemoradiotherapy. Palliative radiotherapy to control bleeding.
**Cisplatin is the main chemotherapy agent used.

Question 19

The HPV jab covers against…

Answer 19

HPV 6, 11, 16 and 18 (the causes of 99.7% of cervical cancers)

Question 20

Cervical screening aims to…

Answer 20

reduce the incidence of, and mortality from, cervical cancer through a systematic, quality assured population-based screening programme for eligible women

Question 21

When is Liquid based cytology to detect abnormalities of the cervix done?

Answer 21

done if high-risk HPV detected in cervical cell sample from smear

Question 22

5 risk factors for cervical cancer

Answer 22

Persistent high-risk HPV infection.
Exposure to HPV is increased by multiple partners.
Smoking
Immunocompromise (HIV, transplant patients, immunosuppressants)
COCP is associated with CIN but this is probably due to reduced use of barrier contraception, thereby increasing exposure to HPV.

Question 23

6 abnormalities which can be detected from cell cytology

Answer 23

Borderline changes in the squamous or endocervical cells. 
Low-grade dyskaryosis. 
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
Invasive squamous cell carcinoma. 
Glandular neoplasia

Question 24

Individual tests positive for high-risk HPV and receive a negative cytology report next step

Answer 24

should have the HPV test repeated at 12 months.

If HPV testing is negative at 12 months, individuals can be safely returned to the routine recall system.

Question 25

2 stains used in colposcopy and their effects

Answer 25

Acetic acid: makes abnormal areas (such as CIN) turn white – sometimes referred to as ‘acetowhite’. Iodine solution: normal tissue on the outside of the cervix stains brown, pre-cancerous abnormalities may not stain with iodine. The cells on the inner part of the cervix do not stain brown.

Question 26

2 stains used in colposcopy and their effects

Answer 26

Acetic acid: makes abnormal areas (such as CIN) turn white – sometimes referred to as ‘acetowhite’. Iodine solution: normal tissue on the outside of the cervix stains brown, pre-cancerous abnormalities may not stain with iodine. The cells on the inner part of the cervix do not stain brown.

Question 27

5 reasons for referral to colposcopy

Answer 27

previous abnormal cytology unable to obtain cervical sample on smear inadequate cervical sample (repeat smear) dr concerned about appearance of cervix dr referral due to symptoms

Question 28

when is punch biopsy taken

Answer 28

to confirm histological diagnosis if any abnormalities are suspected after acetic acid and iodine tests

Question 29

CIN abbreviation

Answer 29

cervical intraepithelial neoplasia

Question 30

Significance of CIN grading

Answer 30

the higher the grade of CIN, the higher the risk of progression to carcinoma.

Question 31

Most common type of ovarian cancer

Answer 31

Epithelial ovarian tumours: | Most common – 90% ovarian cancers.

Question 32

6 subtypes of epithelial ovarian cancer

Answer 32

``` Serous Endometroid Clear cell tumours Mucinous tumours Brenner tumours: Undifferentiated: do not fit into any of the above categories. ```

Question 33

Less common type of ovarian cancer

Answer 33

Germ cell tumours: Derived from primitive germ cells of embryonic gonad. 5-10% of all ovarian tumours.

Question 34

Ovarian cancer which is most common in younger women <35.

Answer 34

germ cell tumour

Question 35

Ovarian cancer risk factors (11)

Answer 35

smoking, obesity, hx infertility, nulliparous, early menarche/late menopause, HRT, Family Hx, BRCA1 and 2 gene, medical Hx breast ovarian or bowel cancer, Hx endometriosis

Question 36

4x protective factors ovarian cancer

Answer 36

Childbearing Breastfeeding Early menopause COCP

Question 37

Symptoms ovarian cancer (9ish)

Answer 37

``` Very non-specific, can be: Abdominal pain Abnormal vaginal/ uterine bleeding Loss of appetite Abdominal distension Change in bowel habits Urinary frequency Dyspepsia Pelvic or abdominal mass that may be associated with pain Constitutional symptoms – fatigue, weight loss, anorexia, depression. Ascites. ```

Question 38

Blood test for ovarian cancer

Answer 38

CA125

Question 39

Next step in ovarian cancer investigations following positive CA125 (>35)

Answer 39

USS, particularly trans-vaginal USS

Question 40

definitive diagnosis for ovarian cancer

Answer 40

biopsy which is performed in secondary care.

Question 41

which type of endometrial/uterine cancer is not linked to oestrogen, grows faster and more likely to spread

Answer 41

type 2