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Obstetrics and Gynaecology > Gynaecology Oncology > Flashcards

Gynaecology Oncology 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 pelvic pain or pressure?

A

Ovarian
Uterine
Vulvar

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3
Q

What cancers present with abdominal pain and bloating?

A

Ovarian

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4
Q

What cancers present with change in bowel habits?

A

Ovarian

Vaginal

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5
Q

What cancers present with itching or burning of the vulva?

A

Vulvar

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6
Q

What cancers present with changes in vulva colour or skin?

A

Vulvar

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7
Q

When does cervical cancer most commonly affect women?

A

25-34yo

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8
Q

Histologically, what type of cancer can cervical cancer be?

A

70% squamous
15% adenocarcinoma
15% mixed

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9
Q

What is squamous cell cervical cancer commonly associated with?

A

99.7% contain HPV DNA

HPV 16 and 18

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10
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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11
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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12
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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13
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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14
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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15
Q

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

A

Urgent colposcopy and biopsy

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16
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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17
Q

Where does cervical cancer metastasise to?

A

Lung
Liver
Bone
Bowel

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18
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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19
Q

What is a trachelectomy?

A

Removal of the uterine cervix

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20
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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21
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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22
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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23
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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24
Q

What is a smear poor at picking up?

A

Adenocarcinomas

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25
How are smear results categorised?
``` Borderline or mild dyskaryosis Moderate dyskaryosis - CIN II Severe dyskaryosis - CIN III Suspected invasive cancer Glandular neoplasia Inadequate ```
26
What is done if a smear comes back as HPV negative?
Return to normal recall
27
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
28
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
29
What should be done if a smear is inadequate?
Repeat smear If persistent (3 inadequate samples) - colposcopy assessment
30
What is the peak age of endometrial cancer?
65-75 years old
31
What is the most common type of endometrial cancer?
Adenocarcinoma
32
What is happening to the incidence of endometrial cancer?
Rising - possibly due to obesity
33
What is the pathophysiology of endometrial cancer?
Most due to unopposed oestrogen stimulating endometrium No protective effects of progesterone
34
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 ```
35
How does endometrial cancer present?
Post-menopausal bleeding Clear/white vaginal discharge Pre-menopausal - abnormal bleeding, pelvic pain and dyspareunia
36
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
37
How is stage 1 endometrial cancer managed?
Total hysterectomy + bilateral salpingo-oophorectomy + peritoneal washing
38
How is stage 2 endometrial cancer managed?
Radical hysterectomy + pelvic lymphadenectomy + radiotherapy
39
How are stage 3/4 endometrial cancer managed?
Maximal debulking + chemo + radio May palliate
40
What is the difference between a total and radical hysterectomy?
Total: uterus + cervix removed Radical: uterus + cervix + parametrium + top part of vagina removed
41
What can be protective against endometrial cancer?
COCP | Smoking
42
What is endometrial hyperplasia?
Thickening of uterine cavity due to too much oestrogen with too little progesterone
43
How is endometrial hyperplasia managed?
Hyperplasia without atypia - progesterone (Mirena coil) + surveillance biopsies Atypical hyperplasia - as stage 1 - total hysterectomy + bilateral salpingo-oophorectomy + peritoneal washing High risk of becoming malignant
44
What is the peak age women get ovarian cancer?
60 years old
45
How can ovarian cancer be classified?
Epithelial - 90% Germ cell Sex cord stromal
46
What are the types of epithelial ovarian cancers?
Serous, mucinous, endometriod etc. Arise from surface epithelium due to irritation during ovulation
47
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
48
What do sex-cord stroll ovarian cancers arise from?
Connective tissue cells
49
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 ```
50
What must be done in women >50yo with a new onset of IBS?
Ovarian cancer testing - can present similarly
51
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
52
What other tests can be done in <40yo in primary care for suspected ovarian cancer? Why?
AFP Beta HCG Raised levels suggest alternate tumours
53
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
54
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 ```
55
What are the protective factors against ovarian cancer?
Reduced ovulations - multiparity - breastfeeding - COCP
56
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)
57
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
58
What features on USS of ovaries cause concern?
``` Multilocular cyst Solid areas Metastasis Ascites Bilateral lesions ```
59
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
60
What is the management for ovarian cancer?
Combination of surgery and chemo Laparotomy - tumour debunking Hysterectomy, salpingo-oophorectomy and infra colic omentectomy
61
How is ovarian cancer followed up?
5 year CA125 monitoring
62
What is the epidemiology of vulval cancer?
Very rare cancer 90% squamous Mostly >75yo
63
How do vulval cancers present?
Lump Ulceration + bleeding Pruritus Pain
64
When would you refer someone to gynae under 2 week wait for suspected vulval cancer?
Lump | Ulceration + bleeding
65
Where do vulval cancers affect?
Labia majora - 50% Labia minora - 20% Clitoris and bartholin's glands - infrequent
66
What are the risk factors for vulval cancer?
VIN HPV Lichen sclerosus
67
How is vulval cancer diagnosed?
Examination and biopsy
68
Where do vulval cancers spread?
Inguinal and femoral lymph nodes
69
How are vulval cancers managed?
Surgical - radical or wide local resection Senitel lymph node biopsy +- groin node dissection Reconstructive surgery often performed
70
What is VIN?
Premalignant state that occurs spontaneously or due to pre-existing vulval disorder such as lichen sclerosis
71
How does VIN present?
Itching | Plaque like white patches
72
How is VIN diagnosed?
Biopsy - confirm not invasive cancer
73
How is VIN managed?
Laser therapy | Wide local excision
74
What are some complications of a Lletz biopsy (for suspected cervical cancer)
Scarring = cervical stenosis Cervical incompetence Infection and pyometra

Obstetrics and Gynaecology (21 decks)

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