Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
64 Cards in this Set
- Front
- Back
|
What is the most common gynae cancer?
|
Endometrial cancer
|
|
|
Risk factors for endometrial cancer?
|
Old age
Early menarche and late menopause Prolonged oestrogen exposure (Tamoxifen, HRT, Obesity, PCOS) Nuliparity High SES Hx of infertility Diabetes HTN Family history - HNPCC Lynch II |
|
|
What factors are protective against endometrial cancer?
|
Pill - reduces risk by 50%
Normal periods |
|
|
Sx of endometrial cancer
|
Irregular vaginal bleeding
Discharge Postmenopausal bleeding Abdominal distension Dysuria |
|
|
What is the most common form of endometrial cancer?
|
Adenocarcinoma
|
|
|
What investigations should be done for endometrial cancer?
|
Outpatient endometrial sampling
Ultrasound - to look for fibroids, adenomyosis, polyps, endometrial hyperplasia Hysteroscopy Dilatation and curettage Ca125 can suggest spread outside the uterus |
|
|
Treatment for endometrial cancer?
|
Hysterectomy + bilateral oopherectomy and salpingectomy
Peritoneal cytology Pelvic +/- para-aortic node disection Radiotherapy and chemotherapy (for advanced disease only) Hormones |
|
|
What cells is ovarian cancer derived from?
|
90% Coelomic epithelium
Stromal cells (thecal, granulosa) Germ cells (rare) - occur in young women - require immediate surgery |
|
|
Risk factors for ovarian cancer?
Protective factors |
RF
Low fertility or low parity Early menarche or late menopause Incessant ovulation FHx Increasing age Protective OCP - 5 years decreases risk by 50% breast-feeding hysterectomy |
|
|
When is the peak incidence of ovarian cancers?
|
age 65
|
|
|
Can you screen for ovarian cancer?
|
Not really - screening tool are not very effective
Transvaginal ultrasound CA 125 - only 50% pts will have - low positive predictive value - in both benign and malignant but more likely malignenant - false positives and negatives High risk population (BRCA; HNPCC; FHx) Very easy to spread directly into peritoneal cavity so by the time it is picked up it too late |
|
|
What surgery can you do for ovarian cancer?
|
Prophylactic oopherectomy - FHx, genetic,
Staging lapartotomy - aim to identify pts who will benefit from adjuvant therapy - peritoneal washings and biopsies; omenectomy; appendectomy; pelvic and paraaortic lymphadenectomy TAHBSO - total abdominal hysterectomy with bilateral salpingo-oopherectomy Primary cytoreductive surgery - removal of as much tumour as possilble - optimal reduction < 2cm Interval debulking Palliative Chemotherapy is not effective |
|
|
Although ovarian cancer is generally asymptomatic what Sx might you get?
|
Vague lower abdominal pain; abdominal distension; dyspepsia; anorexia, early satiety
Sx of mass effect = Urinary changes - frequency; constipation; increased abdominal girth (ascites or tumour) Menstrual changes |
|
|
What investigations should be done for a suspicious ovarian mass?
|
Bimanual examination (solid, irregular or fixed pelvic mass - ovarian cancer)
CA-125 - for basline - not diagnostic FBC, LFTs, EUC Transvaginal US - best to visualise ovaries CT scan - abdomen and pelvis - good for mets If abnormal vaginal bleeding - endometrial biopsy to rule out concurrent endometrial cancer, colposcoy +/- ECC to rule out cervical cancer, mammogram of breast lesion identified or RF |
|
|
At what stage do most epithelial ovarian cancers present
|
Stage III disease
|
|
|
What are borderline ovarian tumours
|
About 15% of all epithelial ovarian tumours
Tumour cells display malignant characteristics histologically but no invasion is identified Can metastasize but not common Generally slow growing with excellent prognosis |
|
|
Which malignant tumours cause an elevated CA-125?
|
Ovarian, Uterus
Pancreas, stomach, colon, rectum |
|
|
Which non-malignant tumours cause an elevated CA-125
|
benign ovarian neoplasm
Endometriosis Pregnancy Fibrosis PID Cirrhosis Pancreatitis Renal failure |
|
|
RF for cervical cancer
|
Early coitarche
Low SES Multiple sexual parnters Smoking HPV exposure (oncogenic subtypes) |
|
|
Presentation of cervical cancer
|
Vaginal bleeding - post coital or intermenstrual
Vaginal discharge pain Urinary or bowel symptoms |
|
|
How is cervical cancer diagnosed?
|
Papsmear
Colposocopy Biopsy |
|
|
Describe the possible findings on a papsmear/biopsy
|
1. Possible low grade - changes could be due to infalmmation, HPV or infection (bacteria, virus, fungi, yeast etc)
2. Definite low grade squamous intraepithelial lesion - changes usually due to HPV - may be called HPV changes or CIN 1 3. High grade - very likely to be CIN 2 or CIN 3 (moderate or severe dysplasia) 4. Cancer NB: CIN only diagnosed on biopsy |
|
|
What are the treatments for cervical dysplasia?
|
1. Large loop excision of the transformation zone
Semi-circular wire loop removes the portion of the cervix that contains the precancerous changes - tissue is not destroyed and can be sent to pathology 2. Laser vaporises or burns the abnormal tissue 3. Cone biopsy Usually done when papsmear results indicate abnormal changes in glandular cells, abnormal cells are in the endocervical canal or early cancer is suspected - cone shaped or cylinidical section of the cervix containing the abnormal cells is removed suing a laser or scalpel |
|
|
Discuss the possible complications of treatment for cervical dysplasia (i.e. LLETZ, laser, cone biopsy)
|
Haemorrhage
Infection Cervical stenosis - painful periods, difficulty with labour or infertility Cervical incompetence - risk of miscarriage or preterm labour rarely - damage to bowel or bladder LLETZ Burns to the top of the vagina or vulva (heal without complication - not painful) |
|
|
What is the treatment for cervical cancer?
|
Surgery = Hysterectomy and pelvic lymphadenectomy (can spare ovaries if pre menopausal)
Radical trachelectomy (removal of cervix) if fertility is desired Radiotherapy has similar outcomes to surgery Adjuvant = Chemo or brachytherapy |
|
|
What are the 2 types of hydatidform mole?
|
Partial and complete
Occur in 1/1000 pregnancies Refers to a spectrum of proliferative abnormalities of the trophoblast |
|
|
What is the chromosomal make-up of a complete mole
|
46 XX or 46XY- chromosomes completely of paternal origin
- 2 sperm fertilise empty egg or 1 sperm with reduplication Diffuse trophoblastic hyperplasia, hydropic swelling of chorionic villi, no fetal tissues, or membranes present |
|
|
Are incomplete or complete moles malignant?
|
Complete - No but there is a 15-20% risk of progression to malignant sequelae
Incomplete - No there is < 4% risk of malignancy |
|
|
What is the chromosomal make-up of an incomplete mole?
|
Often triploid - XXX, XXY, XYY
Chromosome complement from both parents usually related to single ovum fertilised by 2 sperm |
|
|
What clinical feature in pregnancy should make you think of gestational trophoblastic disease?
|
Development of hypertension early in pregnancy (< 20 weeks)
|
|
|
Which type of hydatid mole is associated with fetal parts?
|
incomplete mole is associated with fetus or fetal parts
There is no fetal membranes or tissues present in the complete mole |
|
|
Which type of mole has the feature of uterus large for dates?
|
Complete mole
|
|
|
What is the classic US finding for complete mole
|
No fetus - just a snow storm due to swelling of villi
|
|
|
What is the US appearance of an incomplete mole?
|
Molar degeneration of placenta +/- fetal anomalies, multiple echogenic regions corresponding to hydropic villi and focal intra-uterine haemorrhage
|
|
|
Management of hydatid mole?
|
Suction D&C with sharp curettage and oxytocin
Consider hysterectomy if patient no longer desires fertility Prophlyactic chemo - no proven benefit Chemotherapy for GTN if develops after evacuation |
|
|
What kind of follow-up is required of hydatid moles after treatment?
|
Contraception to avoid pregnancy
Serial Beta HCGs every week until negative (usually takes several weeks, then montly for 6-12 months) - prior to trying to conceive again increase or plateau of beta HCG indicates GTN -> patient needs chemotherapy |
|
|
What are the 3 types of malignant gestational trophoblastic neoplasia
|
Invasive mole or persistent GTN
Choriocarcinoma Placental site trophoblastic tumour |
|
|
What type of cancer is found in the fallopian tube?
|
Adenocarcinoma
|
|
|
What is the classic triad seen in fallopian tube cancer?
NB: this only occurs in 15% of patients |
watery discharge (most specific) = hydrops tubae profluens
vaginal bleeding or discharge - 50% of patients crampy lower abdominal/pelvic pain |
|
|
What is the cell type in the majority of vulvar cancers?
|
Squamous cell carcinoma
Remainder: basal cells, paget's bartholin's gland carcinoma |
|
|
What are the 2 types of vulval cancer
|
Type I - HPV related - younger women (type 16 and 18)
Type 2 - non HPV related, associated with current or previous vulvar dystrophy - post menopausal women |
|
|
What are the RF for vulval cancer
|
HPV infection
VIN (vulval intraepithelial neoplasia) = precancerous change which presents as multicentric white or pigmented plaques on vulva - progression to cancer rarely occurs with appropriate management (excision or ablation) |
|
|
Where do most lesions occur in vulval cancer
|
1. Labia majora
2. Labia minora 3. clitoris or perineum |
|
|
How does vulval cancer commonly present?
|
Localised pruritus or mass (most common)
Raised red, white, or pigmented plaque, ulcer, bleeding, discharge, pain, dysuria |
|
|
Differential diagnosis for woman with post menopausal bleeding
|
Endometrial cancer; Cervical cancer; Ovarian cancer; Uterine cancer
Atrophic endometrium, endometrial hyperplasia Polyps (endometrial/endocervical) Vaginal atrophy (most common) Lichen sclerosis Withdrawal from exogenous oestrogen Vaginal/endometrial infection Iatrogenic - IUD; ring; HRT Trauma |
|
|
Define post menopausal bleeding
|
Vaginal bleeding 6 months after menopause
|
|
|
What type of things should you ask in a history of a woman with postmenopausal bleeding
|
Colour - dark or fresh
Timing - post coital - cervical cancer Onset of bleeding in relation to menopause Associated symptoms - dyspareunia, vaginal irritation - atrophic vaginitis - weight loss, abdominal pain, swelling - Ca Menstruation - early menarche, late menopause - endometrial ca Papsmear Previous hysterectomy GP - nulliparous risk of endometrial cancer Past medical hx Prolonged oestrogen therapy - increased risk of endometrial ca |
|
|
Investigations in a woman with post menopausal bleeding
|
Abdo palpate - fibroids, masses
Bimanual exam Speculum exam + papsmear FBC, CA125, LFTs, EUC, CRP Transvaginal US - fibroids, masses Hysteroscopy - polyps, fibroids + Endometrial biopsy - D/C Vulval biopsy if indicated Vaginal and endocervical swabs if discharge |
|
|
What are leiomyomatas
|
fibroids
Benign smooth mm tumour of the uterus Most common gynaecological tumour |
|
|
Are fibroids malignant or can they become malignant
|
They aren't malignant
They have minimal malginant potential - 1:1000 BUT enlarging fibroids in a post menopausal women should prompt consideration of malignancy |
|
|
Clinical features of fibroids
|
Majority asymptomatic
Abnormal uterine bleeding (dysmenorrhea, menorrhagia) pressure/bulk sx - pelvic pressure/heaviness, urinary frequency, urgency, acute urinary retention (rare but surgical emergency) , constipation, bloating Acute pelvic pain if fibroid degeneration, fibroid torsion (pedunculated subserosal) Infertility (submucosal) |
|
|
What are the 4 types of fibroids
|
Subserosal
Intramural Submucosal Pedunculated - subserosal or submucosal |
|
|
What are the potential pregnancy complications of fibroids
|
potential enlargement and increased pain, obstructed labour, difficult C-section
|
|
|
What are the different treatments for fibroids?
|
Treat only if symptomatic, enlarging or menorrhagia
1. Watch and wait - Sx minimal, fibroids < 6-8cm, not submucosal 2. Medical - antiprostaglandins, tranexamic acid, OCP/depo-provera, GnRH agonist 3. Uterine artery embolisation occludes both uterine artiers - shrinks fibroids by 50% at 6 months (NOT an option if wanting to childbear) 4. Surgery - myomectomy, endometrial resection of fibroid and endometrial ablation for menorrhagia; hysterectomy DON"T operate during pregnancy - icnreased vascularity and potential pregnancyh loss |
|
|
What is a dermoid cyst
|
Germ cell tumour
Benign cystic teratoma that contains elements of all 3 cell lines - dermal appendages (sweat and sebaceious glands, hair follicles, teeth) |
|
|
Treatment for a dermoid cyst
|
Laparoscopic cystectomy
BUT may recur |
|
|
What are the complications associated with benign cysts
|
Most are asymptomatic BUT
they can rupture or undergo torsion - pain (originates iliac fossa - radiates to the flank) |
|
|
What types of benign functional ovarian cysts can you get?
|
Follicular
Lutein Theca-lutein Luteoma of pregnancy Endometrioma (chocolate cyst = endometriotic cyst within ovary ) |
|
|
Pathogenesis of a follicular ovarian cyst
|
Follicle fails to rupture during ovulation
|
|
|
What is the pathogenesis of a lutein ovarian cyst
|
corpus luteum fails to regress after 14 days becoming cystic or haemorrhagic
|
|
|
What is the pathogensis of a theca lutein cyst?
|
Due to atretic follicles stimultaed by abnormal B-HCG levels
Often during molar pregnancy, choriocarcinoma |
|
|
Management of follicular cyst and lutein cyst
|
Symptomatic or suspicious - surgical exploration
If < 6cm - wait 6 weeks and re-examine - will usually regress with next cycle OCP (ovarian suppression) will prevent development of new cysts |
|
|
Management of theca-lutein cysts
|
Conservative - they will regress as beta HCG levels fall
|
|
|
What is a luteoma?
|
Occurs usually during multiple pregnancy
It is a benign functional ovarian cyst that is usually bilateral and due to prolonged elevation of B-HCG |
