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64 Cards in this Set

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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