23. Gynaecology Oncology Flashcards
Ovarian cancer presentation:
80% occur in postmenopausal women, peaks in 70s
Ovarian cancer signs and symptoms
o Abdominal distension
o Bloating and ascites
o Pelvic/abdominal pain and mass
o Urinary urgency/Frequency
Investigations in ovarian cancer
- Cancer markers: (CA125 >30U/L, germ call markers AFP/HCG, LDH)
- Ascitic tap (cytology)
- USS – ascites, tumours, blood flow on doppler
- Image guided biopsy, laparoscopy or laparotomy
Ovarian cancer management:
- Combination of treatment and 6 cycles of chemotherapy
- Surgery
- +- Adjuvant treatment
Combination surgery and chemotherapy for ovarian cancer:
- PDS Primary Debulking Surgery, followed by 6 cycles of chemotherapy OR
- 3 cycles of NACT neo-adjuvant chemotherapy, IDS Interval Debulking Surgery, 3 further cycles of chemotherapy OR
- 6 cycles of NACT, DDS Delayed Debulking Surgery, 2 further cycles of chemotherapy
Combination surgery and chemotherapy for ovarian cancer (Shortcut):
- PDS, 6CT
- 3NACT, IDS, 3CT
- 6NACT, DDS, 2CT
TAH BSO
Total abdominal hysterectomy and bilateral salpingo-oophorectomy
Surgery for ovarian cancer:
- TAH BSO
- Omentectomy
- Bowel resection
- Removal of masses and nodes
Adjuvant treatment for ovarian cancer:
- Adjuvant chemotherapy
- Chemotherapy (carboplatin and paclitaxel 3 weekly)
- Vascular endothelial growth factor inhibitor (Bevacizumab)
- PARP inhibitors (BRCA- Olaparib, Non-BRCA-Niraparib)
Radiotherapy in ovarian cancer treatment:
NO role
Adjuvant chemotherapy – disease grades:
For all I-IVb aside from:
- Low grade serous 1A
- Grade 1 and 2 endometroid 1A
- Grade 1 and 2 mucinous 1A
Chemotherapy variants in ovarian cancer:
- Single agent: carboplatin
- Neutropenia, thrombocytopenia, neuropathy, alopecia – paclitaxel
Classification of ovarian cancer:
Primary (Epithelial, Stromal, Germ cell)
Secondary/Metastatic
Epithelial ovarian cancer examples:
- High grade serous carcinoma
- Low grade serous carcinoma
- Endometrioid
- Mucinous
- Clear cell
Aetiology of ovarian cancer:
Factors reducing a number of ovulations reduces risk of ovarian cancer
Ovarian cancer risk reduction:
- Pregnancy
- COCP
- Sterilisation
Ovarian cancer risk increase:
- HRT
- Age>50
- Endometriosis
- Subfertility
- Familial cancer (BRCA1, BRCA2, RAD51C/D, BRIP1)
Patterns of spread of ovarian cancer:
1) Transcoelomic
2) Lymphatic to pelvic and paraaortic lymph nodes
Follow up tests for ovarian cancer:
- CA 125
- CT
Staging of ovarian cancer:
Stage I (ovaries only) Stage II (spread to pelvis) Stage III (spread to peritoneal cavity and retroperitoneal lymph nodes) Stage IV (spread to liver, or distant metastasis)
Ovarian germ cell tumours examples:
- Mature cystic teratoma
- Struma ovarii (thyroid tissue in ovarian mass)
Ovarian germ cell tumour:
- Young women or children
- AFP, hCG, LDH (all raised)
- Conservative surgical management
Endometrial cancer presentation:
- Average onset 63yo
- Most are postmenopausal
Symptoms of endometrial cancer:
- Postmenopausal bleeding or menstrual abnormality
Investigations for endometrial cancer:
- USS (thickened endometrium >5cm)
- Endometrial biopsy (sampling, hysteroscopy)
- MRI (myometrium and pelvic nodes)
- CT chest/abdomen/pelvis
Primary treatment for stage 1-2 endometrial cancer:
- Hysterectomy and BSO
- Lymphadenopathy and Sentinel lymph node biopsy
- Surgery
Primary treatment for stage 3-4 endometrial cancer:
- Hysterectomy
- Lymphadenectomy
- Removal of all visible disease
Hormonal treatment for endometrial cancer:
- High oral dose progesterone and progesterone IUD
- Fertility sparing (grade 1 tumour)
- Unfit for surgical management
Endometrial cancer pathology/type:
- Adenocarcinoma (endometrioid)
- Sarcoma (leiomyosarcoma, endometrial stromal sarcoma, undifferentiated sarcoma)
Molecular stratification of endometrial cancer:
- MMR abnormal (mismatch repair gene immunohistochemistry)
- POLE mutant (DNA polymerase epsilon)
- P53 wild type (protein product of TP53)
- P53 mutant (aggressive, adjuvant therapy)
Endometrial cancer FIGO staging:
Stage I (body of uterus) IA (<0.5 myometrium invaded) or IB (more than >0.5) Stage II (cervical stroma) Stage III (extends outside of the uterus) IIIA (serosa of uterus and adnexa) IIIB (+vaginal involvement) IIIB (+nodal involvement Stage IV (involvement of bladder and rectum)
Adjuvant treatment for endometrial cancer:
Radiotherapy (improves local control but not survival)
Hormonal therapy (stage III/IV disease, uncertain benefit)
Chemotherapy (Advanced disease)
How does recurrence of endometrial cancer present?
Vaginal bleeding and pain (majority within 3 years)
Cervical cancer demographics:
Peaks at 30-35 and 80-85 yo.
Symptoms of cervical cancer:
- Abnormal vaginal bleeding and discharge
- Advanced cases: lower limb oedema, haematuria, pelvic pain,
3 examples of abnormal vaginal bleeding:
- Postcoital
- Intermenstrual
- Postmenopausal
Diagnosis of cervical cancer:
- Colposcopy and cervical biopsy
- Examination Under Anaesthesia
- MRI pelvis, CT chest/abdomen/pelvis
Cervical cancer staging:
Stage I: confined to cervix
Stage II: beyond uterus
Stage III: pelvic side wall, lower 1/3 vagina or hydronephrosis, pelvic nodes
Stage IV: outside true pelvis or involving bladder/rectum
Surgical treatment of cervical cancer:
- Cone biopsy or simple hysterectomy
- Radical hysterectomy complications
- Primarily Stage I
Chemoradiotherapy treatment of cervical cancer:
- Stage IB-IV
- Radiotherapy
- Brachytherapy to central tumour
- External beam radiotherapy
- Platinum-based chemotherapy
Radiotherapy chronic complications:
- Proctosigmoiditis, cystitis
- Fistulas (rectovaginal, vesicovaginal)
- Small bowel obstruction or fistula
Adjuvant treatment for cervical cancer:
Chemoradiotherapy – post-op for high risk factors
- Lymph node involvement
- Positive surgical margins
- Invasion of paracervical tissue
- Lymphovascular invasion
Recurrence of cervical cancer – treatment:
- Previous surgery -> radiotherapy
- Previous radiotherapy -> removal of pelvic organs
- Chemotherapy is palliative
Preinvasive states for cervical cancer:
- CIN (cervical intraepithelial neoplasia)
- AIS/CGIN (adenocarcinoma in situ/ cervical glandular intraepithelial neoplasia
Aetiology of cervical cancer:
- HPV infection, strains 16, 18 – invasive disease
- These 2 produce E6 and E7 proteins that inhibit the function of tumour suppressor genes (p53 and RB)
Risk factors for cervical cancer:
- Early age 1st intercourse
- Multiple sexual partners
- Smoking
- HIV
- High grade cervical intraepithelial neoplasia
Vulval cancer presentation:
- Pruritis
- Pigmentary changes
- Vulval bleeding, discharge, dysuria
- Vulval lump or mass
Vulval cancer staging:
Stage I: confined to vulva
Stage II: extended to adjacent perineal structures and negative nodes
Stage III: extended to adjacent perineal structure and positive inguino-femoral nodes
Stage IV: invasion of other regional structures (anus, rectum, upper vagina)
Treatment for cancer staging:
- Primary lesion (radical local excision or vulvectomy)
- Regional lymph nodes dissection (inguinal node)
- Adjuvant radiotherapy (irradiation of pelvic and groin with >2 nodes involvement
Complement for Lupus
Complement: C3 and C4, both decreased
HELLP
H - haemolysis (elevated LDH)
EL – elevated liver enzymes (AST, ALT)
LP – low platelets (thrombocytopenia)
Red cell casts diagnosis:
Glomerulonephritis
