Gynae Onc Flashcards
Staging endometrial cancer
1 limited to uterus
Up to 8% have vaginal mets
<70% have node dx
A endometrium/ <50% myometrium
B 50% myometrium, not beyond uterus
2 into cervical stroma
3 local/ regional spread
A into serosa +/- adnexa
B vagina/ parametrium
C pelvic/ paraaortic nodes
4 rectum/ bladder +/- distant mets
Sarcoma
1a <5cm
1b >5cm
2a adnexa
2b extrauterine pelvic tissue
3 invades abdominal organs
A - 1
B >1
C nodes
4a bladder/ rectum
4b distant mets
Staging ovarian cancer
Stage 1 - one or both ovaries
A - 1 ovary, no surface disease and neg washings
B - both ovaries and no surface disease and neg washings
C 1/ both surgeries with spill (during surgery 1c1 or before 1c2 or + washings ascites 1c3)
Stage 2 - spread to lower pelvic structures
A uterus/ tubes
B other intraperitoneal tissues
Stage 3 - 1 or 2 with implants outside pelvis/ + retroperitoneal nodes
A + nodes +/- microscopic mets out of pelvis
B macroscopic extra pelvic peritoneal mets <2cm +/- retroperitoneal nodes (inc liver/ spleen capsule)
C as above but >2cm
Stage 4
A pleural effusion with + cytology
Other - liver, spleen and extra abdo organ mets
Staging cervical cancer
Investigations endometrial cancer
Exam:
Abdo, if fixed/bulky likely advanced, groin (nodes), vulva/vagina (bimanual), ascites
Sample lining - pipelle (>90%sens) and likely hysteroscopy D&C ~70% cavity sampled
If low grade endometroid (1-2): Pelvic MRI (degree of myometrial involv) and CXR
If grade 3/ sarcoma: CTCAP (90% nodal dx is microscopic)
?PET if concern for node involvement
Investigations ovarian cancer
Imaging:
Young: USS/ MRI
If >45yrs CT - or concerning features on USS
Ca125
>80% stage 3 and 50% stage 1 will be +
(1% healthy women)
Young: bhcg, afp, lash (germ cell), sex chord - test, E2, FSH, inhibin,
All: CEA (1-3 mucinous, can look at ratio with CA125)
Ca 19-9 >70% mucinous, 25% serous
And for other causes of pelvic mass
ORADS scoring risk of malignancy based on complexity 1-5 (1 physiological, 5 >50% risk malignancy)
Investigations cervical cancer
Treatment endometrial ca
MDT - confirm pathology, further imaging
Staging and grading
Gold standard: now laparoscopic radical hysterectomy, BSO and washing’s + nodes (as per LACE)
If <45 and low stage can leave ovaries (if RF for ovarian cancer ?remove)
(Prev TAH and BSO with washings and nodes)
Assess for extra uterine spread - stage 4, may abandon
Pelvic lymph node dissection Nodes centre specific esp if low stage/ grade - improved staging, no survival benefit
Recommend if >grade 2/ >50% myometrium, extra uterine mets, enlarged nodes, type (serous, clear cell)
Consider sentinel node mapping
>96% sens
Less morbidity
Washings: not part of staging but for prognosis if +ve
Consider brachytherapy if non resectable/ not surgical candidate
Adjuvant: grade 3+/ stage 1c+, + nodes
Palliation (chemo rad stage 3/4)
No imp survival < stage 2 but less local recurrence
Progesterone - optimisation of co-morbidities
Manage sx
If palliative
Chemo: carboplatin, carbopaxil
Follow up: 3/12 for 2+ yrs, 6/12 for 5+ Inc exam
Consensus based, not good evidence
Stage 1a/b and low grade - hyst, BSO, washings
Stage 1c+, high grade stage 1 - Inc PLND, consider Brachy
Treatment cervical ca
Treatment ovarian cancer
Early stage 1-2 (1a and b no residual disease)
(USO and staging (if young/ fertility preserving)
Washings, omental bx)
TAH and BSO and staging
If no obv disease except ovaries - washings, omentectomy, pelvic/ para-aortic node sampling
Other 1 and 2 - surgery as above and chemo
Advanced - stage 2-4a
Primary debulking vs neo-adjuvant chemo
Primary cytoreduction - eliminate macroscopic tumour (aim <1cm) + adj chemo
(Exploratory midline incision, explore peritoneal surfaces, ascites for cytology)
Can neo-adjuvant chemo then interval debulking (3 cycles, surgery, chemo)
Chemo (not fit for surgery)
IV/ intraperitoneal
Epithelial - carboplatin, paclitaxel
Stromal - vincristine, cyclophosphamide, bleomycin, cisplatin, paclitaxel
VEGF inhibitors - bevacizumab (slow tumour progression, reduces ascites)
PARP inhibitor
Follow up
Post op 4-6 weeks (recovery, support, histo)
High recurrence rates
Consider genetic testing
MDM - 3-4/12 for 2 yrs, annual 5yrs
No evidence for imaging surveillance
Consider Ca125 for recurrence of raised at dx
Borderline tumours
Tumours of low malignant potential
1/3 <40 so unilateral SO (is stage one/ wanting fertility)
TAH and BSO if stage 2+
50% have N Ca125
Can send frozen section during
Mostly serous/ mucinous
Serous
70%
usually slow growing/ confined to ovary
23% recurrence with cystectomy
11% with USO
5% with BSO
Risks: infertility, G0, IVF
Risk reduction: COCP, parous, BF
10y survival >95%
Mucinous
11%
10-30% microinvasion
If assoc pseudomyxoma peritonei likely from appendix (remove appendix if concern)
Endometriod
2-10%
Histo like complex endometrial hyperplasia
Recurrence - can be as peritoeal
Chemo types
Endometrial hyperplasia types and management
Investigation:
USS ET>4mm
Pipelle endometrial bx (will miss 2%)
Hysteroscopy D&C
Smear
Examination
Risk factors - manage (weight, smoking, unopposed oestrogen)
Without atypia
80% spont resolve
<5% cancer progression >20 yrs
Progesterone: levonogestrel IUCD> PO (prov 10-20mg OD or norethist 10-15mg OD)
Surgery - not 1st line
6/12 surveillance - biopsy (if resolves and no RF can d/c if ongoing RF annual surveillance)
If remains ? Cont vs hysterectomy
Histo: crowding of enlarged glands in stroma w/out nuclear atypia
With atypia / EIN
Lifestyle and MDT
Consider fertility referral
If wanting fertility - D&C (don’t miss cancer) and progesterone
70% regression, 25% recurrence after stopping
Biopsy 3, 6, 12/12 then can stop for fertility
Recommend hysterectomy later
1st line: laparoscopic hysterectomy +/- BS +/- O (ideally conserve if <45yrs - discuss risks/ benefits)
Histo: endometrial glands with enlarged cells, inc nuclear:cytoplasmic ratio, irregular nuclei
25-60% (40) coincide with cancer on histo
Endometrial cancer
90% uterine cancers
Lifetime risk 3%
25% have known hyperplasia
Incidence 60s
Worse if high stage, grade 3, older, >2%, clear cell, serous, adeno-squamous
75% stage 1 at dx
Biopsy helpful if >50% cavity involved
Endometrial cancer RF
Obesity
Chronic anovulation/ PCOS
Nulliparoua
DM
Hyperplasia
Tamoxifen 3% >5 yrs (2-3x Inc risk)
Ix if sx
Oe secreting tumours (granulosa cell/ germ cell)
Genetic syndromes (lynch, cowden)
Surgical procedures
(MDM decision)
Consent - Inc alternatives, risks and benefits
Pre-op: consent, anaesthetic review and optimise other health conditions, social work
Bloods - CBC, iron, group and hold, UEC, ?coags
In OT:
WHO checklist - Inc sign in, check allergies, HCG, VTE px, procedure, concerns, abs
Position
Prep
Time out
Catheter
Procedure steps
Sign out - procedure confirmed, concerns, EBL, histo, plan for post op
ERAS - mobile, TROC, E&D, prepped for home, PT/OT/SW
Plan for follow up - info re histo
Advice re wound care, mobilisation, driving
Review in ….months
