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
Endometrial ca types
Type 1
>80%
Low grade, endometroid adenocarcinoma
Well diff
Precursor: hyperplasia
Good prognosis, earlier px, younger women
Oe driven
Assoc PTEN
Type 2
Higher grade, aggressive, less common
Assoc with older age, atrophy
Types:
Clear cell (<4%)
serous (10%)
carcinosarcoma
Inc risk relapse
Not Oe sens
Assoc p53, HER2, P16
sarcoma (<10:100000), aggressive, low grade - adeno-, high grade leiomyo-, RF (FH, RT, tamoxifen) 1/3 extra uterine on dx
Treat: RT if high grade otherwise surgery
Colposcopy perform
CIN management
Vulval - VIN and LS
Vulval cancer
Vulval cancer management
Vaginal cancer management
Side effects Radiotherapy
Inflamed mucous membranes
Cystitis
Enteritis/ colitis/ proctitis
Vaginal ulceration
Desquamation of skin
Abnormal discharge
Fibrosis
Fistula
Sexual dysfunction
Vaginal stenosis
Adhesions
Premature ovarian insufficiency/
Menopause - fertility and long term health consequences
Fractures
Pain
Telangiectasia
Peritoneal cancer
Similar to ovarian
?originates in tubes
STIC
Familial cancer syndromes
Types and risks (not BRCA)
BRCA syndrome
Ovarian cancer and RF
Risk 1:70
10% hereditary
RF: age, exposure to oestrogen, white, infertility, endometriosis (RR 2), smoking (RR 2)
? Minor trauma with ovulation - Inc trauma, Inc risk malignant transformation
Reduce risk: surgery, salpingectomy>BTL, COCP (>5yrs >30% reduction), breast feed, multiparous, cycle suppression
STIC - 75% ovarian cancer
Most dx advanced dx <25% stage 1
Little evidence for follow up CA125/ USS
Ovarian cyst
Inc risk progesterone tx
Management ovarian cyst
Treat if persistent + symptomatic/ enlarging/ concerning features
If large/ concern for borderline/ ca - avoid spillage (remove intact and into bag or laparotomy)
Risk of upstaging
In young - aim cystectomy, consent for risk of oophorectomy
Option for frozen section during to decide on surgery or whether to complete at later date after MDM
Check pelvis for extra ovarian dx, photos
Complications of cyst: rupture, haemorrhage, torsion, pressure sx
Ovarian torsion USS signs
Lack of blood flow colour Doppler (may miss if intermittent)
Enlarge ovary (oedema/ haematoma)
Probe pressure
Midline position
Free pelvic fluid
Torsion management
NBM
Imaging
Analgesia
Laparoscopy and aim to detort (aim to preserve if young)
Consider pexy
*if <48h then good chance of viability (more predictive than look of ovary)
?oophorectomy in pregnancy (Inc risk recurrence) - consider affect on ovarian reserve
Differentials ovarian cyst
Physiological - follicular (failed ovulation), corpus luteum (after ovulation, blood accumulation in centre)
Benign: endometriosis, theca lutein cyst (assoc with high HCG - molar, ov induction), epithelial cysts (serous cystadenoma, mucinous cystadenoma), brenner tumour, fibroma, mature teratoma (dermoid)
Borderline (low malignant potential) - serous, mucinous, endometroid
Malignant: high or low grade serous, mucinous carcinoma, endometroid carcinoma (assoc with endometrial cancer 15-20%), clear cell carcinoma, sertoli leydig tumour (assoc androgens), immature teratoma and other germ cell
Ovarian cancer types
High grade serous
70-80% epithelial and malignant ovarian disease. Often advanced, age 50s, 10% BRCA, often debulk then chemo (sens to chemo platinum/paclitaxel), high recurrence.
Low grade serous
Uncommon. Advanced and poor prognosis. Insensitive to platinum chemo. Assoc borderline.
Mucinous carcinoma
25% cancer. Often present earlier. Assoc borderline. Often large. ? Appendix as primary.
Endometroid Carcinoma
>10% cancer. Chemosens. Better prognosis. Often found early. Assoc endometriosis. >15% have endometrial cancer.
Clear cell carcinoma
Perimenopause. Better prognosis. October found early. But if late - worse prognosis than serous/endometroid. Less sens platinum chemo.
Sex chord
5% cancer.
Granulosa cell majority in 50s (can be juvenile). Large unilateral. Sx of Oe/ progesterone (precocious puberty) associated with endometrial hyperplasia >25%, cancer >5%.
Sertoli Leydig
Rarest. Androgen secreting. Unilateral and large. Raised AFP.
Germ cell
15% cancer
1/3 immature teratoma - LDH/AFP. Young. Chemo sens.
1/3 dysgerminoma - LDH.
Others Inc choriocarcinoma 2% GCT. Placental origin. Raised HCG.
