Gynae Onc Flashcards
Lynch Syndrome
1. Inheritance
2. Genes involved
3. Lifetime risk of Endometrial Ca
- Autosomal Dominant
- Defective DNA mismatch repair, which affects the MSH2, MLH1, MSH6 and PMS2 genes.
- 25-60% lifetime risk of EC and present at younger ages.
What pre op work up is required for Granulosa Cell tumour ?
Endometrial biopsy - this releases oestrogen which may result in endometrial changes.
Stromal cells include:
- Theca cells
- Fibroblasts
- Leydig cells
Granulosa cells and Sertoli cells are present in…
Gonadal primitive sex cords
Sex cord stromal tumours
a) pure sex cord tumours
b) pure stromal tumours
A) Pure sex cord tumours
- Granulosa cell tumour (adult type and juvenile type)
- Sertoli cell tumour
- Sex cord tumour with annular tubules
B) Pure stromal tumours
- Fibroma
- Thecoma
- Fibrosarcoma
- Leydig cell tumour
C) Mixed sex cord stromal tumours (Sertoli-Leydig tumours)
Germ Cell Tumour
- Teratoma
- Embryonal carcinoma
- Non gestational choriocarcinoma
- Dysgerminoma
- Yolk sac tumour
- Mixed germ cell tumour
Tumour markers to be performed in women under 40 with complex ovarian masses
- Ca125
- LDH
- AFP
- HCG
Tumour markets in postmenopausal women with complex ovarian mass?
- Ca125
- CEA
- Ca19.9
Can aid diagnosis and indicate the likelihood of mucinous or Krukenberg tumours (upper or lower GIT)
Overall 5 year survival rate for ovarian Ca?
< 35%
Ovarian cancer is ? commonest cancer in women in the UK?
5th
(After breast, colorectal, lung, uterine)
Lifetime risk of being diagnosed with Ovarian Ca?
Lifetime risk of a women having ovarian ca who had a first degree relative with Ovarian Ca?
1 in 48.
5% lifetime risk if 1st degree relative.
Ca 125 should be measured in primary care if a patient reports any of the following ?
- Persistent abdominal distension or bloating
- Feeling full and or loss of appetite
- Pelvic or abdominal pain
- Increased urinary urgency and or frequenct
How to calculate RMI?
RMI = U x M x Ca125
U = US Score
(Multilocular cysts, solid areas, ascites, bilateral lesions).
M = menopausal status (pre = 1,
Post = 3)
RMI > ? Should be referred to specialist cancer centre
> 250
Stage I Ovarian Cancer:
- stage Ia
- stage Ib
- stage Ic (1c1, 1c2, 1c3)
Stage Ia: Tumour limited to 1 ovary, capsule intact, no tumour on surface, negative washings.
Stage Ib: Tumour confined to both ovaries with ovarian capsule intact and no tumour on the surface of the ovary. Peritoneal cytology is negative.
Stage Ic: tumour confined to both ovaries:
- 1c1 = surgical spill
- 1c2 = capsule rupture before surgery or tumour on ovarian surface
- 1c3 = malignant cells in the ascites of peritoneal washings
Stage II Ovarian Ca
Tumour involves 1 or both ovaries with pelvic extension (below the pelvic brim) or primary peritoneal cancer.
IIa: Extension and/or implant on uterus and/or fallopian tubes
IIb: Extension to other pelvic intraperitoneal tissues.
Stage III Ovarian Cancer?
Tumour involves 1 or both ovaries with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes.
IIIa: +ve lymph nodes and or microscopic metastasis beyond the pelvis
IIIb: macroscopic, extrapelvic, peritoneal mets < 2cm +/- pos retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen.
IIIc: macroscopic, extrapelvic, peritoneal mets > 2cm +/- retroperitoneal lymph nodes. Included extension to capsule of liver/spleen.
Stage IV Ovarian Cancer?
Distant mets including peritoneal mets.
IVa: pleural effusion with pos cytology
IVb: Hepatic and /or splenic parenchymal mets, mets to extra abdominal organs (Inc lymph nodes and lymph nodes outside of the abdominal cavity)
Ovarian Ca: treatment options for well/moderately well differentiated Stage Ia/IIb?
- TAH + BSO + Omentectomy
- Under surface of diaphragm should be visualised and biopsied
- Pelvic and abdominal peritoneal biopsies and pelvic and para aortic lymph node biopsies are required and peritoneal washings should be obtained.
Ovarian Ca: treatment for poorly differentiated Ia/Ib - stage II
- Adjuvant Chemotherapy - carboplatin single agent has been shown to significantly improve survival from 74% - 82%.
- Women with high risk stage I disease (grade 3 or stage Ic) should be offered adjuvant chemotherapy consisting of 6 cycles of carboplatin.
Ovarian Ca: treatment of Stage III and Stage IV?
- TAH + BSO + omentectomy and debulking + chemotherapy
- The volume of disease left at the completion of the primary surgical procedure is related to patient survival.
Surface Epithelial Stromal Ovarian Tumours:
1. Subtypes
2. Age group
3. Account for what % of all ovarian tumours?
4. Originate from?
- Serous, mucinous, endometrioid, clear cell, transitional cell
- Middle age or older, rare before puberty
- Account for 60% of all ovarian tumours and 90% or malignant ovarian tumours
- Originate from the surface epithelium of the ovary. Can be benign, borderline or malignant
Serous Ovarian Tumour - formed by cells resembling what?
Internal lining of the fallopian tube.
Types of serous ovarian tumour?
- Benign - serous cystadenoma
- Borderline serous tumour
- Malignant - serous cystadenocarcinoma
Serous Cystadenoma features ?
- Benign serous ovarian tumour.
- Thin wall cyst with straw coloured fluid. Int lining of the cyst is usually flat but may display a few course papillary projections.
- Account for 25% of all benign ovarian tumours and 66% of all ovarian serous tumours.
- 4th and 5th decade
- Bilateral in up to 20% of patients
Borderline Serous Ovarian Tumours
- More exuberant and finer papillary projections within the cyst cavity.
- Small tumourlets may be found within the abdomen or pelvis in up to 40% of patients.
- 10-15% of all ovarian serous tumours.
- 5th decade of life.
- 1/3 are bilateral.
Borderline serous ovarian tumour 5 year survival?
70 - 95% - treatment is surgical
Malignant serous cystadenocarcinoma features?
- Partially cystic with loculations, solid areas and delicate papillae the project into the cyst cavities
- Make up 33% of all ovarian serous tumours and 50% of all malignant ovarian tumours
- 6th decade
- 2/3rds are bilateral
- Most are widely disseminated at time of diagnosis
5 year survival rate for malignant serous cystadenocarcinoma? (Stage I-IV)
Stage 1 - 76%
Stage 2 - 56%
Stage 3 - 25%
Stage 4 - 9%
Mucinous ovarian tumours - formed from cells resembling what?
Endocervical or intestinal epithelium
Benign mucinous ovarian tumours?
- Multiloculated cysts filled with opaque, thick, mucoid material.
- 25% of all benign ovarian tumours and 75-85% of all mucinous ovarian tumours.
- 3rd to 5th decade
- Rarely bilateral
Borderline mucinous ovarian tumour ?
- Similar to benign tumours but have solid regions and exhibit papillae projecting into the cyst chambers.
- 10-14% of all ovarian mucinous tumours.
- 4th to 6th decade of life.
Malignant Mucinous Tumour
Contain more papillary projections within the cyst cavities, larger solid areas and larger areas of necrosis and haemorrhage.
5-10% of all malignant ovarian neoplasms.
6th decade.
Malignant Mucinous Tumour of the Ovary - 5 year survival? (Stage I - IV)
Stage 1 - 83%
Stage 2 - 55%
Stage 3 - 21%
Stage 4 - 9%
Late extraperitoneal recurrences, particularly in the lungs are characteristic of malignant mucinous tumours.
Endometrioid ovarian tumours are associated with what cell type?
Cells that resemble the endometrium.
May be associated with endometriosis,
Endometrial hyperplasia or carcinoma.
Clear cell tumour of the ovary - associations ?
2/3rds are Nulliparous
50-70% have endometriosis
Which tumour marker may be elevated with Dysgerminoma?
LDH
Commonest germ cell tumour. 10-15% are bilateral.
Endodermal sinus tumour (yolk sac tumour)- which tumour markers may be elevated?
AFP and LDH
Which tumour marker may be elevated in the presence of Granulosa cell tumour?
Serum Inhibin.
Granulosa cell tumour
1. Age groups
2. Presenting symptoms
- 5% pre pubertal girls, 50% in post menopausal bleeding
-> produce Oestrogen.
Associated with hyperplasia and carcinoma.
Present with precocious puberty, menorrhagia, irregular bleeding, PMB or acute abdominal pain because of tendency to rupture.
RMI score and risk of cancer ?
< 25
25 - 250
> 250
< 25 - 3%
25 - 250 - 20%
> 250 - 75%
CTAP should be performed
On all postmenopausal women who have ovarian cysts and RMI > 200.
Asymptomatic, simple, unilateral, unilocular ovarian cyst, < 5cm diameter.
- Risk of malignancy?
- Follow up?
- <1% and 50% resolve spontaneously within 3 months.
- In the presence of a normal Ca125, can be managed conservatively with rpt evaluation in 4-6 months.
Discharge from follow up after 1 year if the cyst remains unchanged or reduced in size with normal
ca125.
Women with RMI < ? Are suitable for laparoscopic management?
200!
Where possible, avoid intraperitoneal spillage.
BRCA1 - breast Ca pathology?
- Young age
- Invasive ductal carcinoma
- Higher tumour grade, lymphocytic infiltration and ‘pushing’ margins.
- Triple negative phenotype (compared with sporadic breast cancers)
BRCA2
- ER status
- HER2 status
- ER positive
- HER 2 negative
Prevalence of Lynch Syndrome in women with endometrial cancer?
3%
What is the most frequently used first line adjuvant chemotherapy following primary surgery for ovarian cancer ?
Paclitaxel and Carboplatin
6 cycles
3 weekly intervals
What % of patients with Ovarian Ca initially respond to first line chemotherapy?
75%
In ovarian cancer, Define:
- Complete response to chemotherapy
- Partial response to chemo
- Malignant disease not detectable for at least 4 weeks
- Tumour size reduced by at least 50% for more than 4 weeks
In advanced ovarian ca, what is an indication for neoadjuvsnt chemo followed by IDS?
- Bulky supracolic omental disease
- Liver Mets
Ovarian Ca:
- Platinum resistant disease
- Platinum refractory disease
- Platinum sensitive disease
- Platinum Resistant- Patients who develop recurrent disease within 6 months of receiving their last dose of platinum.
- Platinum Refractory - patients who develop resistance while receiving chemotherapy.
- Platinum sensitive - patients who develop recurrence beyond 6 months after completing the last dose of platinum.
Platinum free interval and response rate to second line chemotherapy?
Platinum sensitive > 12 months = 40-75%
Partially platinum sensitive 6-12 months = 25-30%
Platinum resistant < 6 months = 10-20%
Platinum refractory = < 10%
What is recommended to reduce risk of cancer in patients with Lynch Syndrome ?
Aspirin - reduces risk of all cancer types in lynch syndrome carriers.
When should surgery be offered to women with Lynch syndrome who have completed child bearing?
1. MLH1 and MLH2
2. MSH6
3. PMS2
Offer TAH BSO by:
1. Age 35
2. Age 40
3. Age 50
What % of endometrial cancers and ovarian epithelial cancers are hereditary?
5% endometrial cancers
20% epithelial ovarian cancers
BRCA1
1. Lifetime risk of ovarian ca by age 70
2. Lifetime risk of Breast ca by age 70
- Ovarian Ca 63%
- Breast Ca 85%
BRCA2
1. Lifetime risk of ovarian ca?
2. Lifetime risk of breast ca?
- 27% by age 70
- 84% by age 70
Ovarian tumours associated with BRCA 1 and BRCA2?
- High grade serious ovarian tumour
- Endometrioid ovarian cancer
Usually present in advanced stage (mainly papillary serous cystadenocarcinoma).
Other cancers associated with BRCA mutation?
Stomach, pancreatic, prostate, colon
BRCA1 doubles or triples lifetime risk of pancreatic cancer.
BRCA2 triples or quintuples it.
4-7% of people with pancreatic cancer have BRCA mutation.
BSO reduces ovarian ca risk in BRCA mutation by what %?
80-96% decrease in Ovarian Cancer risk
BSO in premenopausal BRCA 1&2 carriers reduced breast cancer risk by what % for BRCA1 and BRCA2 carriers?
BRCA1 - 56%
BRCA2 - 46%
Risk reduction surgery is greatest if performed before 40 years of age.
Lifetime risk for colorectal and endometrial cancer with lynch syndrome?
40-60% compared with 3% risk of endometrial cancer in the general population.
Lifetime risk of ovarian cancer with Lynch syndrome compared to general population?
17% compared with 1.4%
Amsterdam II clinical criteria used to identify families with Lynch Syndrome?
3 or more relatives with an associated cancer (colorectal, endometrial, small intestine, ureter or renal pelvis)
2 or more successive generations affected.
1 or more relatives diagnosed before age 50
1 should be a first degree relative of the other two
FAP should be excluded in the case
Of colorectal cancer.
When to offer risk reducing surgery in patients with Lynch Syndrome and with what gene mutations?
TAH + BSO should be offered no later than 35-40 years for MLH1, MSH2 and MSH6 carriers.
Insufficient evidence to offer RR surgery to PMS2 carriers.
Peutz-Jeghers Syndrome:
1. Inheritance
2. Gene
3. Cancer association
4. Screening
- AD
- Germline mutation in the STK11 gene
- Associated with GI polyps and increased risk of breast, GI and Gynae tumours
Women are at increased risk of developing:
1. Sex cord stromal ovarian tumours
2. Adenoma malignum of the cervix
- Annual cervical screening from age 18 and TVUS and Ca125 measurement from 25 years have been suggested.
Characteristic pigmented lesions on the lips and buccal mucosa.
Incidence of endometrial cancer?
7/1000 postmenopausal women in the UK
Risk of endometrial cancer in context
Of PMB?
10%
Risk of malignancy in endometrial polyp in:
1. Pre menopause
2. Post menopause
- 1-2%
- 5-6%
Endometrial Cancer - stage 1
Stage 1: tumour confined to the body of the uterus.
Ia - no or < 50% myometrial invasion
Ib - 50% or more myometrial invasion
Endometrial Cancer - stage II
Tumour invades the cervical stroma but does not extend beyond the uterus.
** endocervical glandular invasion should only be considered stage I.
Endometrial Cancer - stage III
Local and /or regional spread of the tumour.
IIIa - invades serosa or adnexae
IIIb - vaginal and/or parametrial involvement
IIIc - pelvic or para aortic nodes
Endometrial cancer - stage IV
Tumour invades bladder and /or bowel mucosa and / or distant mets
IVa - invades bladder or bowel mucosa
IVb - distant mets, including intra abdominal mets and / or inguinal nodes
Cellular classification of Endometrial cancer and incidence
- Endometrioid Adenocarcinoma (75-89%)
- Uterine serous papillary serous adenocarcinoma (<10%)
- Clear cell adenocarcinoma (4%)
- Mucinous Adenocarcinoma (1%)
- SCC (<1%)
Stage 1 endometrial cancer treatment
Ia: no or < 50% myometrial invasion
- TAH + BSO (pelvic lymphadenectomy not beneficial)
Ib: 50% or more myometrial invasion
- TAH + BSO + pelvic and peri aortic node sampling should be performed
Post op radiotherapy has been shown to reduce the risk of regional recurrence with no improvement in overall survival.
Stage 2 Endometrial cancer treatment
- TAH + BSO + node sampling followed by postoperative radiation therapy.
- Preoperative intracavitary and external beam radiotherapy followed by TAH + BSO + biopsy of para-aortic nodes
- Radical hysterectomy and pelvic lymphadenectomy in selected cases
Stage 3 Endometrial Cancer treatment
- TAH + BSO + radiotherapy
- Patients with inoperable disease caused by the tumour extending to the pelvic wall: Radiotherapy with intra-cavitary and external-beam radiotherapy.
- Chemotherapy with a combination of doxorubicin and cisplatin +/- paclitaxel and granulocyte colony-stimulating factor is an alternative to radiotherapy
- Patients who are not candidates for surgery or radiotherapy may be treated with progestogen
Endometrial Cancer overall 5 year survival rate?
78%
Risk of positive nodes in Endometrial Cancer with tumour size:
1. <2cm
2. >2cm
- <2cm - 5.7%
- > 2cm - 21%
Simple Hyperplasia: Histology
- Gland to stroma ratio is greater than 1:1
- Areas of “gland crowding” still contain small amounts of stroma in between glands, and the individual glandular contours can be easily distinguished
- Glands are usually round or elongated; however, shape and size irregularity are common including cystic dilation
- Lining epithelium usually displays proliferative-type morphology with pseudostratified or mildly stratified columnar cells containing elongated cigar shaped nuclei
- Cellular stroma with variable mitotic activity, uniformly distributed blood vessels
Atypical Hyperplasia: Histology
- Gland to stroma ratio is greater than 1:1
- These areas of “gland crowding” still contain small amounts of stroma in between glands, and the individual glandular contours can be easily distinguished. There are back-to-back glands
- Cytologic atypia is present and characterised by:
-> Nuclear enlargement and rounding
-> Open to coarse, irregularly distributed chromatin
-> Inconspicuous nucleoli, visible only at high power magnification
-> Loss of polarity
Regression rate of Endometrial Hyperplasia without atypia with conservative mgmt vs Progesterones?
- Conservative - 75-80%
- Progesterone - 90-95%
Outpatient follow up of endometrial hyperplasia without atypia?
6 monthly endometrial biopsies.
2x negative 6 monthly endometrial biopsies are required for discharge unless RFs present, then consider annual follow up.
Recommended follow up following treatment for VIN?
6 monthly for 2 years then yearly for 5 years
High risk HPV associated VIN vs differentiated VIN?
High risk HPV associated VIN - usual, classical or undifferentiated VIN. Associated with smoking + immunocompromise. Most common type of VIN. Women age 30-40.
d-VIN: women with conditions that predispose to Vulval Ca eg. LS. More likely to be associated with SCC vulva.
50-60 years.
VIN management?
Follow up after treatment ?
- Immunisation with HPV vax
- Discourage cigarette smoking
- Biopsy visible lesion
- Biopsy recommended in postmenopausal women with apparent genital warts and in women with condyloma in whom topical therapies have failed.
- WLE of cancer suspected.
Follow up at 6 and 12 months after initial treatment and annually thereafter.
Paget’s disease of the Vulva
1. Type of Ca
2. Diagnosis + treatment
3. Associations
- Adenocarcinoma-in-situ, similar to Paget’s disease of the breast
- Associated with puritis and appears as red crusted plaques with sharp edges
- Confirm diagnosis with biopsy
- Treat with vulvectomy
** Associated with Adenocarcinoma of the apocrine sweat gland, other genital tract (vulva, Cx, endometrium, ovary) and urinary tract malignancies
What antibodies have been detected in 60-80% of women with LS?
Extracellular matrix protein 1 antibodies.
Features of LS on examination?
- Pale, white atrophic areas affecting the vulva
- Purpura is common
- Fissuring
- Stenosis of the introitus
- Erosions, blistering very rare
- Vaginal mucosa NEVER involved
Changes may be localised or in a figure of 8 distribution including the perianal area. Loss of architecture may include loss of the labia minors and/or midline fusion. The clitoral hood May seal over the clitoris so it is buried.
Extra genital disease occurs in what % of women with Vulval LS?
What % of women with extra genital LS do not have genital disease?
10% - white, dry plaques may be found on the inner thigh, buttocks, lower back, abdomen, under the breasts, neck, shoulders and armpits
6%
Risk of development of SCC in patients with Lichen Sclerosus?
<5%
Treatment of LS?
- Hygiene and lifestyle advice
- Clobetasol Proprionate (ultra potent topical steroid)
a. Daily for 1 month
b. Alternate days for 1 month
c. Twice weekly for 1 month with review at 3 months
Randomised studies show that application of ultra potent topical corticosteroids significantly improves LS in 75-90% of patients, compared to roughly 10% in placebo groups.
Vulval Lichen Planus
1. Features
2. Antibodies present in 61% of patients?
Inflammatory disorder affecting the skin, genital and oral mucous membranes. May also affect the lacrimal duct, oesophagus and external auditory meatus.
Weak circulating basement membrane zone antibodies identified in 61% of patients w/ erosive lichen planus of the Vulva.
Vulval lichen planus, signs:
1. Classical
2. Hypertrophic
3. Erosive
- Classical: papilla on the keratinised anogenital skin, with or without striae on the inner aspect of the vulva.
- Hypertrophic: present as thickened warty plaques which may become ulcerated, infected and painful. Can mimic malignancy. Perineum and perianal area.
- Erosive: the most common subtype to cause vulval symptoms. The mucosal surfaces are eroded. At the edges of the erosions, the epithelium
Is mauve + pale (Wickhams striae).
Vulval psoriasis and the Koebner effect?
Skin lesions appearing on lines of trauma eg. Irritation from urine, tight fitting clothing
Vulvodynia definition?
Vulval pain for > 3 months and is not caused by an infection, skin disorder or other medical conditions.
Types of vulval biopsy?
- Incisional biopsy
A biopsy taken with the intent of securing a diagnosis only. This should ideally contain the interface between normal and abnormal epithelium and be large enough for the pathologist to be able to adequately provide evidence of substage (in stage I cases). - Excisional biopsy
A biopsy taken that includes all of the abnormal epithelium but does not provide a tumour-free zone of 1 cm (after fixation) on all dimensions. This would normally be performed in cases of vulval intraepithelial neoplasia (VIN) or when there is a low suspicion of invasive carcinoma and the operator wishes to limit the amount of cosmetic harm. - Radical excision
An excision performed with the intent of achieving clearance of at least 1 cm (after fixation) on all aspect of the tumour(s). Depending on the site and size of the tumour, this could vary from a radical local excision to a radical vulvectomy.
Vulval Ca survival:
1. No LN involvement
2. Inguinal node involvement
3. Iliac or other pelvic node involvement
- > 80%
- < 50%
- 10 - 15%
Stage I Vulval Ca
Stage I
Tumour confined to the vulva
IA: Tumour ≤ 2cm in size, confined to the vulva or perineum with stromal invasion ≤ 1.0mm and no nodal metastases
IB: Tumour ≤ 2cm in size or with stromal invasion > 1.0mm, confined to the vulva or perineum with negative nodes
Stage II Vulval Ca
Stage II
Tumour of any size with extension to adjacent perineal structures (lower third of the vagina, lower third of the urethra or anus) with negative nodes
Stage III Vulval Ca
Stage III
Tumour of any size with or without extension to adjacent perineal structures (lower third of vagina, lower third of urethra or anus) with positive inguino-femoral nodes
IIIA: One lymph node metastasis ≥ 5mm or 1-2 lymph node metastases < 5mm
IIIB: Two or more lymph node metastases ≥ 5mm or 3 or more lymph node metastases < 5mm
IIIC: Positive nodes with extra-capsular spread
Stage IV Vulval Ca
Stage IV
Tumour invades other regional structures (upper 2/3 of urethra, upper 2/3 of vagina) or distant structures
IVA: Tumour invades upper urethra and / or vaginal mucosa, bladder mucosa, rectal mucosa or fixed to pelvic bone or presence of fixed / ulcerated inguino-femoral nodes
IVB: Any distant metastases including pelvic nodes
Treatment of Stage I vulval Ca
1. Ia
2. Ib
Ia - Wide local excision
Ib - If tumour size >2cm and stroll invasion >1mm, recommend groin node dissection
Vulval Ca recurrence and disease free margins?
Disease free margin:
> 8mm - 0% recurrence
< 8mm - 47% recurrence
WLE with minimum margins of 15mm surrounding the specimen should be sufficient.
Cervical Cancer - Stage I
Confined to the cervix – extension to the body of the uterus would be disregarded
IA: Invasive carcinoma which can be diagnosed on microscopy only with deepest invasion ≤ 5mm and largest extension ≤ 7mm
Stage 1A1: < 3 mm depth of invasion and < 7mm wide
Stage 1A2: 3 - 5 mm depth, < 7mm wide
IB: Clinically visible lesions limited to the cervix or pre-clinical lesions greater than stage IA. All macroscopically visible lesions even with superficial invasion are stage IB.
Cervical Cancer - Stage II
Cervical carcinoma invading beyond the uterus but not to the pelvic side-wall or the lower third of the vagina
II A: No parametrial invasion
IIB: With obvious parametrial invasion
Cervical Cancer - Stage III
Tumour invades the pelvic side-wall and / or the lower third of the vagina and / or causes hydronephrosis or non-functioning kidney (unless known to be due to another cause). On PR, there is no cancer-free space between the tumour and the pelvic wall
IIIA: Involves lower third of the vagina with no extension to the pelvic wall
IIIB: Extension to the pelvic wall and / or hydronephrosis or non-functioning kidney
Cervical Cancer - Stage IV
Tumour extends beyond true pelvis or involves the mucosa of the bladder or rectum (proven on biopsy). Bullous oedema does not on its own permit allocation to stage IV
IVA: Spread to adjacent organs
IVB: Spread to distant organs
Cervical Ca Survival:
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
Stage 1 - 95% 5 year survival
Stage 2 - Over 50% 5 year survival
Stage 3 - 40% 5 year survival
Stage 4 - 5% 5 year survival
Stage Ia SCC Cervix - Treatment options
- Hysterectomy - if depth of invasion <3mm and no lymphovascular invasion
- Conization - depth of invasion <3mm with no LV invasion and the margins of the cone are neg. Fertility preserving option.
- Radical Hysterectomy - tumour invasion 3-5mm (stage Ia2). +/- LN dissection. Risk of LN involvement 10%.
- Intracavity Radiotherapy - depth of invasion < 3mm and no LV invasion. Should be reserved for when surgery is not an option.
Stage Ia adenocarcinoma Cx - treatment
Hysterectomy traditionally used as disease is multi-focal and typically within the endocervical canal
Knife cone biopsy in women who wish to retain fertility. Cone should be at lease 2.5cm in depth with clear margins of 5mm or more.
Stage Ib Cervical cancer - treatment options
- Radical vaginal trachelectomy: laparoscopic lymphadenectomy plus removal of the upper vagina, cervix and parametrium. A permanent suture is placed around the isthmic portion of the uterus and future pregnancies are delivered by caesarean section. Recurrence rates are similar to those in women who have undergone radical hysterectomy. Pre-term delivery rates are 20-25%.
- Radical hysterectomy and bilateral pelvic lymphadenectomy.
- Radical hysterectomy and bilateral pelvic lymphadenectomy with postoperative total pelvic radiotherapy plus chemotherapy
Radiotherapy - External-beam pelvic radiotherapy plus intracavitary brachytherapy.
Stage IIa Cervical Cancer - treatment options?
- Intracavitary radiotherapy combined with external-beam pelvic radiotherapy plus chemotherapy with cisplatin or cisplatin/5-FU for patients with bulky tumors. Radiotherapy to para-aortic nodes may be indicated in primary tumors 4 cm or larger.
- Radical hysterectomy and pelvic lymphadenectomy. The high incidence of compromised margins, parametrial spread, and positive nodes leading to postoperative radiotherapy / chemotherapy makes surgery a less suitable approach
Stage IIb cervical cancer - treatment options
Radiation therapy plus chemotherapy: Intracavitary radiotherapy plus external beam radiotherapy and to the pelvis combined with cisplatin or cisplatin/fluorouracil chemotherapy
Stage III cervical cancer - treatment options
Radiotherapy plus chemotherapy: Intracavitary radiotherapy and external beam radiotherapy to the pelvis combined with cisplatin or cisplatin/fluorouracil chemotherapy
Stage IV cervical cancer - treatment options
Radiotherapy plus chemotherapy: Intracavitary radiotherapy and external-beam pelvic radiotherapy combined with cisplatin or cisplatin/fluorouracil chemotherapy
IVb: Palliative radiotherapy/ chemotherapy
Routine follow up offered following treatment for CIN I, CIN II, CIN III?
TOC in 6 months
HPV neg - routine screening
HPV pos - refer to colp
HPV unavailable - rpt testing at 3 months
What % of patients will not respond to ultra potent topical steroids in treatment of LS?
10-25%
Ovarian Ca:
In women whose disease is thought to be confined to the ovary, optimum digital staging comprises?
- Midline laparotomy
- TAB + BSO + infracolic omentectomy
- Biopsies of peritoneal deposits
- Random biopsies of pelvic and abdominal peritoneum
- Retroperitoneal lymph node sampling
What proportion of women with PMB have endometrial cancer?
10%
Ovarian tumour type associated with BRCA 1 and 2 mutations ?
Mainly papillary serous cystadenocarcinoma.
High grade CIN excised with incomplete margins - when is re excision not offered?
- Age < 50
- No evidence of invasive disease
- No evidence of glandular abnormality
In individuals over 50 who have CIN III at the deep lateral or endocervical margins and in whom satisfactory screening samples and cold cannot be guaranteed - must have rpt excision
Bowel fistulae occur in what % of women undergoing radiotherapy for Cervical Ca?
% of women that experience bowel obstruction?
- 8%
- 14.5%
5 year survival for ovarian ca?
46%
Depth of excision for LLETZ depending on transformation zone
1. Type 1
2. Type 2
3. Type 3
- Type 1: 7-10mm
- Type 2: 10-15mm
- Type 3: 15-25mm
Aim <10mm in women of reproductive age.
Vulval Ca 5 year survival
1. No LN involvement
2. Inguinal node involvement
3. Iliac and other pelvic LNs
- > 80%
- <50%
- 10-15%
Bladder atony following radical hysterectomy for cervical cancer?
2-3% of women experience long term voiding difficulties requiring intermittent self catheterisation.
Planning pregnancy taking Tamoxifen - advice?
Stop Tamoxifen 3 months prior to TTC
Chance of achieving a live birth of a normal pregnancy with co existing complete molar pregnancy?
25%
Incidence of breast cancer in Pregnancy?
1/3000
What % of patients with Granulosa cell tumour have:
1. Endometrial Hyperplasia
2. Endometrial Carcinoma
- 1/3 women will have endometrial hyperplasia
- 10-15% will have Endometrial Carcinoma
Regression of CIN
1. CIN I
2. CIN II
3. CIN III
- CIN I - 50-60% within 1 year
- CIN II - 40% within 1 year, 60-65% within 2 years
- CIN III - 6-50%
What is the PPV for endometrial
ca in women who present with new/change in vaginal discharge?
1.1
Treatment of malignant germ cell tumours?
BEP
Bevacizumab MOA?
VEGF
By how much is the risk of developing cervical cancer increased in COC users for 5+ years compared to non users?
Double
For patients wishing to preserve fertility, radical trachelectomy + cerclage + bilateral pelvic LND is an option for patients with cervical cancer up to which stage?
1B1
Bevacizumab
Humanised anti VEGF monoclonal antibody.
Can be incorporated into the treatment of recurrent and metastatic cervical cancer.
Risk of missed EC following inadequate pipelle biopsy ?
4.5%
Tumour Markers and associated ovarian neoplasia:
1. AFP
2. HCG
3. LDH
4. Ca125
5. CEA
6. Estradiol
7. Testosterone
- AFP
- Immature teratoma, Sertoli-Leydig cell tumour, yolk sac tumour, embryonal carcinoma - HCG
- Dysgerminoma, embryonal carcinoma - LDH
- Dysgerminoma, immature teratoma - Ca125
Epithelial tumours - CEA
Epithelial tumours - Estradiol
Juvenile Granulosa cell tumour - Testosterone
Sertoli-Leydig tumour
CGIN:
1. Incidence
- 1:2000 smears
Occurs in older age group compared with CIN. There is concomitant CIM in approx 50%. There are multi focal, skip lesions.
Perform endometrial biopsy whilst awaiting urgent colp and perform Pelvic US to exclude oestrogen producing ovarian cyst.
What proportion of ovarian cancers are a result of BRCA mutations ?
10-15%
What is the incidence of hypercalcaemia in all oncology patients?
30%
Often found in disseminated disease so tends to be a poor prognostic factor.
Operative mortality for pelvic exenturation for recurrent FIGO III vulval Ca?
As high as 14%
