Gynae oncology Flashcards
GONC template
Assess - symptoms, risk factors, co-morbidities, level of functioning
Staging - may be imaging, biopsy or surgical
Treatment - GONC review, surgical, chemo, RTX, palliation. Psychosocial input.
- Benefits
- Risks
- Alternatives
?Genetic component
Follow up - surveillance, recurrence risk, survivorship
Written information, referral to support groups
Myomectomy histology returns STUMP. How do you manage this?
Counsel that malignancy potential is uncertain
Not a cancer at present but not entirely benign
Refer to gynae onc MDM
Pathology review
Follow up imaging
Risk of recurrence or metastasis
Once family complete hysterectomy likely recommended
Explain to a patient why colposcopy is needed and what to expect
- Indication: Cervical screening has found abnormal cells in your cervix. Cells can often go away on their own but there is a risk they could also turn into cervical cancer if not treated.
- Procedure: takes around 15-20 mins.
- Undress from the waist down and lie down in a chair with padded supports for your legs.
- A device called a speculum is inserted into your vagina and opened so we can see the cervix.
- A microscope with a light called a colposcope is used to look carefully at your cervix.
- We apply liquids to the cervix to highlight any abnormal areas.
- We biopsy any abnormal areas; we take a very small sample and it can briefly feel uncomfortable for a second while we take it.
- You will have some abnormal brown discharge or a little bit of bleeding after the procedure.
Describe how you peform colposcopy
Consent, chaperone
Inspect vulva, vagina
Appropriately sized speculum to visualise cervix
Inspect SCJ and assess type of TZ (1,2,3) - need to see ALL otherwise unsatisfactory
Inspection to naked eye - masses, ulceration, bleeding, abnormal discharge, vessels
Acetic acid - inspect for acetowhite uptake, speed of onset, density, borders irregular or well defined
Green light filter - abnormal vessels, punctations, moasicism
Lugol’s iodine - inspect for iodine negative areas
Colposcopic impression - location and quadrants affected
Targeted biopsy with Tischler Morgan forceps, send in separate pottles and label as on clockface
Monsel’s to biopsy sites and pressure
Written advcie and follow up wihth results
Document suitability of LA treatment
How do you counsel a patient about risk reducing surgery for BRCA?
Ovarian
Surgery - BSO, washings (laparoscopic or open)
Risk reduction by ~96% ovarian ca, also breast ca if <45y
Do when childbearing complete or by 40 if BRCA1 or by 45 if BRCA2
Surgical and anaesthetic risks - pain, bleeding, infection, injury to adjacent organs, convert to open, hernia, VTE, need for further treatment
Loss of fertility
Surgical menopause - vasomotor symptoms, cardiovascular disease, osteoporosis, dementia, sexual dysfunction. Benefit from MHT (unless personal Hx of breast ca) until natural age of menopause
Risk of incidental malignancy diagnosis at time 5%
Risk reducing ONLY not removing
- 3% risk of primary peritoneal malignancy
- return precautions
Alternatives discussed - symptom observation, annual examinations, annual pelvic USS, CA-125 tracking
Endometrial hyperplasia without atypia
Management
- Counsel - <5% prorgession to cancer over 20years, <1% co-existent cancer
- Treat modifiable RFs and co-existent co-morbiditiy e.g. obesity, HTN, diabetes, hyperlipidaemia
- Conservative management - lower regression rate.
- Progesterone - Higher regression rate. Mirena > continuous > cyclical. Prefer if symptomatic or not regressing spontaneously. Mirena has higher regression, better bleeding control, less side effects.
- Follow up - Resample 6monthly until 2x normal samples. Closer surveillance if relapse risk higher.
- Fertility desired - await normal sample
- Hysterectomy - progression to atypia, non-regression >12months, relapse, persistent AUB, no desire for fertility, declines other options. Add BSO if postmenopausal.
How do you manage an abnormal smear in pregnancy?
Colposcopy by senior/experienced colposcopist
Biopsy if concerned - counsel re increased risks of bleeding, monsel’s is safe
If pre-invasive - colposcopy each trimester, treat post partum if not regressed, VB okay
How do you manage a cervical cancer in pregnancy?
- GONC MDM referral
- Staging - MRI, EUA, consider cystoscopy, colonoscopy, consider lymphadenectomy if <22weeks, CXR
- Ascertain desire to maintain this pregnancy and preserve fertility
- CBC, renal function, LFTs, G&H
- Psychological support
- Avoid intercourse
- Return advice re vaginal bleeding
Stage IA1
* Can do LLETZ or cone + cerclage
* Counsel increased bleeding, infection, miscarriage/PTB depending on gestation
* Monthly reviews
* Vaginal birth okay only if 1A1 otherwise always CS as risk of catastrophoc bleeding, avoid episiotomy as risk of seeding spread
Stage IA2, IB1, IB2
* If >20weeks delay treatment until pregnancy complete, monthly reviews
* Consider: trachelectomy, neoadjuvant chemotherapy, classical CS + radical hysterectomy 34weeks
* Usually avoid transverse lower uterine incision
Stage II+, tumor >4cm
* TOP and radical hysterectomy with fetus inside if <20weeks
* Neoadjuvant chemotherapy to stabilise tumor, stop at least 3weeks pre delivery (risk myelosuppression)
* Classical CS + radical hysterectomy 34weeks
* RTX is contraindicated
If continues - surveillance
Growth USS
Indication for definitve treatment:
* Maternal decision for TOP
* Progression in pregnancy
* Positive lymph nodes
List the FIGO staging of vulval cancer
- Stage I: confined to vulva
- Stage II: extension to lower ⅓ urethra, lower ⅓ vagina and anus.
- Stage III: positive inguinofemoral nodes.
- Stage IV: extension to upper ⅔ of urethra and vagina or distant structures including pelvic lymph nodes.
Vulval cancer management
Assessment, management
Assess:
* Take images (with consent)
* Clinical exam ?ymphadenopathy
* Cervix and vagina examination (ensure not concurrent HPV)
* Biopsy if not confirmed
* Bloods - FBC, U&E, LFTs
* CXR
* CT or MRI - lymph nodes
Management
* GONC MDM
* Psycho-social-sexual support + CNS input
* Surgical excision - WLE vs radical. Risks = pain, bleeding, infection, woundbreakdown, vaginal stenosis, urinary or faecal incontinence, hernia, DVT/PE
* Lymph nodes - SLNBx vs groin dissection
* Adjuvant RTX (inadequate margins, recurrence)
* Adjuvant chemo
* Follow up for recurrence
Outline management principles for the different stages of vulval cancer
Stage IA:
* WLE with 1 cm margin.
Stage IB - II:
* WLE +
* SLNBx vs inguinofemoral node dissection
Stage III:
* Surgical excision
* Adjuvant pelvic and groin radiotherapy
Stage IV:
* Surgical excision
* BL inguinofemoral lymphadenectomy
* adjuvant radiotherapy
* OR primary chemoradiation
Explain to a patient the options of lymph node management with vulval ca
Not needed if 1A, do if 1B +
Bilateral if disease is <2cm from midline due to lymphatic drainage distribution
Result will determine need for adjuvant treatment, not designed to improve prognosis by removing
Areas are inguinofemoral
Sentinel lymph node biopsy
- benefits = less morbidity, smaller incsion, shorter operating time, less lymphoedema, no increase in mortality or relapse
- risks = extra surgery if +ve, incorrect SLN detection or false -ve is 3%. Must consent to do full if no SLN identified.
Groin dissection/lymphadenectomy
- benefits = single surgery, confirms extent of nodal involvement.
- risks = longer surgery, lymphoedema
Outline the FIGO staging for vaginal cancer
Stage I: confined to vagina
Stage II: spread to paravaginal tissues but not pelvic sidewall or LNs.
Stage III: spread to pelvic sidewall, lower ⅓ vagina and renal tract, pelvic and groin nodes.
Stage IV: spread to bladder, bowel, outside pelvis
Vaginal cancer management
Assess:
* Colposcopy of vagina, cervix and vulva, full-thickness biopsies
* +/- EUA if exam difficulties
* Imaging: MRI pelvis, PET-CT
* Bloods: FBC, U&Es, LFTs
Manage:
* Stage I upper vagina: radical hysterectomy, vaginectomy, pelvic lymphadenectomy.
- Stage I lower vagina: radical wide local excision, bilateral groin node dissection.
- Stage II-IV: chemoradiation
List treatment options for VAIN
- Surgical:
- WLE (depends on location)
- CO2 or Argon laser vaporisation (must be certain not cancer)
- Medical:
- Imiquimod/Aldara
- 5-fluorouracil (not well tolerated)
List treatment options for VIN
WLE
- preferred for dVIN (as higher malignant potential)
- depends on location
- allows histological diagnosis
- may find occult SCC
Laser ablation (CO2 or Argon)
- need biopsy prior to be certain not cancer
- preferable if multifocal disease
- not as distorting of anatomy
Imiquimod/Aldara OR fluorouracil
- good response rate
- not all women tolerate
- doesn’t allow histological confirmation
Counsel someone about the HPV vaccine Gardasil 9
- Protects against 9 subtypes of HPV including the commonest causes of cervical cancer and genital warts.
- Provides 90% protection against cervical cancers.
- Most effective if given before sexual activity/contact with HPV but benefit for women who have had sex already.
- Does not contain virus; contains recombinant proteins from the outer shell of the virus. You cannot get HPV from the vaccine itself.
- The vaccine teaches the immune system to recognise the virus so that when exposed to the real thing, antibodies will protect them from infection.
- If <15 years old: 2 x doses 6 months apart.
- If >15 years old: 3 doses at 0, 2 and 6 months.
- Side-effects: local site reaction, mild fever, nausea, dizziness, Guillain-Barre, anaphylaxis.
List the FIGO staging of cervical cancer
- Stage I: only on cervix
- Stage IA1: microinvasion ≤5mm.
- Stage II: invasion beyond uterus but not lower ⅓ vagina or pelvis.
- Stage III: spread to pelvic wall, lower ⅓ vagina, ureteric obstruction, pelvic or para-aortic nodes.
- Stage IV: spread to bladder, bowel or outside of pelvis.
Cervical cancer management
Assess:
* Biopsy
* Examine - lymphadenopathy, extent of vaginal involvement
* USS pelvis
* MRI pelvis
* CT chest, abdo, pelvis
* PET- CT if 1B2+
* FBC, U&E, LFTs
* EUA
Manage:
* GONC MDM
* Psycho-social-sexual support
* Treatment depends on stage and desire to preserve fertility
1A1 = microinvasive
→ Cone biopsy or TAH+BS (ovaries conserve)
1A2 = microscopic but depth 3-5mm
→ Cone biopsy
→ TAH + BS + pelvic lymphadenectomy
→ Radical trachelectomy +/- nodes
1B1= macroscopic <2cm
→ Open radical hysterectomy
→ Radical trachelectomy + nodes - fertility preserve (4% recurrence, 30% PTB, need for CS, cervical stenosis - difficulty conceiving)
1B2 or IIA1
→ Radical hysterectomy - enables precise staging, conserves ovarian function
→ Radiation (both have similar outcomes but varying effect on QoL)
1B3 or IIA2 = tumors >4cm
→ Chemo-radiation (external beam and cisplatinum) THEN vaginal brachy therapy
IIB - IVA = parametria involvement onwards
→ Usually as above with chemo-radiation
→ Consider pelvic exenteration if IVA but poor prognosis
IVB
→ Palliative
→ EBT for local tumor
→ Avastin - angiogenesis inhibitor
Follow up - 3 monthly for 1 year then 6monthly for 1year then yearly for >5years
Outline risks associated with fertility sparing surgery for cervical cancer
- Cone biopsy: bleeding, preterm birth, cervical stenosis
- Simple trachelectomy: bleeding, preterm birth, cervical stenosis, abnormal PVB and discharge, vault scarring/dyspareunia
- Vaginal radical trachelectomy: in addition to the above.
- Parametrium: urinary dysfunction, vaginal shortening, ureterovaginal fistula.
- Abdominal trachelectomy: in addition to above.
- Bilateral uterine arteries sacrificed: endometrial atrophy, lower birth rate, IUGR
- Otherwise - oocyte harvesting and surrogate or adoption
Management of adenocarcinoma in situ
Counsel:
* Precancerous change of glandular cells of cervix
* Difficulty at colposcopy for assessing as can’t visualise endocervical canal and get skip lesions
* Recurrence risk even after cone biopsy so need good follow up
Options:
* Simple hysterectomy - annual vault HrHPV smear 3years then 3yearly for >25years. Colposcopy if HrHPV +ve
* Cone biopsy + ECC + D&C - fertility sparing (but risks of sPTB, cervical stenosis, recurrence).
Co-testing HrHPV and cytology with ECC every 6 months for 3 years.
Explain CIN3
Pre cancerous cell changes of cervix
Spectrum of disease - low grade to high grade
Cervical smear is a screen, biopsy confirms
Changes associated with HrHPV infection
HPV is sexually transmitted but common. Most sexually active people are exposed
High grade makes less likely to clear infection
Other factors associated with reduced clearance are smoking, age, immune suppression - recommend stop smoking
If left untreated can progress to a cancer over longer period 10-15years
Recommended treatment is LLETZ procedure - both therapeutic and also diagnostic to check no further advanced changes
Make a comment on suitability for treatment under local in clinic or GA in OT
Follow up afterwards includes smear + HrHPV for test of cure 6 and 18months (infection takes time to clear and also at risk of reinfection)
Provide written information, involve support people
Offer HPV vaccination
How do you manage breast cancer in pregnancy?
- MDT - breast surgeon, oncology, high riusk obs
- Counsel - pregnancy does not affect breast ca prognosis
- Biopsy (FNA or core) for diagnosis confirmation
- Staging - breast + liver USS, prefer to avoid mammogram, CXR, MRI spine
- Bloods - CBC, renal, LFT (baseline echo if on cardiotoxic chemo)
- Ascertain desire to maintain this pregnancy - TOP may be an option
- Surgery - WLE or mastectomy + SLNBX with scintigraphy +/- axillary node clearance. Reconstruction is best delayed when not pregnant or breastfeeding.
- Chemotherapy - 2nd or 3rd trimester, doxirubicin or anthracycline. WH 3weeks prior to delivery as riks of fetal myelosuppression
- Don’t do RTX in pregnancy - unless life or organ saving
- Psychological support
- Genetic testing, consider implications for other family members (and children)
- Serial growth USS
- Deliver at term, aim vaginal delivery
Postpartum:
* ONC follow up
* Contraception - hormonal contraindicated. Delay pregnancy for >2years as highest risk of relapse in timeframe
* VTE prophylaxis
* Breastfeeding - not on tamoxifen or herceptin, not on treated side, support if would like on contralateral side
* MMH screen with EPNDS
* Consdier implication if BRCA on family, future pregnancy (?PIGD) and own malignancy risk e.g. ovarian
