Gynae oncology Flashcards
Cervical Glandular Intraepithelial Neoplasia (adenocarcinoma):
-Incidence
-Risk factors
-Management
Incidence:
0.15% of all smears AIS.
15-20% of cervical invasive cancers
Ratio of CGIN to CIN 1:50
Risk factors:
Increased estrogen exposure, HPV 16 and 18 (50% HVP 18)
Management:
All CGIN need referral to colposcopy
Colposcopy:
1. Type 3 Cone Bx to 25mm +/- D&C.
2. If evidence of cancer GONC ref.
3. If clear margins = treatment completed. Cytology + HPV + colp in 6/12 and cytology + HPV in 12 months in primary care then if clear back to 5yrly.
4. If
Cervical Intraepithelial Neoplasia
-Incidence
-Pathophysiology
-Risk factors
-Natural History
Pathophysiology:
-Incidence: 80% of women will acquire HPV (Sexually transmitted)
-Oncogenic HPV (ds DNA virus) Viral oncogenes E6 and E7 are over expressed. Stops cell replication suppression
-Affects Transformation zone
-HPV 16&18 cause 70%. 31,33,35,39,45,51,56,58 main types
-80% will clear virus in 1-2 yrs. 10-20% have viral DNA integration into host genome.
Risk factors: Smoking, HIV, Immunosupression, Sexual activity, COC
Natural History:
-CIN 1 70-90% regresses within 2 yrs
-CIN 2 - 50% regresses within 2yrs - 5% progresses to cancer
-CIN 3 30% progression to cancer over 10yrs
What are the different smear results for cervical screening?
LSIL - low grade squamous intraepithelial lesion
ASC-US Abnormal squamous cells of undetermined significance
HSIL - high grade squamous intraepithelial lesion
ASC-H Abnormal squamous cells - cannot exclude high grade squamous lesion
AGC - atypical glandular cells
AIS - Adenocarinoma in situ
SCC Squamous cell carcinoma
Squamous columnar junction and transformation zone of the cervix
-Describe what it is
-Describe how it comes about
-Describe types of TZ
The endocervix is lined with glandular epithelium. The ectocervix is lined with squamous epithelium. The SCJ is where the 2 cells types meet. The original SCJ begins in the endocervix. It migrates to the ectocervix. Here the migrated columnar cells are converted to metaplastic squamous cells under the influence of vaginal acid and a new SJC between the columnar and metaplastic squamous cells is formed. The cells in between the two SJC becomes the TZ.
Type I - Can see all the TZ
Type 2 - TZ has endocervical component but can see
Type 3 - TZ has endocervical component which can’t see
What are the 10 principles of screening
- Is an important health problem
- There is an available treatment
- There are appropriate dx and treatment facilities
- There is a latent phase of the disease
- There is a test / examination for the disease
- The test should be acceptable to the population
- The natural Hx of the disease should be well understood
- There should be an agreed policy on who to treat
- The total cost of finding a case should be balanced with overall medical expenditure
- Case finding should be a continuous process
Describe the management of ASC-US or LSIL at colposcopy (3)
- Guidelines do not recommend treatment of CIN/LSIL
- Repeat an HPV at 12 months
-If negative return to 5yrly screening
-If HPV +ve do cytology. If cytology is negative or LSIL repeat HPV with LBC in 12/12
-If HPV 16 or 18 detected then colp
-If HPV other and HSIL then colp - If HPV + and HSIL/ASC-H on cyto. But LSIL on histo offer diagnostic excision on TZ
Describe management of HSIL on histology
- Treatment of a histological dx of CIN2/3 is recommended
- Test of cure with HPV + LBC co test should be undertaken at 6months
-If HPV and cyto negative repeat in 12 months.
-If HPV+ repeat colp regardless of LBC findings
-If HPV-ve but LBC = LSIL then repeat in 12 months
-If HPV -ve but LBC = HSIL then colp
Describe cervical screening management in immunocompromised ppl (HIV / Organ transplant)
- Should undergo annual smears
- Refer to Colposcopy for all abnormalities
- Consider same management in ppl with immunsuppresent meds or bone marrow transplants
Describe cervical screening if had hysterectomy
- If subtotal - screening is as per ppl with Cervix
- If Total hysterectomy:
-Normal screening in 5yrs prior - no vault smears
-No screening in 5yrs prior - 1 x normal vault smear
-Not returned to 3 yrly screening - 2 x vault smears 12 months apart
-LSIL in hysterectomy specimen - 2 x vault smears
-HSIL in hysterectomy specimen - 2 x vault smears + HPV at 6 months and 12 months then 3 yrly vault smears - Hysterectomy for cervical cancer - 3yrly vault smears
- Immunocompromised - 3 yrl vault smears
- DES exposure - annual vault smears
Describe cervical screening in DES exposed ppl
Ppl exposed in utero have increased risk of clear cell adenocarinoma or vagina and cervix
1. Annual smears and colposcopic examination of cervix and vagina
How should endometrial cells on smear be managed
- If premenopausal and asymptomatic - no further assessment
- If post menopausal consider endometrial sampling
What is the age range for cervical screening in Australia and NZ
- Australia - 25-75yr every 5yrs
- NZ 20-69 every 3 yrs
What is the incidence of cervical cancer in pregnancy?
Invasive cancer - 1:10 000 (15/100 000)
70% of cervical cancer dx in pregnancy is stage 1
5% of pregnancy women develop abnormal cervical cytology
No evidence the natural hx of cervical cancer is altered by pregnancy
When should smears be done for pregnant women
- If up to date and normal smears then do 3 mnths postpartum
- Do smear in pregnancy if:
-Never had smear
-Overdue smear
-Abnormal smear history and due for a smear
Describe differences seen in cytological specimens in pregnancy
- Difficult to interpret smears in pregnancy
- Hormonal changes cause:
-Hyperplasia
-Reactive atypia of squamous and glandular cells
-Aris-Stella reaction with large multi nuclei cells
-Cytotrophoblasts and Syncytiotrophoblasts can be seen
-Increased number of inflammatory cells
-Exaggerated squamous metaplasia
-Increased vascular changes
Colposcopy in pregnant people
-When should it be done
-What should be done
-Who should do it
-Colposcopy should be done for the same indications as for non-pregnant women. It is safe
-Do a Bx ONLY if invasion is suspected on colposcopy.
-If High grade lesion repeat colp at 20-30/40 and then 6 weeks post partum
-Bx is more complicated - bigger Bx, increased bleeding, risk of pregnancy loss
- Colposcopy should be done by an expert colposcopist
-Pregnancy should be recorded on the lab form for pathologist
Describe timing of treatment of cervical cancer in pregnancy
- Only treat is invasive cancer is suspected at colposcopy
- HSIL progression in pregnancy is low
- If stage > 1A1 and <20 weeks treat without delay
- If stage 1A1-1B2 (contained in cervix) and >20 weeks can delay until fetal maturity
- If higher stage then 1B2 and > 20 weeks treat without delay
Describe management of cervical cancer in pregnancy.
- Stage with MRI/CXR +/- Pelvic LN dissection (No CT PET to look for + nodes)
- If Stage 1A1 - treat with cone Bx
- If Stage 1A2 - 1B1 - Large cone / simple trachelectomy
- If Stage 1B2 consider rad hyst after delivery
-can do neoadjuvant chemo while awaiting maturity - If > Stage II treat without delay with chemoradiation.
-If viable deliver and treat
-If non-viable terminate and treat
What is the mode of delivery for pregnant women with cervical cancer?
If CIN2/3 can do vaginal delivery
Always a CS if Stage >1B1 +/- hysterectomy
- increased risk of mets and haemorrhage with VB
Describe CIN1 characteristics on colposcopy
- Mosaicism of blood vessels - fine pattern. Looks like paving
- Fine looped capillaries
- Snow white to bright white acetowhite changes.
- Acetowhite changes slow to appear
- Acteowhite boarder irregular and throughout ectocervix
Describe CIN2 and 3 characeristics on colposcopy
- Coarse mosaic pattern of blood vessels
- Coarse punctation of blood vessels (blood vessels seen end on)
- Sharp boarder
- Rapid appearance of acetowhitening
- Cuffed crypts
- Boarders of lesion raised / prominent
- Location near new SJC
Describe the stains and how they work for colposcopy
- Acteowhite - applied first
-Abnormal cells with increased protein levels change to white - Iodine - applied second - optional
-Abnormal cells don’t take up iodine due to low glycogen content
-Colomnar cells don’t take up iodine
-Good to further deliniate acetowhite changes
What are the treatment options for CIN
- Ablation
-Cryotherapy, laser, cold coagulation, diathermy, thermal ablation - LLETZ
- Cone Biopsy
What are the parameters which need to be met for ablation treatment of CIN (4)
-Satisfactory colp assessment
-Histology is confirmed
-No cancer or glandular lesion
-Whole lesion is visualised
Describe LLETZ procedure for CIN
-When done
-How done
-Success rates
- Done for CIN2/3
- Uses monopolar diathermy
- Depth depends on type of TZ
-Aim depth 7-10mm - Can do under LA
- Success rate 90-98%
- Increased failure in HIV 55% (Cone Bx better choice)
Describe cone biopsy for CIN
-when done
-success rates
- Done when upper limit of TZ not visualised
- Where lesion involves glandular changes
- Where early invasive cancer is suspected 1A1
- 90-94% effective
- Up to 32% failure to cure
What are the long term complications of CIN treatment
- PPROM, PTB, Low BW
-Highest risk with CKC>Laser cone>LLETZ>Ablation
-LLETZ >10mm - Cervical stenosis
-1% with laser
-1-3% with cone bx
-Impacts further colp assessments
-Increases risk labour dystocia RR 3.17 for CS
-Haematometra/pyometra/subfertility
What is the definition of a borderline ovarian tumour
Ovarian tumour which shows:
1. NO stromal invasion
2. Epithelial stratification
3. Cellular atypia
4. Increase mitotic activity
5. Nuclear pleomorphism
Describe the epidemiology of borderline ovarian tumours
-Types and incidence of these
-Demographics of women affected
-Stage at diagnosis
-Risk of progression to invasive cancer
- Serous - 45-60% (70%). Mucinous 30-50% (11%)
-Also seromucinous, endometriod, clear cell and Brenners - 5-10% - 15-20% of all epithelial ovarian neoplasms
- 33% in women <40yr
- Most diagnosed at stage 1 (75%)
- 2% risk of progression to low grade serous
What are the USS features of borderline ovarian tumours?
- Multiloculated (40% of mucinous 30% of serous)
- Solid cystic components (40% of mucinous, 78% of serous)
- Internal papillations (40% of mucinous, 78% of serous)
- Thickened septa
- Bilateral - 50% serous are bilateral
What tumour markers are useful in the dx of borderline ovarian tumours
- Ca125 is not useful
-Elevated in 20-35% of stage 1 serous
-Elevated in 15-20% of mucinous
-Elevated in 80-90% of advanced serous tumours
Describe the management of borderline tumours
Management is with surgery:
1. If not for fertility - TAH + BSO + Washings + Omentectomy + peritoneal bx
2. If for fertility - USO or if bilateral tumours - cystectomy / bilateral partial oophorectomies + washings + omental bx
3. If mucinous tumour consider appendectomy
4. Can be done laparoscopically
5. If recurrence treat surgically
No evidence adjuvant therapy is useful unless invasive implants - overall response is low.
-Studies suggest CT doesn’t change time to recurrence
FU: No evidence to suggest any modality of use for FU
-Can consider 6 monthly USS.
-Do if micropapillary pattern seen or intraepithelial implants
-Recommended FU until complete radical surgery undertaken
What is the recurrence rates of borderline tumours following:
1. Cystectomy
2. USO
3. If have non fertility sparing surgery
4. If have fertility sparing surgery
- Cystectomy - 25%
- USO 15%
- NFS - 5% (BSO)
- FSS 10-20% (up to 40% in literature)
What are the survival rates for borderline ovarian tumours
Stage 1 - 99% at 5yrs
Stage 2 - 98% at 5 yrs
Stage 3 - 96% at 5 yrs
Stage 4 - 77% at 5 yrs
What are the factors that affect prognosis of borderline tumours?
1. Serous
2. Mucinous
- Serous
-Management with cystectomy = increased risk of recurrence but survival unchanged
-Micropapillary architecture
- implants - 66% at 7yrs
-Microinvasion
-Grade not significant - Mucinous
-Extra ovarian tumours
-Pseudomyxoma peritoneii
-Implants
-Invasive foci within tumour - Intraepithelial carcinoma
-Grade
What are the features of Micropapillary serous tumours
-Present in 10-15% of serous borderline tumours
-Tumour contains cribiform and filiform formations
-Likely to have invasive implants
-Likely to be bilateral
-Has higher recurrent rates and mortality rates
-Can progress to low grade serous cancers
-Not often chemosensitive
Describe the staging for ovarian/fallopian/peritoneal cancers
Staging is the same for all ovarian/fallopian/peritoneal cancers
Staging is surgical
Stage 1: Confined to ovaries or fallopian tube
-1a - 1 ovary or tube
-1b - both ovaries or tubes
-1c - surgical spill (1c1) / pre-operative rupture (1c2) / + washings (1c3)
Stage 2: Both ovaries with pelvic extensions or peritoneal cancer
-2a - Extension and / or implants on uterus / tubes / ovaries
-2b - Extension to other pelvic intraperitoneal tissues
Stage 3: Spread outside of pelvis or to retroperitoneum LN
-3a - positive retroperitoneal LN
-3b - Macroscopic peritoneal involvement <2cm
-3c - Macroscopic peritoneal involvement >2cm
Stage 4: Distant mets excluding peritoneal mets
-4a - Pleural effusion with positive cyto
-4b - Distant extra abdominal mets including inguinal LN
Describe the epidemiology of epithelial ovarian carcinoma
-Incidence
-Most common age
-Risk factors and protective factors
- Most common type of malignant ovarian tumour - 90%
- Lifetime risk 1.4% (1:70) / ~2%
- Most common in women over 50yrs
-At least 30% of ovarian masses in women >50 - malignant - Risk factors: Older age, nulliparity, early menarche, late menopause, endometriosis, smoking, obesity
-Genetics
- BRAC 1 - 40% BRAC 2 - 20% HNPCC - 7% (25% of ovarian cancers)
- 5% if one 1st degree, 7% if two 1st degree relatives - Protective factors: COC - 50% reduction if >5yr use, pregnancy - 50% reduction if >3 children, lactation, Salpinectomy, hysterectomy
What are the five types of epithelial ovarian cancers
- High grade serous
- Low grade serous
- Endometriod carcinoma
- Clear cell carcinoma
- Mucinous Carcinoma
Describe high grade serous carcinoma
-Prevalence
-Peak age
-Prognosis
-Pathology
- Most common type of epithelial tumour. 70-80%
- Peak age 45-65yrs
- Most Dx at stage 3 or 4. Poor prognosis - 20% with +LN. Majority relapse
- Pathology:
-up to 20cm, smooth or papillary projections, cystic or multiloculated.
-Associated with BRAC 1/2
-Cytology: marked cytological atypia with high mitotic rate. Comes from STIC lesions
Describe low grade serous epithelial tumour
-Prevalence
-Prognosis
-Pathology
- Uncommon - 5%
- Most Dx at advanced stage - poor prognosis. Slow growing and indolent. Insensitive to CT. Majority relapse
- Pathology:
-Similar to HGSC. Less haemorrhage and necrosis.
-May originate from fallopian tube
Cytology - psamomma bodies. Uniform nuclear size and less mitotic activity
Describe endometriod ovarian carcinoma
-Prevalence
-Peak age
-Prognosis
-Pathology
- 10% of all EOC
- Common in 30-40yrs
- Earlier dx so better prognosis. Chemosensitive
- Pathology:
-Associated with endometriosis
-Associated with endometrial carcinoma - 15-20%
-Associated with Lynch syndrome
-Usually unilateral, solid or cystic, can have chocolate cyst components
Cytology: Low grade
Describe Clear cell epithelial ovarian cancer
-Prevalence
-Peak age
-Prognosis
-Pathology
- 5-10% of all EOC
- Perimenopausal women
- Presents early (stage 1 or 2) - good prognosis. Not chemosensitive
- Pathology:
-Associated with endometriosis, VTE and paraneoplastic hypercalcemia
-Average size 15cm, thick walled, uniloculated, yellow fluid
-Associated with Lynch syndrome
Cytology: Hobnail appearance
Describe mucinous Carcinoma - epithelial ovarian
-Prevalence
-Peak age
-Prognosis
-Pathology
- 3-4% of EOC
- Perimenopausal age group
- Good prognosis - most dx at stage 1
- Pathology:
-Mostly from GI tumour mets
-Likely arise from borderline mucinous tumours
-8-20cm, unilateral, solid/cystic, confined to ovary
-Produce ca19-9
Describe mature cystic teratomas
-Prevalence
-Peak age
-Pathology
-Complications
- Most common benign tumour of women of reproductive age 20-30’s
-Account for 95% of all teratomas - Pathology:
-Arises from germ cells - contains cells from all 3 layers
-Bilateral in 10-15% of women
-Fast growth
-Malignant transformation in 0.2-2% - Increased if Age >50, size >10cm - Torsion is common, if rupture can cause chemical peritonitis
Describe serous cystadenoma
-Prevalence
-Pathology
- Second most common benign ovarian neoplasm in reproductive age women
- Pathology
-Thin walled, uni/multiloculated
-12-23% bilateral
-5-20cm in size
Cytology: lined with epithelia simillar to fallopian tube
Describe mucinous cystadenomas
-Prevalence
-Pathology
- 3rd most common benign ovarian neoplasm in reproductive age women
2.Pathology
-More likely to be multiloculated cf serous
-Bilateral 5% of cases
-Grow larger than serous cystadenomas
-Lined with mucin producing cells
Describe RMI
-Components
-Sensitivity and specificity
RMI = Risk of Malignancy index = Ca125 x M x U
1. Ca125 (less accurate in premenopausal women, can be neg in stage 1)
2. USS findings (U) - 1 point for each - multilocular cysts / solid areas/ bilateral lesions/ascites / mets
=1 if 1 point = 3 if 2-5 points
3. Menopausal state (premenopausal = 1, post menopausal = 3)
A score over 200 = malignancy
-Sensitivity 78%
-Specificity 87%
What is the role of screening for ovarian cancer
- No role for screening with ca125, USS or pelvic exam
-Low sens and spec
-High likelihood of false positives
-No Survival benefit
What is the treatment for epithelial ovarian cancer
- Staging laparotomy with hysterectomy, BSO, omentectomy, pelvic and para aortic LN dissection, appendectomy if mucinous, washings.
- Chemotherapy
-Type depends on stage.
-Combination CT - platinum (carbplatin / cisplatin) and taxane based (Paclitaxel / docetaxel)
Stage 1a/1b Grade 1-2 - no adjuvant CT
Stage 1a/1b Grade 3, 1c or 2
-Adjuvant platinum based CT 3-6 rounds
Stage 3 and 4
-Cytoreduction surgery and combination CT
-Either first or as interval debulking
-Platinum and taxane bases 6 rounds
-+/- maintenance Bevacizumab (VEGF inhibitor. Adds 3-4months survival) or PARP inhibitors for those with BRCA - If desiring fertility - USO + annual FU
How should epithelial ovarian cancer be followed up?
Follow-up every 3 months for 2 yrs then 6 months for 3 yrs then annually.
PET scan is the most useful for looking at recurrence of disease
How should recurrent epithelial ovarian cancer be managed
Most stage 3 and 4 will recur - average time 16 months.
Recurrence should be sx based no survival benefit with imaging or Ca125 monitoring
1. If recurrence less than 6 months = platinum resistant
-consider non-platinum CT
2. If recurrence more than 6 moths = platinum sensitive
-Consider more platinum CT + non-platinum CT
-Consider Bevacizumab
3. Consider secondary cytoreductive surgery
4. If BRCA consider PARP inhibitor
What is the prognosis of Epithelial ovarian cancer by stage
-5yrs survival %
-Prognostic factors
Prognostic factors: younger age, better ECOG, lower amount of initial disease, lower grade tumours
Stage 1 - 89%
Stage 2 - 71%
Stage 3 - 41%
Stage 4 - 20%