Gynae Oncology Flashcards
Treatment of Persistent GTN with FIGO score >6
Combined chemotherapy
Continue for 6 weeks after HCG levels are normal
Overall 5 year survival of breast cancer
57-66%
What is the false positive rate of mamographic screening
10% in younger women
5% in older women
Cervical screening guidelines for England Wales Scotland N. Ireland
England - 25-49 yo 3 yearly
50-64 yo 5 yearly
Wales and N. Ireland - as England
Scotland - 20-60 yo 3 yearly
Presentation of Paget’s disease of the vulva
Burning
Raised erythematous lesion
Treatment of choice for Paget’s disease of the vulva
Surgery
Recurrence rate after surgical treatment of Paget’s disease of the vulva
30%
What proportion of cervical invasive cancers are squamous carinomas?
90% squamous
10% adenocarcinoma
What is the commonest type of vaginal cancer
90% squamous
Usual management of invasive vaginal cancer
Radiotherapy
Management of squamous or adenocarcinoma of the cervix
Both managed the same
Best treated with surgery +/- radiotherapy
Does methotrexate have any impact on adenocarcinoma of the cervix
Yes but not curative. Causes some regression
Presentation of adenocarcinoma of the endocervix
PV bleeding
Offensive PV discharge
Pain
Haematuria
Management of smear showing CIN 1 (mild dyskaryosis)
Check HPV status
If HR HPV +be refer to colposcopy
Management of smear showing CIN 2
Refer to colposcopy
Clinical presentation of androgen producing tumours
androgen producing tumours are usually adrenal or ovarian
rapid hair growth
virilization and clitoral enlargement
masculinization
androgenic symptoms
timeframe of 3 to 6 months
What hormone do Granulosa cell tumours produce?
What are the symptoms
Granulosa cell tumours produce oestrogen
can lead to vaginal bleeding and breast tenderness
General symptoms - bloating etc
may lead to endometrial hyperplasia, polyps or endometrial cancer.
ultrasound appearance vary from completely solid to cystic
Most common Type of Ovarian Cancer
Epithelial Cancers
90% of ovarian cancers
What proportion of ovarian cancers are Germ cell carcinomas?
And who do they affect
Germ cell carcinoma
5% of cases of ovarian cancers
Usually in women in their 20’s
Three main subtypes of ovarian Germ cell carcinoma
Three main subtypes:
teratoma
dysgerminomas
endodermal sinus tumors
Other subtypes are Embryonal cancer polyembryoma choriocarcinoma mixed type
What proportion of ovarian cancers are Stromal carcinoma?
What are the 2 main types?
Stromal carcinoma
5% of cases of ovarian cancers
Two main types:
granulosa cell tumors
sertoli-leydig cell tumors
Granulosa cell tumours typically secrete oestrogen
What proportion of ovarian cancers are Small cell carcinoma?
Who do they usually affect?
Small cell carcinoma of the ovary
0.1% of cases of ovarian cancers (very rare)
Usually in women in their 20’s
Definitions Complete Molar pregnancy
Complete Molar: Abnormal diploid conceptus with absence of foetus (typically 46XX)
Define Partial Molar pregnancy
Partial molar
Abnormal triploid conceptus that may have fetal tissue typically 69XXY
Define Choriocarcinoma
Malignant tumour of trophoblast
What proportion of pregnancies are molar?
1 in 1000 pregnancies per year are molar
What proportion of pregnancies are effected by choriocarinoma
1 in 45,000 pregnancies effected by choriocarcinoma
70% of choriocarcinoma occurs after molar pregnancy
20% after TOP
10% after normal pregnancy
Classic Clinical Features of molar pregnancy
Irregular vaginal bleeding
Hyperemesis
Large for gestational age uterus
Early Miscarriage
Classic Biochemical Features of molar pregnancy
Excessive HCG production
In 3% of cases excess HCG sufficient to trigger hyperthyroidism
Diagnosis of molar pregnancy
Ultrasound assessment
Formal diagnosis is on histopathological assessment following evacuation
Advice regarding chemo for breast cancer and breastfeeding
should not breastfeed whilst taking tamoxifen, trastuzumab (herceptin®) or during chemotherapy.
Women on chemotherapy should wait at least 14 days from their last chemotherapy dose before breastfeeding
What is the most common cancer in females?
Breast cancer
How many pregnancies are affected by breast-cancer development?
Breast cancer in 1 in 3000 pregnancies
Treatment of breast cancer during pregnancy
Surgical treatment can be considered in all trimesters
Systemic chemotherapy contraindicated in 1st trimester - high rate of fetal abnormality
Chemo Safe from the second trimester.
Radiotherapy contraindicated until after delivery - unless life saving/preserve function eg spinal cord compression
Tamoxifen and trastuzumab (herceptin®) contraindicated in pregnancy
Why is breastfeeding while on chemotherapy not advised?
risk of neonatal leucopenia.
Breast feeding should be delayed until 14 days after last chemotherapy dose
What is associated with Differentiated VIN?
Differentiated VIN is associated with lichen sclerosus
What is Undifferentiated or usual/classical VIN associated with?
Undifferentiated or usual/classical VIN is associated with high risk HPV - 16 + 18
undifferentiated VIN is often seen in younger women and may be multifocal
Predisposing conditions to vulval cancer
lichen sclerosus (may lead to differentiated VIN prior to carcinoma)
high-risk HPV i.e. 16 and 18 (may lead to undifferentiated or usual type VIN prior to carcinoma)
What is the Risk of developing invasive vulval disease in women with lichen sclerosus?
4%
5 yr survival of vulval cancer
No LN involvement >80%
Inguinal LN involvement <50%
Iliac and other Pelvic LNs 10-15%
What is stage 1 vulval cancer
Confined to vulva
1A = Lesions ≤ 2cm with < 1mm stromal invasion
1B = Lesions > 2 cm in size OR with stromal invasion > 1 mm confined to the vulva or perineum
What is stage 2 vulval cancer
Stage 2 vulval cancer
Tumour of any size
with extension to adjacent perineal structures
- lower 1/3 urethra
- lower 1/3 vagina
- anus
with negative nodes
What is stage 3 vulval cancer
Stage 3 vulval cancer
Tumour of any size
with or without extension to adjacent perineal structures (lower 1/3 urethra; lower 1/3 vagina; anus)
with positive inguinofemoral nodes
3A (I) = 1 LN met (≥5 mm)
OR (II) 1 - 2 LN met (< 5 mm)
3B (I) = 2+ LN mets (≥5 mm)
OR (II) 3+ LN mets (< 5 mm)
3C = Positive nodes with extra capsular spread
What is stage 4 vulval cancer
Tumour invades other regional (upper 2/3 urethra; 2/3 vagina) or distant structures
4A (I) = Upper urethral and/or vaginal mucosa; bladder mucosa; rectal mucosa or fixed to pelvic bone
OR (II) Fixed / ulcerated inguinofemoral LN
4B = Any distant mets including pelvic LN
Bowel obstruction may occur in what percentage of women following radiotherapy for cervical carcinoma
10-15%
Side effects from treatments of gynae malignancies with radiotherapy
of F treated for gynae malignancies:
Infertility
> 50% have GI SE - diarrhoea, rectal bleeding and fistula formation.
Bowel obstruction up to 14.5% following radiotherapy for cervical ca
Bowel fistulae up to 8% after tx of cervical ca.
Intraoperative ureteric injury in 1% of radical hysterectomy without prior radiotherapy
1% undergoing radiotherapy develop ureteric fibrosis + obstruction
Radiation cystitis - 26% who survive > 5 yr
Bladder atony common after radical hysterectomy. 2-3% requiring intermittent self-catheterisation.
Shortening and stenosis of Vaginal epithelium common
Dyspareunia is 55%
What follow up is advised for women treated for CIN 1-3
cervical screening at 6 months after treatment
Women with one previous molar pregnancy have what chance of the subsequent pregnancy being molar
1 in 80
Women with more than one previous molar pregnancy have what chance of the subsequent pregnancy being molar
1 in 10
In PMB an endometrial thickness with TVS of ≤ 4mm means what probability of endometrial carcinoma
<1%
Advice regarding timing of cervical smear for pregnant women
In pregnancy routine cervical screening should be deferred until at least 12 weeks postnatal.
If previous smear abnormal refer for specialist opinion re mid-trimester sampling
High risk HPV types for cervical cancer
16 + 18
HPV 16 + 18 account for what % of cervical cancer?
70%
What types of HPV does gardasil cover?
16, 18 = cervical ca
6, 11 = warts
What % of smear tests come back normal?
94%
What proportion of women have cervical cancer cells on their smear test?
1 in 1000
What proportion of smears on average are insufficient?
2%
What % of women who have a smear are referred to colposcopy?
4%
Management of an inadequate cervical smear
Repeat smear - not before 3m
If 3x inadequate smears refer to colposcopy - 6 weeks
Management of a borderline or low Grade dyskaryosis smear?
Test for HR HPV
if HPV +be refer to colp within 6/52
If HPV -ve refurn to routine recall
Management of moderate / severe smear (high grade dyskaryosis)
Refer to colposcopy - urgent 2 week wait
Management of suspected cervical cancer or a glandular abnormality on smear test
Refer to colposcopy - 2 week wait
Life time risk of endometrial cancer in a patient with lynch syndrome?
50%
What cut of for the endometrium on tv Uss is used for excluding cancer in PMB patients
4mm
When a 4mm cut of is used on uss for excluding cancer in PMB patients what % of women will have an endometrial cancer which is missed?
1%
Bowel fistulae occur in what % of women having pelvic radiotherapy for cervical cancer?
5-10%
GI side effects from pelvic radiotherapy
Diarrhoea
Rectal bleeding
Fistulae
Bowel obstruction
Urinary side effects from pelvic cancer surgeries or radiotherapy
Intraoperative ureteric injury - 1%
Ureteric fibrosis
Radiation cystitis
Bladder atony
Sexual function side effects from pelvic radiotherapy
Vaginal shortening Vaginal stenosis Dysparunia Vaginal dryness Psyhoclogical dysfunction
Management of a patient with a RMI of >200
CT abdomen and pelvis
Refer to gynae onc MDT
What groups of patients are at higher risk of developing a complete molar pregnancy
Girls <15yo
Women > 45 yo
Women with a previous molar pregnancy
Breast cancer occurs in how many pregnancies
1 in 3000
Advice re breastfeeding whilst on breast cancer treatment
Women should not breastfeed whilst taking tamoxifen, trastuzumab (herceptin®) or during chemotherapy.
Women on chemotherapy should wait at least 14 days from their last chemotherapy dose before breastfeeding.
Advice regarding tamoxifen and timing of conception
If planning future pregnancies women should stop tamoxifen three months prior to trying to conceive.
What % of endometrial cancers are genetic
2-5%
5 year survival in vulval cancer without lymph node spread
vulval cancer without lymph node spread
5year survival is over 80%
