Gynaecological Cancer Flashcards
Risk factors of Ovarian Cancer
- Low parity
- Early menarche and late menopause
- Obesity
- Age
- Inherited BRCA1 gene
How is ovarian cancer classified by WHO?
- Epithelial tumours
- Germ cell tumours
- Stromal or sex cord tumours
What are the pathology epithelial origins of ovarian cancer?
- Serous (80%) (high grade and low grade)
- Endometrioid
- Clear cell
- Mucinous
Other:
Brenner (transitional cell)
Mixed cell epithelial tumors
Undifferentiated
Unclassified
What are the clinical features of ovarian cancer?
- Early diagnosis not possible due to lack of symptoms
- Pelvic pain
- Obstipation due to tumour compression
- Diarrhea
- Vaginal bleeding
- Ascites in advanced stage: abdominal
distention - enlarged LN
- nausea, vomiting, weight loss
What are the metastatic routes of spreading on ovarian cancer?
- Direct: bowel, bladder, vagina, peritoneum etc
- hematogenous
- lymphagenous: iliac, hypogastric LN etc
Secondary Ovarian Cancer: krukenburg, breast etc
What is the FIGO classification for ovarian cancer?
STAGE 1: tumour limited to ovaries
STAGE 2: tumour limited to 1/2 ovaries with pelvic organ spread or primary peritoneum
STAGE 3: tumour in both ovaries, fallopian tubes with spread beyond peritoneum outside of pelvis or metastasis to retroperitoneal LN
STAGE 4: Distant metastases outside of peritoneal cavity
*Stage I-3 is curative and Stage 4 is palliative
Treatment ideas for Ovarian Cancer?
Surgical
Chemotherapy
Biologic therapy
Gene therapy
Immunotherapy
Hormonotherapy
What is the treatment for early stage I/IIA in ovarian cancer?
- total hysterectomy
- bilateral adnexectomy (salpingooforectomy)
- omentectomy
If reproduction must be conserved:
- unilateral salpingo-ooforectomy simultaneous wedge resection of opposite ovary
What is the treatment for advanced IIb/c, III i IV in ovarian cancer?
- total hysterectomy with bilateral adnexectomy and omentectomy
- maximal cytoreduction if above not possible
*residual tumour < 1cm - Chemotherapy after surgery (adjuvant tx)
What is the medical management for ovarian cancer?
Chemotherapy:
- Paclitaxel
- Carboplatin
Target Therapy:
- bevacizumab
Hormone therapy:
- tamoxifen
- anastrazole
- leuprolide
Immune therapy:
- pembrolizumab
Gene therapy: BRCA mutation
- olaparib
What are non-epithelial ovarian cancers?
- 10% of all ovarian cancer
- germ cell (dysgerminom & seminoma)- first 2 decades
- sex cord (Granuloso-theca cell tumors - stromal tumours) - above 50
Treatment of non-epithelial ovarian cancer?
Surgery:
- total hysterectomy with bi adenxectomy and omentectomy
From stage IC till stage IV PEB (BEC) regimen is mandatory:
(Cisplatin+Etopozid+Bleomicyn) aka BEC
-PE (Amp.Cisplatin +Amp.Etopozid)
-TC (Paclitaxel +Carboplatin)
What is cervical cancer?
- changes of epithelium leading to cervical intraepithelial neoplasia (CIN)
CIN is included in one of the groups of squamous intraepithelial lesions (L-SIL)
CIN 2 and CIN 3 (neoplasia of intermediate and high grade): invasive forms of squamous cell carcinoma (H-SIL)
Risk factors and Etiology of cervical cancer and how can it be prevented?
- HPV 16 and 18
- Smoking
- Multiple sex partners
- Early age sexual initiation
*prevention by HPV vaccination e.g. bivalent vaccine for type 16 and 18
Clinical features of cervical cancer?
- abnormal vaginal bleeding: intermenstrual or post-coital
- discharge
- pelvic pain
- lower back pain and symptoms of bladder and rectum (in advanced stages)
What is the FIGO staging for cervical cancer?
STAGE 1: confined to cervix
STAGE 2: invades beyond uterus (but no lower 3rd of vagina or to pelvic wall)
STAGE 3: Invasion of lower 3rd of vagina, extends to pelvic wall, hydronephrosis/non-functioning kidneys
STAGE 4: extended beyond pelvis into mucosa of bladder and rectum
Treatment of microinvasive cervical cancer- stage Ia?
Conization
If treatment, then margins must be good
If stage Ia has CIN on the margins of the cone, and the clinical finding is such that the vaginal part of the cervix is completely flattened, the assessment of the extent of reintervention/operation is made by a multidisciplinary team
Consider:
- depth of invasion
- tumour width
- LN invasion
- differentiation of tumour
What is the treatment plan for locally invasive cervical cancer (stage Ib and IIa)?
- radical surgical intervention
- hysterectomy
- resection of the parametrium
- bilateral salpingectomy with ovariectomy
- removal of the upper part of the vagina
- pelvic lymph node dissection
*postoperative chemoirradiation are mandatory
What is the treatment plan for locally advanced cervical cancer (stage IIb - IV)?
- Standard approach is- radical
chemoirradiation - Using cisplatin and brachytherapy and external radiation
*carboplatin if px is cisplatin intolerant
*pembrolizumab if PDL1 positive
+/- bevacizumab
What is the most common type of uterine cancer and what are its risk factors?
Endometrial Cancer
RF:
- early menarche and late menopause
- low parity
- Age >55
- smoking
- tamoxifen use
*Other type is uterine sarcoma
Clinical features of endometrial cancer?
Early stages:
- vaginal bleeding
- abnormal discharge
Advanced stages:
- pressure in pelvis
- Uterine enlargement
Premenopausal women:
- intermenstrual bleeding
- abnormal lengths of menstruation cycle
What is the FIGO staging for endometrial cancer?
STAGE 1: confined to uterus
STAGE 2: invasion of cervix
STAGE 3: local regional spread e.g. serosa, adnexa
STAGE 4: extends outside of pelvis and into rectum and bladder
Treatment for stage I endometrial cancer?
- Total hysterectomy
- with bilateral salpingo-oophorectomy
- with or without lymphonodectomy
Treatment for stage Ib-II for endometrial cancer?
Combine surgery with post-operative combined radiotherapy
Treatment of stage III-IV for endometrial cancer?
- maximal debulking
- adjuvant post-op combined radiotherapy
Chemotherapy:
- Doxirubicin
- Cisplatin
*if relapse, consider carboplatin and pacliataxel
What is the choice of target and immune therapy for endometrial cancer? Mention hormone therapy too.
Target and Immune Therapy:
- Pembrolizumab
Hormone therapy:
- Levonorgestrel
- megestrol
- anastrazole
What are the etiologies and risk factors of vulvar cancer?
- HPV infection: 16 and 18
- smoking
- atypical vulvar hyperplasia
- lichen sclerosis
- Anogenital region neoplasm
Clinical picture of vulvar cancer?
- precancerous lesion appearing as a wart or crusted ulcer
- Carcinoma IS appear as blue wart with itchiness
- Smelly discharge
- pruritus
How is vulvar cancer classified in FIGO staging?
STAGE 1: confined to vulva and/or perineum
(Tumour < 2cm and stromal invasion <1mm)
(Tumour > 2cm and stromal invasion >1mm)
STAGE 2: invasion of adjacent perineal structures e.g. lower/distal third of urethra/vagina or anal involvement without LN
STAGE 3: invasion of any adjacent perineal structure of upper third with any number of non-fixed LN
STAGE 4: fixed to bone or distant metastases with ulcerated LN metastases
Stage 2,3,& 4: is tumour of any size
What are the risk factors of vaginal cancer and clinical picture?
Vaginal cancer has 2 types:
- SCC (most common) and ADC
Risk Factors:
- HPV
- Chronic vaginal irritation
- smoking
Clinical features:
- contact bleeding
- bloody discharge
- wart like lesions
- itchiness
What is the FIGO staging for vaginal cancer?
STAGE 1: confined to vagina
STAGE 2: invades paravaginal tissue but not pelvic wall extension
STAGE 3: extends to pelvic wall
STAGE 4: invades mucosa of rectum and bladder and extends beyond pelvis
What organs does vaginal cancer metastasise to?
SCC:
- lung
- liver
ADC:
- lung
- supraclaviclar LN
- pelvic LN
What is the treatment plan for vulvar and vaginal cancer?
First line: vulvectomy when possible
- lymphadencetomy
Radiotherapy and chemotherapy when metastasis occurred to LN or nearby organs
- Cisplatin
- Brachytherapy
MoA of Bevacizumab for Ovarian Cancer
- multiple effects which contributes to improvement of therapy efficacy
- regression
- inhibition
- anti-permeability
*can lead to HTN: reduction of NO production and renal injury leading to sodium misbalance, volume overload
What is Olaparib? Indications?
- strong inhibitor of human poli (ADP-ribose) polymerase enzyme (PARP-1, PARP-2 i PARP-3)
- PARP needed for single stranded DNA repair
- prevents the dissociation of PARP and traps it on the DNA
Indications:
- platinum intolerance
- BRCA mutated
- serous and endometrioid epithelial ovarian
- Fallopian and primary peritoneal carcinoma of high grade
What is pembrolizumab?
- immunotherapy drug (Keytruda®) may be used to treat recurrent ovarian cancer
- an immune checkpoint inhibitor
How do you treat platinum resistant recurrent ovarian cancer?
- Paclitaxel (weekly)
- AC regimen (Cyclophosphamide +Doxorubicin)
- Mono Gemcitabine
- Caps. Etopozid oral (Vepezid, Lastet)
Tbl. Melfalan (Alkeran) +Pronisone
Diagnostics of non-epithelial?
- US of abdomen or pelvis
- MSCT of chest
- MSCT of abdomen/pelvis
- MRI of abdomen/pelvis
- Determination of beta-HCG,AFP,LDH,all other laboratory.
- Determination of Inhibin
What is Cervical Intraepithelial Neoplasia?
- The cancer develop through sequential changes of epithelium which are denoted as cervical intraepithelial neoplasia (CIN)
- CIN is included in one of the groups of squamous intraepithelial lesions (L-SIL)
- CIN 2 and CIN 3 (neoplasia of intermediate and high grade) precede to most of invasive forms of squamous cell carcinoma (H-SIL)
Diagnostics in Cervical Cancer.
- Inspection and palpation of primary tumor.
- Palpation of ingvinal and supracervical lymph nodes.
- Colposcopy.
- Endocervical curretage.
- Conisation.
- Hysterscopy.
- Cystoscopy.
- PET for extrapelvic metastases
- CT/MRI/PET for determining stage
