Module 17 - Gynaecological Oncology Flashcards
You review a 34 year old women who is due to commence radiotherapy for cervical cancer. She is concerned about the effects of radiotherapy on her bowel. Bowel obstruction may occur in what percentage of women following radiotherapy for cervical carcinoma?
10-15%
Bowel obstruction may occur in up to 14.5% of women following radiotherapy for cervical carcinoma
Dyspareunia is reported by what percentage of women following radiotherapy for cervical carcinoma?
55%
What is the 5 year survival for women with vulval cancer with inguinal lymph node involvement? (Stage III)
<50%
What is the 5 year survival for women with vulval cancer with iliac lymph node involvement? (Stage IV)
10-15%
What is the incidence of bladder atony following radical hysterectomy for cervical cancer?
2-3%
What is the incidence of bowel fistulae formation following radical hysterectomy for cervical cancer?
8%
What proportion of CIN I and CIN II regress spontaneously within 2 years?
50%
What proportion of HPV infections are cleared within 1 year?
70%
What proportion of HPV infections are cleared within 2 years?
90%
Being commenced on single agent chemotherapy advances menopause by how much?
1 year
What is the lifetime risk of developing ovarian cancer with the BRCA1 mutation?
40-50%
What is the lifetime risk of developing ovarian cancer with the BRCA2 mutation?
10-30%
What is the lifetime risk of developing ovarian cancer with Lynch syndrome?
10%
A woman has had genetic testing and been found to carry the BRCA1 gene. What is her risk of developing breast cancer before the age of 70?
70%
What is the overall risk reduction in mortality with surgery for women with BRCA gene mutations?
60-80%
What is the overall risk reduction in ovarian cancer with surgery for women with BRCA gene mutations?
80-90%
When do you perform risk reducing surgery for women with BRCA 2 gene mutation?
Age 40-45
When do you perform risk reducing surgery for women with BRCA 1 gene mutation?
Age 35-40
When do you perform risk reducing surgery for women with Lynch syndrome?
Age 40
A woman has had genetic testing and been found to carry the BRCA2 gene. What is her risk of developing breast cancer before the age of 70?
45%
What proportion of endometrial hyperplasia without atypia will regress to normal endometrium?
75-80%
What proportion of endometrial hyperplasia without atypia will persist?
15-20%
Can women breastfeed whilst on chemotherapy?
No, they should wait 14 days after their last chemo dose to breastfeed
A woman on tamoxifen for breast cancer asks you when she can start to conceive?
3 months after stopping tamoxifen
When can women with a history of breast cancer start on hormonal contraception?
5 years after remission
What is the risk of endometrial carcinoma if the endometrial thickness on US is <3-4mm?
<1%
What is the lifetime risk of developing endometrial cancer with Lynch syndrome (HNPCC)?
40-60%
What proportion of endometrial cancers are caused by Lynch syndrome?
3%
What is the lifetime risk of developing endometrial cancer for the average woman?
3%
How many additional cases of breast cancer are there for women receiving combined HRT for 5 years?
6 per 1,000
Approximately what proportion of cases initially classified as borderline ovarian tumours on frozen section are later identified as invasive tumours?
1/3
What is the lifetime risk of developing colorectal cancer with Lynch syndrome (HNPCC)?
80%
What is the 5 year survival for stage I cervical cancer?
80%
What is the 5 year survival for stage II cervical cancer?
50%
What is the 5 year survival for stage III cervical cancer?
20%
What is the 5 year survival for stage IV cervical cancer?
7%
What is the 5 year survival for stage I ovarian cancer?
80-90%
What is the 5 year survival for stage II ovarian cancer?
65-70%
What is the 5 year survival for stage III ovarian cancer?
30-60%
What is the 5 year survival for stage IV ovarian cancer?
15%
What is the 5 year survival of stage I endometrial cancer?
70%
What is the 5 year survival of stage II endometrial cancer?
50-60%
What is the 5 year survival of stage III endometrial cancer?
30%
A woman has had a laparotomy at 21/40 because of acute abdomen and US showing an adnexal mass. The histopathology has shown a malignant germ cell tumour. How common are germ cell tumours in pregnancy?
40%
A 38 year old woman has been treated for breast cancer with surgery and Tamoxifen.
For how long should her Tamoxifen be stopped before she plans a pregnancy?
3 months
60 year old woman with a partially solid and cystic ovarian mass. Psamomma bodies are recognised. What type of ovarian cancer is it?
Serous cell carcinoma
65 year old woman is admitted with intestinal obstruction. Large, multilocular mass with smooth surface, and predominantly solid. Removal of the appendix is recommended. What type of ovarian cancer is this?
Mucinous adenocarcinoma
Woman with known endometriosis, presenting with recurrent bouts of pyrexia. Large, cystic tumour that is partially solid is noted on US. Hobnail cells are recognised. What type of ovarian cancer is this?
Clear cell carcinoma
Patient has had surgery for endometrial cancer. The ovarian tissue examination reveals Call-Exner bodies. What type of ovarian cancer is this?
Granulosa cell tumour
25 year old lady presents with acute abdomen to A&E. TVS pelvis has shown an ovarian cyst, which is subsequently operated on for suspected ovarian torsion. The right ovarian cyst is not torted, but the ovary is removed as it looks suspicious. Histology shows Schiller-Duval bodies. What type of ovarian cancer is this?
Yolk sac tumour (Endodermal sinus tumour)
Which invasive tumour is associated with signet ring cells?
Krunkenberg tumour
Which invasive ovarian tumour is associated with Walthard cell nest?
Brenner tumour
What proportion of simple endometrial hyperplasia progress to endometrial carcinoma over 20 years?
1%
What proportion of complex endometrial hyperplasia progress to endometrial carcinoma over 20 years?
4%
What proportion of endometrial hyperplasia without atypia progress to endometrial carcinoma over 20 years?
<5%
A woman with atypical endometrial hyperplasia is planned for TAH. What is the risk of finding a concomitant cancer?
43%
What proportion of women with endometrial hyperplasia will have micrometatasis to the ovary?
2-4%
What proportion of endometrial hyperplasia with atypia progress to endometrial carcinoma over 20 years?
30%
What is the 5 year survival for women with vulval cancer with no lymph node involvement? (Stage I or II)
> 80%
A young woman that is HPV +ve is diagnosed with vulval cancer. Which vulval cancer is this likely to be?
Basaloid carcinoma
What proportion of granulosa cell tumours are associated with endometrial hyperplasia?
40%
What is the lifetime risk of developing ovarian cancer?
1.4%
What is the risk of endometrial atypia with endometrial polyps?
0.8%
What is the risk of endometrial cancer with endometrial polyps?
3.1%
What proportion of postmenopausal bleeding is caused by atrophic endometritis/vaginitis?
60-80%
What proportion of postmenopausal bleeding is caused by exogenous oestrogens?
15-25%
What proportion of postmenopausal bleeding is caused by endometrial cancer?
10%
What proportion of postmenopausal bleeding is caused by endometrial hyperplasia?
5-15%
What proportion of postmenopausal bleeding is caused by endometrial polyps?
2-12%
What is the risk of underlying endometrial cancer in a woman with PMB who is >80 years old?
25%
What is the risk of underlying endometrial cancer in a woman with PMB who is <50 years old?
1%
What is the risk of underlying endometrial cancer in a woman with PMB who is obese?
18%
What is the risk of underlying endometrial cancer in a woman with PMB who has diabetes?
21%
What is the risk of underlying endometrial cancer in a woman with PMB who is obese and has diabetes?
29%
What are the top 3 most common gynae cancers in the UK?
1) Endometrial
2) Ovarian
3) Cervical
If taking Tamoxifen for breast cancer, how long should this be discontinued for before trying to conceive?
3 months
Which medications in the treatment of breast cancer are contraindicated in breastfeeding and pregnancy?
Tamoxifen and Trastuzumab (Herceptin)
When can you give systemic chemotherapy for the treatment of breast cancer in pregnancy?
From the 2nd trimester onwards
Systemic chemotherapy is contraindicated in 1st trimester (due to high rate of fetal abnormality). Safe from the second trimester.
When can you perform surgery for breast cancer in pregnancy?
Surgery is safe in all trimesters
When can you give radiotherapy for the treatment of breast cancer in pregnancy?
Radiotherapy contraindicated until after delivery (unless life-saving/preserve function eg spinal cord compression)
When can you start breastfeeding following chemotherapy for breast cancer in pregnancy?
14 days after the last chemotherapy dose
Breast feeding whilst on chemotherapy is not advised due to risk of neonatal leucopenia. Breast feeding should be delayed until 14 days after last chemotherapy dose.
What is the overall prevalence of malignancy within endometrial polyps?
3%
What is the incidence of vulval cancer in the UK?
3.7 per 100,000 women
Uncommon in women <50 years old
Most common in women >65 years old
Peak age up to 90 years old
What is the risk of developing invasive disease in women with lichen sclerosus?
4%
Which gynaecological cancer results in the highest proportion of deaths worldwide?
Cervical cancer
What proportion of all female cancers does vulval cancer comprise?
<1%
However, there has been an increased incidence due to HPV
What are the different types of vulval cancer?
1) Squamous cell carcinoma - 90%
2) Bartholin’s carcinoma - 5%
3) Basal cell carcinoma - 3%
4) Malignant melanoma - 3%
5) Sarcoma - 2%
What are the risk factors for vulval cancer?
1) HPV +ve - 30% risk of cancer
2) Lichen sclerosis - 4% risk of progression to cancer. Make up 30% of squamous cell carcinomas
3) Lichen planus
4) Lichen simplex
5) Smoking
6) Immunosuppresion
7) Increasing age
8) Paget’s disease (extra-mammary) - 4-8% cause cancer
What are the different types of VIN (Vulval Intraepithelial Neoplasia)?
1) VIN undifferentiated (usual) type
HPV associated - 16 & 18. 9-16% risk of cancer if untreated, 3% risk if treated
Younger women
Multifocal
May have medical treatment - Imiquimod cream 5%
2) VIN differentiated type
Lichen sclerosis
30% risk of progression to cancer
Older women
Unifocal
WLE is the treatment, no medical treatment
What is the 5 year survival for vulval cancer with no lymph node involvement (stage I or II)?
> 80%
What is the 5 year survival for vulval cancer with inguinal lymph node involvement (stage III or above)?
<50%
What is the 5 year survival for vulval cancer with pelvic lymph node involvement (stage IVb?)
10-15%
Which imaging modality is used to stage vulval cancer?
MRI pelvis
What is the FIGO staging + treatment for vulval cancer?
Stage I - Tumour confined to the vulva. Negative nodes
Ia - <2cm + stromal invasion <1mm
<1% risk of spread to LN (negligible)
Rx - WLE
Ib - >2cm or stromal invasion >1mm
Increased risk of LN spread - do groin LN dissection
Depth 1-2mm - 8% LN involvement
Depth 3-5mm - 30% LN involvement
Rx - WLE + unilateral LN dissection (if lateral) or bilateral LN dissection (if medial)
Stage II - Tumour of any size with spread to lower 1/3 urethra, lower 1/3 vagina or anus. Negative nodes.
Stage III - Tumour of any size +/- spread to adjacent organs. Positive nodes.
3AI - 1 LN ≥5mm
3AII - 1-2 LN <5mm
3BI - 2 or more LN ≥5mm
3BII - 3 or more LN <5mm
3C - LN with extra-capsular spread
Stage IV - Tumour spreads to upper 2/3 urethra, upper 2/3 vagina, anus. Positive nodes.
4AI - Upper urethra, upper vagina, bladder mucosa, rectal mucosa
4AII - fixed or ulcerated inguinal nodes
4B - distant mets, incl. pelvic lymph nodes
Lateral tumour - >1cm beyond. Perform unilateral LN dissection
Medial tumour - <1cm from midline. Perform bilateral LN dissection
Which vulval cancers do you perform WLE with no LN dissection for?
1) Basal cell carcinoma
2) Malignant melanoma
3) Verrucous cancer - don’t give radiotherapy as can develop anaplastic transformation
What is the treatment of Bartholin’s gland carcinoma?
Hard to diagnose
Deep-seated
Painful
Adenocarcinoma mostly, also squamous cell carcinoma
Rx - WLE + removal of part of anal sphincter + colostomy + bilateral LN removal
How do you perform a biopsy for vulval lesions?
Wedge biopsy
Take normal skin and lesion
Go deeper than 1mm (ideally 3-4mm deep)
How do you perform a WLE in vulval disorders?
Need a margin of 15mm in fresh tissue - this becomes 7mm in fixed contracted tissue
What are the indications of radiotherapy in vulval carcinoma?
1) Primary - if unfit for surgery
2) Neoadjuvant - debulking to decrease morbidity from primary surgery
3) Adjuvant - if 2 or more LN return as positive
4) If there is extra-capsular spread from LN (Stage 3c) - increased risk of pelvic spread. Will need pelvic + groin irradiation
What factors increase the risk of recurrence for vulval cancers?
1) There are 3 or more positive groin LN nodes
2) Lesion is >4cm
What is the treatment of recurrence of vulval cancers?
1) Imaging
2) Surgical excision - if small and localised
3) Chemotherapy
4) Chemoradiotherapy - if more advanced
How do cervical cancers spread?
Vertically and horizontally
Down + out
How are cervical cancers staged?
1) Clinical staging. Can up-stage or down-stage:
EUA + Cystoscopy + Sigmoidoscopy
2) MRI Pelvis with contrast (Stage IA1 + IA2)
3) PET-CT/MRI (Stage Ib + above)
What is the FIGO staging + treatment for cervical cancer?
Stage IA - Microscopic disease. Not visible
IA1 - confined to cervix. <3mm depth
<1% risk of LN involvement
Rx: LLETZ + 3mm margin
OR
Knife cone biopsy
No LN dissection. Fertility-sparing treatment
IA2 - confined to cervix. >3 - <5mm depth
Rx: Surgery + bilateral LN dissection
Radical Hysterectomy (uterus, tubes, ovaries, parametrium, upper 2cm cuff of vagina, B/L pelvic LN)
Fertility-preserving Rx: Radical Trachelectomy + cervical suture
Stage IB - clinically visible
IB1 - >5mm depth + <2cm diameter
Radical Trachelectomy up to IB1 (<2cm)
IB2 - ≥2 - 4cm
If MRI shows no LN involvement - Rx: Radical hysterectomy + LN dissection
IB3 - >4cm
Stage II - Beyond uterus but not lower 13 vagina
IIA1 - Upper 2/3 vagina without parametrium. <4cm
IIA2 - >4cm
IIB - parametrium
Stage III - Involved lower 1/3 of vagina
IIIA - Lower 1/3 vagina
IIIB - parametrium +/- hydronephrosis or non-functioning kidney
IIIC - pelvic/para-aortic nodes
Stage IV - distant mets
IVA - Bladder or rectal mucosa involved
≥IB3 - IVa - Chemoradiotherapy. 5 weeks of Cisplatin. No surgery
IVB - Distant mets
Palliative radiotherapy if: pain, vaginal bleeding, bony mets, spinal cord compression
Chemoradiotherapy if patient fit
Radiotherapy: 1) External beam radiotherapy
2) Brachytherapy
A - vertical
B - horizontal. Parametrium
When do most recurrences of cervical cancer occur?
Within first 3 years of treatment
What are the major risks with trachelectomy?
1) Premature labour - 40-50%
2) Extreme prematurity - 20%
3) Cervical stenosis - 10%
What techniques can be used to limit the adverse effects from radiotherapy in cervical cancer?
1) Hb should be >12
2) Improve nutrition
3) Pack bladder away
4) Vaginal dilators
5) Early sex to decrease risk of stenosis
What is the follow-up regime after fertility-preserving surgery for cervical cancer?
Long-term FU with colposcopy for 10 years or until hysterectomy
How often are cervical smears done after radiotherapy for cervical cancer?
Never do cervical smears after radiotherapy
After a TAH, when are cervical smears done?
3 scenarios
1) Never had a cervical smear. Do a vault smear 6/12 after surgery
2) Normal smear prior to surgery. No smear needed
3) CIN prior to surgery. Do vault smear at 6/12 and 18/12
What is the lifetime risk of endometrial cancer for an obese woman (body mass index 40 kg/m2)?
10-15%
What is your lifetime risk of ovarian cancer if one family member is affected?
4-5%
What is your lifetime risk of ovarian cancer if two family members are affected?
7%
Have to send for genetic screening
What proportion of women with endometrial hyperplasia will have micrometatasis to the ovary?
2-4%
What proportion of women with endometrial hyperplasia will have micrometatasis to the ovary?
2-4%
Which tumour markers are raised with Granulosa cell ovarian tumours?
Inhibin
AMH
Oestradiol
Which tumour markers are raised with Yolk sac ovarian tumours?
AFP
LDH
Which tumour marker is raised with Dysgerminoma ovarian tumours?
LDH
What proportion of cases reported as
borderline tumours on frozen section are later reclassified as invasive tumours?
1 in 3
What proportion of ovarian neoplasms do borderline tumours make up?
10-15%
What proportion of serious borderline tumours are bilateral?
30%
NB: Serous borderline tumours are the most common and comprise 50% of all borderline tumours
What proportion of serious borderline tumours occur in women <40 years old?
30%
