ONC Flashcards
- Pseudomyxoma peritonei
a) can only occur if a primary cyst rupture
b) associated with pleural effusions
c) classically associated with bowel obstruction
d) responds to radiotherapy
e) responds to chemotherapy
c) classically associated with bowel obstruction
- Acute left heart failure is most likely to occur with which antineoplastic agent
a) vincristine
b) cisplatin
c) bleiomycin
d) doxorubicin
e) cyclophosphamide
d) doxorubicin
Vincristine
- cytotoxic, chemotherapy
- use for gestational trophoblastic disease, ovarian germ cell tumours
- main side effects chemotherapy induced peripheral neuropathy, neuropathic pain, , hyponatraemia, constipation and hair loss
Cisplatin
- Use for metastatic ovarian cancer
- main SE – ototoxicity, renal toxicity, anaphylaxis, vesicant ( severe chemical burns ie to eyes, skin and mucosal pain ) in high doses and irritant at lower doses
Bleiomycin
- use for malignant pleural effusion and off label for germ cell tumours
- Main SE – pulmonary toxicity to fibrosis, severe idiosyncratic reaction, hyperpigmentation, stomatitis and mucositis,
Doxorubicin
- Use for Metastatic ovarian ca
- Main SE: Acute and delayed Cardiotoxicity for severe HF, secondary malignancy – AML acute myelogenous leukemia and myelodysplastic syndrome,impaired hepatic function
Cyclophosphamide
- Use for ovarian ca and breast ca
- SE: Reversible alopecia, dose related N+V, leukopenia
- A 55 y.0. woman seeks your advice regarding exposure to DES. She used DES during both of her pregnancies. All of the following statements are true except:
a) her daughter has an increased risk of infertility
b) her daughter has an increased risk of developing clear cell CA of the vagina
c) her daughter has an increased risk of cervical dysplasia
d) her son has an increased risk of genital tract abnormalities
e) she has an increased risk of breast cancer
All true, see below fro RANZCOG
(DES mothers) are at an increased risk of developing breast cancer.
(DES daughters) are at an increased risk of breast cancer, rare vaginal and cervical clear cell adenocarcinoma (CCA), precancerous changes to the cells in the vagina and cervix, fertility problems and pregnancy problems.
These women also have higher rates of structural abnormalities of the uterus; these are associated with increased perinatal risks of preterm birth and reproductive loss.
(DES sons) an increased risk of testicular abnormalities but not testicular cancers or fertility problems.
- A 28 y.o. woman in her first pregnancy presents with a threatened miscarriage at 16/40. On examination a 3cm exophytic lesion is seen on her cervix. Biospy confirms adenocarcinoma. Do you:
a) await maturity
b) arrange EUA, cystoscopy, IVP and CXR
c) irradiate
d) perform radical hysterectomy and PLND
e) reassess after TOP
b arrange EUA, cystoscopy, IVP and CXR
Stage 1b1 ( < 4cm )
- Treatment – Radical hysterectomy and PLND or chemoradiation
- Young so radical hysterectomy
- Outcome same for both treatment
- LN involvement 15.9%
- 5 yr survival 60-95%
If desires fertility:
Radical trachelectomy and PLND
- Remove cervix, parametrium and vaginal cuff
- Permanent nylon suture at the base of uterus to replace cervical function
- Future birth via CS
Intraoperative findings that are indications for abandoning radical hysterectomy for cervical cancer include all of the following EXCEPT
A. Stage IIA disease with a unilateral 30 mm diameter ovarian cyst.
B. intraperitoneal metastasis.
C. extra-nodal parametrial/pelvic sidewall disease.
D. extensive, unresectable pelvic lymph node disease.
A. Stage IIA disease with a unilateral 30 mm diameter ovarian cyst.
CERVICAL CA:
Stage 1a1 ( <3mm stromal invasion and ≤ 7mm diameter ) – cone biopsy if margin clear no need for further treatment, if margin not clear then simple hysterectomy
Stage 1a2 ( 3-5mm stromal invasion and < 7mm diameter ) – modified radical hysterectomy or simple hysterectomy and PLND
Stage 1b1 < 4cm tumour - ( Radical hysterectomy and PLND or chemoradiation )
- Chemo
- Ext beam radiation ( 30min/day x 5/7 x 5/52)
- Weekly cisplatin
- Brachytherapy at end of treatment ( x2 )
-
Stage 1b 2 ( >4cm ) – IV a ( adjacent organs ie bladder and rectum ) – chemoradiation
Stage 2 – Ext beyond cervix
2a – no obvious parametrial involvement and 2/3rd of upper vagina
2b – parametrial involvement
Stage 3 – pelvic sidewall and lower 1/3rd of vagina + hydronephrosis
a- Lower 1/3rd of vagina
b- Side wall and hydronephrosis
Stage IVb – palliative Radiotherapy
The primary group of lymph nodes that drain the vulva is the
a. deep inguinal.
b. deep femoral.
c. obturator.
d. superficial inguinal.
d. superficial inguinal.
A 25 yr old women developed hirsutism, wt gain and deepening of the voice over the last year. Her menstrual cycles are irregular and infrequent. Examination reveals severe facial hair growth and clitoromegaly. The uterus is slightly enlarged. The patient is obese and the ovaries are very difficult to palpate. Investigation shows a testosterone concentration of 17.3 nmol/L (normal range 0.5 - 2.8) and a DHEAS concentration of 9.8 umol/L (normal range 0.9 - 11.7). The MOST APPROPRIATE next step in this patient’s evaluation is
A. measurement of serum androstenedione.
B. measurement of serum 17-hydroxyprogesterone.
C. CT scan of the adrenals.
D. vaginal ultrasound of the ovaries.
D. vaginal ultrasound of the ovaries.
`
-Late onset CAH presents at puberty with virulisation.Elevated DHEAS. dx by serum 17 OHP
- this is rapid onset ? pelvic mass, and high testorterone- could be a virilising tumor. ( levels > 6.94nmol/Lor DHEAS > 24nmol/L indicate virilising tumour (eg sex chord tumour: sertoli or legdig cells). Elevated DHEAS would suggest adrenal source of the androgen secreting tumour)
A 22-year-old woman has infrequent (three times yearly) heavy menses which last10 to 12 days and increased facial hair growth. She is normotensive and moderately obese. Her last menstrual period started 25 days ago and ended 12 days later. A biopsy specimen from the endometrium would MOST LIKELY show
A.supranuclear vacuoles.
B. stromal oedema with perivascular decidualisation.
c. haemorrhagic stroma and collapsed endometrial glands.
d. crowding of straight tubular glands.
d. crowding of straight tubular glands.
Which one of the following statements concerning pseudo myxoma peritonei is CORRECT? Pseudo myxoma peritonei;
A. Requires leakage from a parent cyst for the development of the condition.
B responds to treatment with alkylating agents.
C. is characteristically associated with intestinal obstruction.
D. responds to treatment with total abdominal irradiation
C. is characteristically associated with intestinal obstruction.
- Uterine sarcoma. Risk factors include:
a) family history
b) multiparity
c) previous pelvic irradiation
d) exogenous oestrogen
c) previous pelvic irradiation
- Ca of one ovary. One lymph node with tumour between renal vein and IVC. Stage is:
a) Ia
b) I
c) II
d) III
e) IV
D. STAGE 3
Staging of ovarian Ca
o Stage I – confined to ovary
o Ia – one ovary, capsule intact, no tumour on surface
o Ib – both ovaries, capsule intact, no tumour on surface
o Ic – one or both ovaries, tumour on surface of one or both ovaries: or capsule ruptured; or with ascites present containing malignant or with positive peritoneal washings
o Stage 2 – confined to true pelvis, growth on one or both ovaries
o 2a – growth to the uterus and / or tubes
o 2b – extension to other pelvic tissues
o 2c - stage 2a or 2b (capsule ruptured, ascites, surface tumour, positive pelvic washings)
o Stage 3 – Tumour involving one or both ovaries with peritoneal implants outside the pelvis and /or positive retroperitoneal or inguinal nodes
o 3a – microscopic disease outside the true pelvis negative nodes
o 3b – abdominal deposit < 2cm size, negative nodes
o 3c – abdominal implants > 2cm size or positive nodes
o Stage 4 – growth involving one or both ovaries with distant metastases. If pleural effusion present, there must be positive cytology to allot a case to stage 4. Parenchymal liver metastasis equals stage 4
- Lady with Ca Cx on biopsy. EUA extending unilaterally to left pelvic sidewall. Treatment options:
a) Radical hysterectomy and LN dissection
b) Radiotherapy then extended hysterectomy
c) Pelvic exenteration-
d) External beam radiation
e) Palliative irradiation
Stage 3b - Answer – chemoradiation therefore d : external beam radiation
Stage 2 a – lower 2/3rd of vagina
2b – parametrium
Stage 3a – lower 1/3rd of vagina
3b – pelvic side wall
Pelvic exenteration is an extensive operation that when used to treat vulvar cancer includes vulvectomy and often removal of the pelvic lymph nodes, as well as removal of one or more of the following structures: the lower colon, rectum, bladder, uterus, cervix, and vagina.
- 2cm vulval lesion. Wide excision showed invasive Ca to 0.8mm beyond the basement membrane. Therapeutic options include:
a) nothing
b) wider excsion
c) simple vulvectomy
d) radical vulvectomy
e) option d) plus bilateral groin dissection
a
Stage 1a is tumour < or = 2 cm with < 1mm stromal invasion and does not require lymph node dissection or any further treatment
- During a radical hysterectomy the uterine artery is divided at which of the following:
a) at its origin adjacent to the hypogastric artery
b) adjacent to the ureter
c) where it meets the uterus
d) in the wall of the uterus
a) at its origin adjacent to the hypogastric artery
Hypogastric artery ( internal iliac )
Branches – I love going places in my own underwear
Iliolumbar L – lumbosacral G – gluteal ( superior and inferior ) P – pudendal I – uterine M – middle rectal O – obturator U – umbilical
First three posterior divisions of anterior brance
Remainder anterior branches
What percentage of women under 35 will have breast cancer?
a) 1/10
b) 1/60
c) 1/400
d) 1/100,000
b) 1/60
breast cancer lifetime risk ~12%. This means there is a 1 in 8 chance she will develop breast cancer.
In adenocarcinoma of the cervix
a) conservation fo the ovaries is contraindicated
b) exogenous oestrogen is contraindicated
c) exogenous progesterone is contraindicated
d) all of the above
e) none of the above
e) none of the above
What is the lifetime risk of developing ovarian cancer for a woman whose sister has developed ovarian cancer?
a) 0.1%
b) 1%
c) 5%
d) 20%
e) 50%
Answer c 5%
Life time risk 1 in 70
1st degree relative = risk 5%
2x first degree relative = 11%
the incidence of lymph node involvement with micro-invasive disease of the cervix is:
a) 1%
b) 5%
c) 10%
d) 20%
e) 30%
Answer a – 0.6%
Use of vault radiation in endometrial carcinoma aims to treat:
a) pelvic node secondaries
b) vaginal vault secondarises
c) para-aortic secondaries
d) femoral secondaries
b) vaginal vault secondarises
Stage 1c to 2 – external beam radiation and brachytherapy
- increased risk of recurrence
Stage 3 – chemoradiation
Stage 4 – palliation
Stage 1 - uterus
Stage 1 a – endometrium – TAH + BSO
B - <50% of myometrium – TAH + BSO
c> 50% of myometrium – radiotherapy
Stage 2 – uterus and cervix
A – inc endocervical glands
B- cervical stroma
stage 3 – outside uterus but remain in pelvis
a- uterine serosa, adnexa + peritoneal fluid
b- vagina mets
c- mets to pelvis and paraaortic ln
Stage 4 -
A – adjacent sites – bladder and rectum
B – distant sites intraabdominal and inguinal LN
a 30 yo with abdo hyter for intraepithelial Ca of the cervix. Flushed, temp 39 C, PR 140/min, RR 24, clear chest. Most likely diagnosis?
a) PE – no sx
b) Pelvic sepsis secondary to bacteroides fragilis
c) Beta Strep
d) Pelvic vein thrombosis
e) Reaction to blood
b) Pelvic sepsis secondary to bacteroides fragilis
All of the following are typical of massive PE except?
a) pulmonary vascular congestion on CXR
b) retrosternal chest pain
c) right ventricular strain on ECG
d) tachypnoea
a) pulmonary vascular congestion on CXR
CXR findings: Oligemia ( westermarks sign ), increased size of hilum by thrombus impaction, atelectasis with elevation of hemidiaphragm, pleural effusion consolidation, hamptons hump.
- What do you do after TAH/BSO/PLND for endometrial ca with 1 positive LN invasion to inner 2/3 of myometrium
a) external beam MVT
b) progesterone
c) vault Caecium
d) chemotherapy
e) nil
a. External beam pelvic radiotherapy then vault brachytherapy
- 32 yo PG presented at 12/40 for 1st antenatal visit. Pap smear showed CIN3. Colposcopy and biopsy revealed ?microinvasion. She is currently 16/40. Which of the following is correct?
a) cryotherapy
b) cold knife cone biopsy
c) laser cone
d) TAH
e) Radical hysterectomy
b. Knife cone biopsy
Although unless invasive cancer for treatment deferred until after pregnancy
- Most common complication of radical vulvectomy.
a) haemorrhage
b) wound infection
B wound infection
Some wound breakdown is common, but this usually heals with conservative management. If the wound has been closed with skin flaps and necrosis has occurred, the dead skin should be debrided. Hematomas/seromas, although unusual if adequate drainage is maintained, may require evacuation. Signs of infection should prompt obtaining specimens for culture and instituting antibiotics. Urinary tract infection, thromboembolism, and osteitis pubis are additional potential complications.
Late sequelae include stenosis of the vaginal introitus and pelvic organ prolapse.
- Woman who is 16 weeks pregnant with a breast lump which is confirmed to be carcinoma of the breast. She wants the pregnancy but also wants what is best for her?
a) terminate the pregnancy
b) luscs at 36 weeks
c) IOL at 36 weeks
d) Allow to go to term and deliver spontaneously
e) Deliver at 28 weeks
d) Allow to go to term and deliver spontaneously
Green top guideline
Treatment as per non pregnancy state
Diagnosis in pregnancy has no negative impact on survival
Metaanalysis found that gestational breast cancer was associated with higher risk of death, association primarily associated with diagnosis in the post partum
- Management of stage 2 vulval carcinoma ( > 2cm lesion )
a) wide excision
b) radical vulvectomy
c) radical vulvectomy and ipsilateral XRT to groin
d) radical vulvectomy and deep inguinal and femoral LN dissection
e) wide excision and ipsilateral XRT to goin
Answer d with bilateral LN
Stage 1a – lesion confined to vulva with <1mm stromal invasion. No nodal mets – wide local excision, aim for 1cm clear margins
Stage 1b to Iva – Radical vulvectomy and bilateral groin node dissection
1b - <2cm, >1mm stromal invasion. No nodal mets.
Stage 2 vulval cancer - > 2 cm dimension with no nodal involvement
Stage 3 – adjacent spread to lower urethra , vagina or anus or unilateral node mets
Stage Iva – upper urethra, bladder mucosa, rectal mucosa, pelvic bone or lesions with bilateral groin node mets
4b – distant mets, inc pelvic nodes.
NICE GUIDELINE May 2014 –
- wide local excision and groin node dissection
- In a patient with ovarian carcinoma and negative 2nd look laparotomy the chance of disease recurrence are ?
a) 0-20%
b) 20-40%
c) 40-60%
d) 60-80%
e) 80-100%
.
d)
Overall likelihood of relapse after intial therapy for all stages of disease for women with EOC is 62%
UTD: Taking into account the frequency of each stage of disease and its projected relapse rate, the overall likelihood of relapse after initial therapy for all stages of disease for women with EOC is 62 percent; it is 80 to 85 percent for women who present with stage III or IV disease. The likelihood for recurrence depends on many factors, including distribution of disease at initial presentation, success of initial surgical cytoreduction (ie, the presence of any residual disease), rapidity of CA125 resolution, and treatment response after primary therapy. However, a predictive marker for recurrence has not been prospectively verified
- What percentage of patients with vulval carcinoma have tumours with a depth of invasion less than 1mm?
a) 1%
b) 5%
c) 10%
d) 20%
e) 30%
c) 10%
- What percentage of patients with vulval carcinoma with a depth of invasion less than 1mm have nodal disease?
a) nearly zero
b) 2%
c) 5%
d) 10%
e) 20%
Answer a
Answer a nearly zero
- All of the following constitutes indications for cone biopsy in pregnancy, except:
- a minimally invasive SCC on cervical biopsy
- b smear result suggestive of adenocarcinoma in-situ
- c inadequate colposcopy
- d none of the above
- e all or the above
d none of the above
- The second most common vulval malignancy is:
a) sarcoma
b) verrucous carcinoma
c) melanoma
d) adenocarcinoma
e) basal cell carcinoma
c) melanoma
- What is the country with the highest incidence of cervical cancer?
a) Japan
b) USA
c) India
d) Finland
e) France
c. India
- A 32 yo woman counselling re ovarian cancer. 2 x 2nd degree Ca ovary – grandma and aunt. What would you advise?
a) reassure
b) yearly pelvic examination
c) yearly pelvic examination with Ca 125
d) yearly pelvic examination with Ca 125 + US with Doppler
a) reassure
- 16 yo girl presents with pelvic discomfort and a complex cystic mass was found on US. At laparotomy, an immature teratoma was found in the right ovary. Most appropriate Mx:
- a RSO
- b R ovarian cystectomy
- c R ovarian cystectomy & wedge biopsy of L ovary
- d TAH, BSO omentectomy
- e RSO & wedge biopsy of L ovary
RSO
- What is tumour marker for ovarian embryonal carcinoma?
* **
a) BHCG
b) AlphaFP
c) CEA
d) Ca 125
e) LDH
Answer a) b HCG
Most of these tumors produce hCG, while some also make AFP
- What is the next management in 40 yo P3 who has had a cone biopsy showing 1mm of invasive cancer and clear margin?
a) nil further
b) simple TAH
c) radical hysterectomy
d) TAH/BSO
a) nil further
- Patient with a past history of Hodgkin’s disease, treated with chemotherapy. Now enquiring if she can get pregnant? Best test?
a) high FSH
a
- On dermoids
a) 10% are malignant
b) the most common tumour found in pregnancy
c) 20% are bilateral
Answer b)
- Management of stage 3b cervical cancer
a) palliative radiation
b) XRT
c) Exenteration
Answer b)
b) XRT
- 45 yo with 2 family members with ovarian cancer who is booked for elective TAH for menorrhagia. Best option?
a) take out ovaries
b) HRT
a`
- Most common site of primary metastases to the ovary?
a) pancreas
b) liver
c) kidney
d) breast
e) lung
d. breast
- Use of vault radiation in endometrial cancinoma. Aim to treat:
a) pelvic node secondaries
b) vaginal vault recurrences
c) para-aortic node secondaries
d) femoral secondaries
Answer – vaginal vault recurrences
- The most common lymph node involved in ca cervix:
a) femoral
b) obturator
c) external iliac -
d) para-aortic – ovarian
c. external iliac
UTD: The distribution of sites of nodal metastasis were: external iliac (43 percent), obturator (26 percent), parametrial (21 percent), common iliac (7 percent), presacral (1 percent), and paraaortic (1 percent).
Parametrial to internal, external and common ilian and obturator node – paraaortic and presacral late
- What is the increased incidence if 1st degree relative has breast cancer?
a) 10%
b) 30%
c) 50%
d) 100%
e) 200%
d. 100%
- 1.5 x 3 pop average
lifetime risk of breast cancer is 1:8 (12.5%)
in one 1st degree relative with unilateral pre-menopausal breast cancer – 30% lifetime risk
so they put 30/12.5 = 240 – therefore 200% is closest
but is the answer actually b)??
if 1st degree relative with bilateral cancer life-time risk 40-50%
risk no significantly increased if 1st degree relative with post-menopausal breast cancer
- What do you do after rad TAH/BSO/PLA for Ca endometrium with 1 pos pelvic node, invasion to inner 2/3 myometrium, grade 2.
a) external beam MVT
b) vault caesium
c) progesterone
d) chemo
e) nil
a radiation
- A 70 yo lady has metastatic adenocarcinoma of the vagina. The most likely site of the primary is?
a) breast
b) kidney
c) uterus
d) ovary
c) uterus
- A patient who is 28 yo who is at 14 weeks has a 2cm intraductal carcinoma of the breast, has a mastectomy and nodes. The next appropriate management is:
a) termination there and then
b) termination at 16/40
c) CS at 36/40
d) IOL at 36 weeks
e) Leave until term and manage expectantly
e) Leave until term and manage expectantly
- The commonest location of metastatic deposit to the ovary?
a) thyroid
b) breast
c) kidney
d) gallbladder
b) breast
- The treatment of 3cm Paget’s disease on the left labia
a) wide local excision with margin of 5 mm
b) wide local excision with margin of 2 cm
c) vulvectomy
a) wide local excision with margin of 5 mm
Invasive adenocarcinomas may be present within or beneath the surface lesion up to 25% (
Women with Paget disease of the vulva should also be evaluated for the possibility of synchronous neoplasms, as approximately 20 to 30 percent of these patients have a noncontiguous carcinoma (eg, involving breast, rectum, bladder, urethra, cervix, or ovary)
- The ovarian tumour with characteristic signet ring cells is ?
a) endometrioid carcinoma
b) teratoma
c) Krukenberg tumour
d) Brenner tumour
c.
Krukenberg tumour, which can account for 30-40% of metastatic cancers to the ovaries, arises in the ovarian stroma and has characteristic mucin-filled signet-ring cells
Usually bilateral, lesions not usually discovered until the primary disease is advanced
Gastrointestinal cancers and breast cancer are the most common nongenital malignancies that metastasize to the ovary. In studies of 50 or more cases of metastatic neoplasms to the ovary, the sites of primary tumors included: colon cancer (15 to 32 percent); breast (8 to 28 percent); gastric (6 to 22 percent); and appendix (2 to 20 percent
- Ovarian thecoma:
a) predominantly bilateral
b) may produce virilizing symptoms
c) occur predominantly in females less than 14
THECOMA — Thecomas are solid, fibromatous neoplasms and are generally benign. They are composed of theca cells and arise from the ovarian stroma
Thecomas are almost exclusively confined to one ovary and occur predominantly in postmenopausal women (average age 59 years). Thecomas may produce estrogen, and up to 20 percent of patients present with a synchronous endometrial cancer
- Stage 2 ovarina carcinoma had the disease resected down to about 4cm. She had maximal chemotherapy. What is she most likely to die of?
a) uraemia
b) pyelonephritis
c) bowel obstruction
c) bowel obstruction
- A 14 yo lady diagnosed to have adenocarcinoma of the left ovary stage 1a. What is your management?
a) LSO
b) TAH and BSO
c) TAH/BSO and omentectomy
d) TAH/BSO and omentectomy and radiotherapy
e) TAH/BSO and omentectomy and chemotherapy
a) LSO
Stage 1a – limited to one ovary, capsure intact no ascites
If 41 yr old with ovarian cancer – TAH.BSO omentectomy
- Which of the following is correct about carcinoma of the vulva?
a) SCC at the clitoris associates with metastasis of both inguinal nodes at an early stage – No
b) Metastasis to the iliac node with negative inguinal nodes
c) A 3 cm lesion has a 33% chance of positive lymph nodes
d) Stage 3 disease has 40% chance of positive lymph nodes
c) A 3 cm lesion has a 33% chance of positive lymph nodes
0-1cm 7.7% LN 1.2-2cm – 23.9% LN 2.1 -3 cm 31% 3.5 36% LN For all other patients with apparent early stage disease (ie, stage IB to II), inguinofemoral lymphadenectomy is performed because the risk of inguinofemoral lymph node metastases is ≥8 percen
90% SCC of vulva, spread by inguinofemoral LN.
Early stage,
Depth of invasion predictive of LN involvement.
< 4cm sentinel nodes were superficial in 85% cases and 15% sentinel nodes laid deep to cribiform fascia
Inguinofemoral lymphadenectomy is the standard approach to evaluation of the lymph nodes in women with vulvar cancer. Historically, pelvic lymph nodes were also removed, but this was found to have no diagnostic or therapeutic benefit.
Assessment for lymph node metastases is essential for staging. Unfortunately inguinofemoral lymphadenectomy is associated with high morbidity rates. This has led to a shift in practice toward unilateral lymphadenectomy whenever possible. Sentinel lymph node biopsy is an active area of investigation, is used in some institutions for women with early stage disease, and is increasingly being utilized in the US.
- Which of the following is the best treatment option for carcinoma of the cervix stage 3?
a) rad hyst and bilateral inguinal lymphadenectomy
b) rad hyst and bilateringuinal lymphadenectomy and vault radiotherapy
c) external end extended field radiotherapy
d) extended field radiotherapy and chemotherapy
e) intracavity and extended filed radiotherapy
d) extended field radiotherapy and chemotherapy
Cervical Ca
Stage 1 – cervix
1a – microscopic 0.6% PLND
A1 – stromal invasion ≤ 3mm diameter or ≤ 7mm – 4.8 PLN
A2 – stromal invasion > 3mm -≤ 5mm ≤ 7mm
B > 7mm wide or > 5mm deep or visible ≤ 7mm – 15.9%
B1 < 4cm
B2 > 4cm
2 – beyond cervix but not pelvic side wall or vagina –
IIa – no parametrial but up to upper 2/3rd- 24.5%
IIb – parametrial but not ext to pelvic side wall – 31.4
3 – pelvic side wall, lower 1/3rd of vagina. Or hydronephrosis 44.8%
4 – beyond true pelvis or bladder and rectal mucosa – 55%
A – adj pelvic organs
B – distant mets
Treatment 1a1 – cone 1a2- 3-5, <7mm modified radial or simple TAH with plnd - if wanting fert then rept cone with lap PLND 1b1 - < 4cm ( 4.8%) Wertheims hyst and PLDN or Chemorad - fert sparing – radical trachelectomy then PLND
1b2-4a
Chemo rad
4b – palliative + rtx
- Which is not a germ cell tumour?
a) granulosa cell tumour
b) dysgerminoma
c) embryonal cell tumour
d) immature teratoma
a) granulosa cell tumour
– sex cord tumour / stromal
- A 28 yo presents with threatened miscarriage at 16/40. O/E ecm exophytic lesion on cervix, punch biopsy confirms adenocarcinoma. Do you?
a) arrange EUA/cystoscopy / CXR / IVP
b) await maturity
c) irradiate
d) perform radhyst and PLND
e) reassess after TOP
a) arrange EUA/cystoscopy / CXR / IVP
- 1st AN visit at 10/40. O/E 2 cm Ca cervix confined to cervix. SCC on biopsy. What would you advise patient?
a) rad hyst
b) cone biopsy
c) await fetal maturity
d) radiotherapy
neoadjuvant chemotherapy -> await fetal maturity c.
Stage IB1 (Tumor 2 cm or larger) and higher — For patients with stage IB tumors ≥2 cm or higher (table 1), we offer neoadjuvant chemotherapy if they have no evidence of lymph node involvement on lymphadenectomy. Alternatively, neoadjuvant chemotherapy can be administered without prior staging lymphadenectomy, in which case, surgical staging should be performed after delivery. (See “Management of locally advanced cervical cancer”, section on ‘Neoadjuvant chemotherapy’.)
In one review of 50 women treated with neoadjuvant chemotherapy, median gestational age at diagnosis was 19 weeks [33]. Chemotherapy was platinum-based and administered at three-week intervals until 33 weeks gestational age on average. The overall response rate was approximately 90 percent (62.5 percent complete response rate). With a median follow-up of two years, survival by stage was reported as (table 1):
●Stage IB1 – 94 percent
●Stage IB2 – 70 percent
●Stage >IB – 70 percent
If neoadjuvant chemotherapy is administered, treatment should continue up to 34 to 35 weeks of gestation with delivery planned three weeks later (ie, term). We would utilize the standard regimen administered to women with metastatic cervical cancer in the nonpregnant patient, which consists of cisplatin plus paclitaxel delivered every three weeks for up to six cycles [47]. However, it should be acknowledged that the literature regarding the use of chemotherapy in pregnancy is based on case reports and small series [48,49]. Still, these series have mostly reported a relatively favorable risk profile for fetal, neonatal, and maternal complications. We agree with the guidance from the Second International Consensus Meeting on Gynecologic Cancers in Pregnancy and suggest not administering gemcitabine, vinorelbine, topotecan, or biologic agents (including antiangiogenesis agents) in the pregnant patient because of the lack of safety data [33].
The majority of studies do not suggest a difference in the oncologic prognosis of women with invasive cervical cancer diagnosed during pregnancy compared with nonpregnant women with invasive cervical cancer when adjusted for stage; however, data are limited [8,9,53,64-66]. As an example, a retrospective study compared 40 women with pregnancy-associated cervical cancer with 89 nonpregnant women with cervical cancer [8]. Maternal survival was not significantly different in both groups after 30 years of follow-up. Another study evaluated 53 women with stage IB disease diagnosed in pregnancy [9]. Five-year survival was similar to that of nonpregnant controls and was not affected by the time of initiation of therapy during the pregnancy. A large, long-term series of pregnant women with invasive cervical cancer reported 5.5 percent developed a second primary, which is similar to the second primary rate in all women under 50 years of age
- 55 yo with Ca cervix. At EUA tumour extends to one pelvic side wall. Best treatment options?
a) rad hyst and nodes
b) exenteration
c) palliative radiotherapy
d) vaginal radiotherapy then extended hysterectomy
e) external beam radiotherapy – full treatment dose
e) external beam radiotherapy – full treatment dose
CHEMORAD
Stage 3 – extend to pelvic sidewall or lower 1/3rd of vaginal or hydroneph
A – no obv parametrial involvement but involvement of lower 1/3d
B- ext to pelvic side wall and hydronephrosis or non functioning kidney
- What is the lifetime risk of ovarian cancer for someone with one first degree relative with Ca ovary?
a) 1%
b) 5%
c) 25%
d) 50%
e) 90%
b. 5%
Lifetime prob of getting ovarian cancer in US population – 2%
The risk of ovarian cancer is increased when the family history suggests a sporadic case but is substantially greater when there is a hereditary cancer syndrome. A meta-analysis of pooled case-control studies calculated an odds ratio of 3.1 for developing ovarian cancer in women with one first- or second-degree relative with the disorder [8]. Based upon these data, it was estimated that a family history of ovarian cancer in one relative increased the lifetime probability of ovarian cancer in a 35-year-old woman from 1.6 to 5.0 percent. In contrast, women with hereditary ovarian cancer syndromes have a lifetime probability of ovarian cancer of 25 to 50 percent
- A 28 yo woman in her first pregnancy presents with a threatened miscarriage at 16/40. O/E a 3 cm exophystic lesion is seen on her cervix. A punch biopsy confirms adenocarcinoma. Do you?
a) await maturity
b) arrange EUA/cystoscopy/CXR/IVP
c) irradiate
d) perform radical hysterectomy/PLND
e) reassess after TOP
b arrange EUA/cystoscopy/CXR/IVP
