Oncology (NEW) Flashcards

1
Q

Ovarian cancer background

A

Epidemiology

  • 10th most common cancer in Aus women
  • incidence by 85yrs is 1/85
  • risk factors (BEEFALOS)
  • > BRCA mutation
  • > endometriosis
  • > estrogen (nulliparity/HRT/menarche/menopause)
  • > family hx (breast/ovaries/lynch/endometrial)
  • > age
  • > lynch syndrome
  • > obesity
  • > smoking
  • protective factors
  • > hysterectomy/tubal ligation/salpingoophorectomy
  • > OCP
  • > breast feeding

Histopath

  • Epithelial (Some Epithelial Cancers Become Massive)
  • > 70% of tumours/90% of cancers
  • > named cystadenoma/carcinoma
  • > serous (cystadenoma/carcinoma) = most common 75%
  • > endometrioid
  • > clear cell
  • > Brenner tumour
  • > mucinous
  • Germ cell (TESTY minus seminoma)
  • > teratoma (mature = dermoid/immature = rare)
  • > embryonal carcinoma
  • > trophoblastic (non GTD choriocarcinoma)
  • > dysgerminoma (Don’t say seminoma)
  • > yolk sac
  • Sex chord/ stromal
  • > estrogen producing (granulosa/thecoma)
  • > progesterone producing (sertoli-leydig tumour)
  • > fibroma (most common cause of meigs)
  • Metastatic to ovaries
  • > breast/colon/gastric
  • > krukenberg tumours (mucin secreting signet ring)

Pathophys

  • Invasion
  • > only into superficial serosa
  • > does not invade parenchyma
  • Direct spread
  • > uterus/fallopian tubes/ovaries
  • > bladder
  • > sigmoid colon
  • Exfoliative spread
  • > transported throughout peritoneum by fluid movement
  • > liver capsule/sub diaphragmatic space/omentum
  • Lymphatic spread
  • > pelvic
  • > para-aortic
  • Vascular spread
  • very rare
  • late process
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2
Q

Ovarian cancer staging and grading

A

Staging

  • stage 1
  • > tumour confined to ovaries
  • > 1c = local spill of malignant cells
  • stage 2
  • > local spread
  • stage 3
  • > spread to peritoneum outside pelvis
  • > involvement of retroperitoneal lymph nodes
  • stage 4
  • > involvement of distant organs
  • > involvement of lymph nodes outside of abdomen

Grading

  • grade 1
  • > well differentiated
  • grade 2
  • > moderately differentiated
  • grade 3
  • > poorly differentiated
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3
Q

Ovarian cancer management

A

Surgery

  • definitive treatment and diagnosis
  • indicated if high index of suspicion
  • > risk factors
  • > symptomatic
  • > complex or progressing cyst/solid mass on US
  • > raised CA 125
  • method
  • > laparotomy/laparoscopy
  • > cystectomy/oophorectomy

Treatment principles

  • approach based on tumour stage and grade
  • maximal surgical debunking + adjuvant chemo
  • intra-operative histology confirms ovarian carcinoma
  • > surgical staging/biopsies required

Surgical staging

  • > abdominal hysterectomy
  • > bilateral salpingo-oophorectomy
  • > appendectomy
  • > omenectomy
  • > pelvic and para-aortic lymph node dissection

Stage 1 (A/B) or grade 1 or 2

  • favourable
  • survival not improved by chemo post op

Stage 1C or grade 3
-require post operative carboplatin cycles

Stage II, III or IV

  • maximal surgical effort for complete cytoreduction
  • may involve
  • > bowel resection
  • > diaphragm peritoneum stripping
  • > splenectomy
  • optimal debulking
  • > intraperitoneal cisplatin
  • suboptimal debulking
  • > adjuvant carboplatin cycles

Monitoring

  • after remission
  • > hx/exam/CA-125 every 3-4 months

Prognosis

  • remission occurs in 80%
  • treatment response to refractory disease 20%
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4
Q

Ovarian cysts background

A

Epidemiology
-approximately 10% lifetime prevalence

Aetiology

  • Functional
  • > follicular
  • > corpus luteum
  • > theca letum
  • Non functional
  • > endometrioma (chocolate cyst)
  • > polycystic ovary
  • Neoplastic
  • > cystadenoma/cystadenocarcinoma
  • > dermoid
  • > granulosa
  • > sertoli-leydig
  • > krukenberg

Pathophys

  • Follicular
  • > graafian follicle fails to rupture
  • > large, simple cyst
  • > associated with endometrial hyperplasia
  • Corpus luteum
  • > corpus luteum fails to involute
  • > often occurs during first 6 weeks of pregnancy
  • > small/large, simple/complex/haemorrhagic
  • > luteoma is solid corpus luteum cyst
  • Theca lutein
  • > overstimulation of theca interna cells of follicle
  • > due to high levels of b HCG
  • > molar or multiple pregnancy
  • > multiple bilateral septated cysts
  • Polycystic ovaries
  • > may or may not be associated with PCOS
  • Endometrioma
  • > ectopic endometrial tissue bleeds within ovary
  • > haematoma surrounded by parenchyma
  • > complex cyst with internal echoes (ground glass)
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5
Q

clinical evaluation pelvic mass

A

Goal

  • rule out ectopic!!
  • differentiate cyst from malignant neoplasm
  • recognise rupture/torsion

Cyst clinical manifestations

  • usually asymptomatic
  • pain
  • > rupture
  • > haemorrhage creating pressure
  • > torsion
  • follicular
  • > hyperestrogenism
  • > breast tenderness/endometrial thickening
  • corpus luteum
  • > hyperprogesteronism
  • > delayed menses
  • theca lutein
  • > virilisation/thyroid disease/hyperemesis/pre-eclampsia
  • polycystic ovaries
  • > hirsutism/acne/obesity/irregular and infrequent menses
  • endometrioma
  • > endometriosis symptoms

Neoplasia clinical manifestations

  • abdo/pelvic/adnexal pain or pressure
  • adnexal mass
  • non specific symptoms
  • > bloating/early satiety/post prandial fullness
  • > anorexia/nausea/vomiting
  • > urinary urgency/frequency
  • metastatic disease
  • > Meig’s syndrome (adnexal mass/pleural effusion/ascites)
  • > bowel obstruction
  • consider extraovarian primary
  • > breast
  • > GIT
  • > endometrial

Rupture

  • background
  • > functional/endometrial/neoplastic cyst
  • > more common in reproductive age
  • > less common with oestrogen contraception
  • adnexal mass
  • lower quadrant pain
  • > often sudden, severe and focal
  • > often post exercise or sex
  • may present with acute abdomen
  • cervical motion tenderness
  • massive haemorrhage
  • > shoulder tip or upper abdo pain
  • > tachycardia and hypotension
  • > cullens signs

Torsion

  • background
  • > usually occurs with cysts/neoplasia
  • > may occur with normal ovaries
  • > pregnancy or reproductive age most common
  • sudden, severe pelvic pain of variable character
  • adnexal mass
  • nausea and vomiting
  • fever with necrosis
  • signs of acute abdomen are unusual
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6
Q

pelvic mass investigations

A
  • B HCG
  • > if positive, ectopic pregnancy pathway
  • First catch urine
  • > chlamydia/gonorrhoea PID?
  • FBC
  • > anaemia?
  • > thrombocytopaenia?
  • > leukocytosis?
  • Blood group and antibodies

Transvaginal ultrasound

  • Normal findings
  • > follicles (<25mm) in reproductive age
  • > simple cyst 30-50mm
  • Concerning for neoplasia
  • > large (>10cm) simple cyst
  • > complex cyst (solid components/septa/thick walled)
  • > high flow on doppler
  • > ascites
  • > solid mass
  • Concerning for torsion
  • > enlarged ovary with cystic/solid mass
  • > free fluid
  • > diminished/absent blood flow on doppler
  • Concerning for rupture
  • > adnexal mass with free fluid

If concern for neoplasia

  • CT abdo/pelvis/chest
  • > metastatic disease
  • CA-125
  • > usually elevated in epithelial
  • > aids in post treatment evaluation
  • > most useful in post menopausal women
  • > consider other germ cell markers in adolescents
  • Consider synchronous endometrial neoplasia
  • > occurs in approx 10%
  • > endometrial biopsy if uterine bleeding/mass
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7
Q

ovarian cyst management

A
Simple cyst in premenopausal
-almost always benign
-non suspicious 
>expectant management
->serial ultrasounds every 2-3 months
->persists or enlarges = laparoscopy + histopath
-suspicious 
->laparotomy

Complex cyst in premenopausal

  • non suspicious
  • > expectant management
  • > serial ultrasounds every 2-3 months
  • > if persistent or >10cm = laparoscopy + histopath
  • suspicious
  • > laparotomy

Simple cyst in postmenopausal

  • not suspicious and normal CA 125
  • > expectant management
  • > serial ultrasounds + CA 125 every 2-3 months
  • > if persistent or >10cm = laparoscopy/laparotomy + histopath
  • suspicious
  • > laparotomy

Complex cyst post menopausal
-laparotomy

Solid mass in pre/postmenopausal
-first line laparotomy + histopath

Pregnant

  • non symptomatic/not suspicious/small cyst
  • > expectant management
  • symptomatic/large cyst/not suspicious
  • > laparoscopy + cystectomy
  • suspicious
  • > ideally delay laparotomy until post natal
  • > consider in 2nd trimester if malignant
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8
Q

endometrial cancer background

A

Epidemiology

  • most common gynaecological cancer
  • 6th most common cancer in women
  • lifetime risk approx 20/100,000

Aetiology

  • Risk factors
  • > older age
  • > obesity
  • > PCOS/low parity/early menarche/late menopause
  • > unopposed oestrogen/tamoxifen
  • > family hx endometrial/breast/ovarian
  • > family hx lynch/PTEN syndrome
  • Endometrial hyperplasia
  • > hyperplasia without atypia = >5 years to progress
  • > atypical hyperplasia = 2.5 years to progress

Pathophys

  • Type 1
  • > most common (80%)
  • > low grade (1 or 2) endometrioid/mucinous
  • > stimulated by oestrogen
  • > preceeded by endometrial hyperplasia
  • > good prognosis
  • Type 2
  • > not oestrogen receptive/background atrophic
  • > poor prognosis
  • > grade 3 endometrioid/serous/clear cell/undifferentiated
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9
Q

Endometrial cancer evaluation and management

A

Clinical presentation

  • AUB
  • > post menopausal bleeding
  • > premenopausal menorrhagia/inter menstrual bleeding
  • pelvic/inguinal pain
  • fatigue and weight loss
  • diarrhoea/nausea/vomiting
  • persistant cough/dyspnoea
  • > neurological symptoms
  • > exam is usually unrevealing

Transvaginal ultrasound
-abnormal thickening >4mm

Biopsy

  • outpatient pipelle curette
  • > often first line
  • > caution if negative but high index suspicion
  • D&C +/- hysteroscopy
  • > most accurate

Cervical cytology
-sensitivity approx 60%

FBC
-anaemia
EUC
-elevated creatinine?
LFT
-al phos?
  • CT abdo/pelvis/chest
  • > only if advanced disease suspected
  • MRI pelvis
  • > assess depth of invasion/surgical planning
  • PET CT
  • > non surgical candidates for monitoring

Management

  • surgical staging
  • hysterectomy(lap or abdo)/BSO/lymphadenectomy
  • neo/adjuvant radiotherapy (brachytherapy or EBRT)
  • adjuvant chemotherapy for advanced/palliative
  • progestogen/GnRH/tamoxifen + progestogen for recurrent/resistant

Prognosis (5 year survival)

  • Stage 1 = 85%
  • Stage 2 = 75%
  • Stage 3 = 65%
  • Stage 4 = 20%
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10
Q

Cervical cancer staging

A

Evaluation

  • Clinical
  • > rectovaginal under anaesthesia
  • > iliac/para-aortic/supra clavicular for lymphatic spread
  • > palpate liver/spleen and balot kidneys for metastatic
  • Scopes
  • > hysteroscopy/cystoscopy/colonoscopy
  • Imaging (if invasive cancer found)
  • > CT abdo/pelvis/chest
  • > MRI pelvis
  • > PET scan (lymph node involvement)
  • > US/CT guided ultrasound nodes if suspicious

Staging

  • 1 (confined to cervix and uterine corpus)
  • > 1A microscopic invasion (1A1 <3mm/1A2 <5mm)
  • > 1B invasion >5mm
  • 2 (invasion beyond uterus/not pelvic wall/not lower vagina)
  • > 2A = upper 2/3rd vagina but not parametria
  • > 2B = parametria involved
  • 3
  • > lower vagina
  • > pelvic wall
  • > hydronephrosis
  • > pelvic/para-aortic lymph nodes
  • 4
  • > 4A = pelvic organs (bladder/rectum)
  • > 4B = distant spread beyond true pelvis
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11
Q

Invasive cervical cancer treatment and prognosis

A
Stage 1A1 (micro invasive)
-cone biopsy

Stage 1A2-2A (early stage)

  • Radical abdominal hysterectomy + lymphadenectomy
  • > adjuvant chemoradiation if large/nodes/+ive margins
  • Chemoradiation
  • > preferred if bulky disease
  • > cisplatin + EBRT + brachytherapy
  • Trachelectomy
  • > if desiring fertility + small tumour

Stage 2B-4A (locally advanced)

  • Chemoradiation
  • > cisplatin + EBRT + brachytherapy

Stage 4B (metastatic)

  • focal deposits
  • > consider surgery/ablation/radiation
  • chemotherapy +/- bevacizumab (VEGF MA)
  • consider goals of care/palliation

Prognosis (5 year survival)

  • Stage 1 = >90%
  • Stage 2-3 = approx 50%
  • Stage 4 = <20%
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12
Q

Cervical cancer background

A

Epidemiology

  • 12th most common cancer in aus women
  • > 5/100,000
  • > ATSI rate x2
  • Risk factors (HEMISPPACE)
  • > HPV
  • > early sexual debut
  • > multiple sexual partners
  • > immunosuppression
  • > STI
  • > parity
  • > pill (OCP)
  • > age (midlife)
  • > cigarrettes (squamous)
  • > economic (low SES)

Aetiology

  • HPPV infection
  • > 99% linked to oncogenic serotypes
  • > 16 and 18 in up to 80%

Pathophys

  • HPV infections
  • > approx 80% lifetime prevalence
  • > sexual activity (vaginal/oral/anal)
  • HPV link to cancer
  • > usually benign, 95% cleared within 3 years
  • > if cleared, risk returns to baseline
  • > carcinoma develops about 10-15 years post infection
  • Disease progression
  • > infection->persistance to LSIL or clearance
  • > LSIL -> progression to HSIL
  • > HSIL -> regression to LSIL or progress to carcinoma
  • > approx 30% HSIL progress to carcinoma (annual 1.4%)
  • Local invasion
  • > initial corpus
  • > vagina/peritoneum/bladder/rectum
  • Haematogenous spread
  • > lung/liver/bone most common
  • > bowel/brain/adrenals/spleen
  • Lymphatic
  • > obturator and iliac are sentinel
  • > parametrial/para-aortic/pre-sacral
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13
Q

cervical cancer evaluation

A

Hx

  • PC
  • > bleeding (intermenstrual/post coital/menorrhagia)
  • > pain (pelvic/back/dyspareunia)
  • > mucopurulent discharge
  • Advanced disease
  • > obstructive nephropathy
  • > haematuria/haematochezia
  • > vaginal passage urine or stool
  • Menstrual hx
  • > abnormal bleeding
  • Sexual hx
  • > debut/multiple partners
  • > barrier protection/previous STD’s
  • > use of OCP
  • HPV
  • > vaccination
  • > last test/previous results
  • Obstetric
  • > previous children/plans for children
  • Psychosocial
  • > smoking

Exam

  • Abdo
  • > tenderness or masses?
  • Speculum
  • > cervical bleeding
  • > ulceration/exophytic mass/barrel shaped endophytic
  • Bimanual
  • > consider PID
  • > evidence of local invasion

Initial investigations

  • cervical screening if asymptomatic
  • colposcopy if symptomatic or visible lesion
  • endocervical swabs if suspicious for cervicitis

Colposcopy

  • General assessment
  • > TZ type 1 (ectropian)/2 (normal)/3(not visible)
  • > obvious masses/lesions
  • > atypical vessels
  • Apply acetic acid
  • > abnormal = dense white/coarse mosaic/coarse punctation
  • Lugol iodine
  • > homogenous uptake = normal
  • > reduced uptake by neoplastic cells
  • Punch biopsies (pain + bleeding)
  • > provides histopath
  • > approx 2
  • Consider endocervical curette

Preop evaluation

  • Urinalysis
  • > kidney dysfunction
  • FBC
  • > anaemia
  • EUCs
  • > obstructive nephropathy
  • LFTs
  • > alphas in liver/bone mets
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14
Q

cervical cancer screening pathway

A

Screening procedure

  • all women who have been sexually active and 25-74yrs
  • > vaccinated and unvaccinated
  • > can stop at 70 if previous 2 normal
  • routine screening every 5 years
  • invitation, reminder letters

CST pathway

  • first HPV partial genotypical
  • > 16/18
  • > other
  • if positive for any HPV DNA
  • > reflex liquid based cytology on same sample
  • Low risk result
  • > HPV not detected
  • > continue 5 years screening
  • Non 16/18 detected + pLSIL/LSIL
  • > HPV again in 12 months (intermediate risk)
  • ->if -ive = continue 5 year screening (low risk)
  • ->if +ive for any HPV=reflex LBC + colposcopy (high risk)
  • Non 16/18 detected + pHSIL/HSIL
  • > colposcopy (high risk)
  • 16/18 detected
  • > LBC + colposcopy (high risk)
  • Any glandular abnormalities detected
  • > refer to colposcopy (high risk)
  • Hysterectomy
  • > normal screening/benign disease/no path = no testing
  • > treated for HSIL with test of cure = no testing
  • > AIS = 12 month testing indefinitely
  • > subtotal = like general population
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15
Q

cervical cancer histopath

A
  • Carcinoma classification
  • > squamous cell carcinoma (80%)
  • > adenocarcinoma/adenosquamous (15%)
  • > other rare forms (neuroendocrine)

Squamous lesions

  • LSIL
  • > acute HPV infection
  • > increased mitoses/C:N
  • pLSIL
  • > possibly LSIL
  • HSIL
  • > persistent HPV infection
  • > loss of differentiation
  • > CIN2 = p16 positive, not fitting CIN3 criteria
  • > CIN3 = dysplasia in >2/3 thickness but no invasion
  • pHSIL
  • > possibly HSIL
  • Squamous cell carcinoma
  • > invasive epithelial tumour with squamous differentiation
  • Superficial invasive squamous cell carcinoma
  • > favourable prognosis

Glandular lesions

  • Adenocarcinoma in situ
  • > mucosal pre-invasive lesions
  • Invasive adenocarcinoma
  • > invasive epithelial tumour with glandular differentiation
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16
Q

post colposcopy management

A

Normal colposcopy

  • CST negative/LSIL
  • > normal TZ 1 or 2 = 12 month CST
  • > TZ 3 = 12 month CST x2 (HPV any = repeat colposcopy)
  • CST HSIL + TZ 1 or 2
  • > repeat CST + colposcopy 6 months
  • CST HSIL + TZ 3
  • > type 3 excision or repeat CST + colposcopy 6 months

LSIL

  • no treatment needed
  • repeat screening at 12 and 24mnths
  • > return to normal screening if both negative

HSIL

  • Excision of entire lesion + TZ
  • Hysterectomy possible if not childbearing age
  • Cold knife cone biopsy
  • > glandular disease
  • > type 3 cervix
  • LLETZ/LEEP
  • > HSIL
  • > diagnostic (but burnt edges)
  • > therapeutic with cautery
  • Test of cure
  • > co-test at 12 months
  • > repeat every 12mths until negative twice in a row
  • > return to normal screening

Glandular

  • AIS
  • > no desire for childbearing = hysterectomy
  • > desire childbearing = cone biopsy with clear margins
  • adenocarcinoma
  • > hysterectomy +/- chemoradiation

Invasive disease
-cone/hysterectomy/chemoradiation/trachelectomy

17
Q

Intracervical neoplasia treatment

A

Overal

  • Goal
  • > removal of entire lesion + TZ
  • Methods
  • > cone biopsy
  • > LLETZ
  • > laser/ablation (rarely performed)
  • Efficacy
  • > no clear benefit of one over the other
  • Complications
  • > major intraoperative bleeding (rare)
  • > post op bleeding (rare, more with cone)
  • > infection (rare, more with cone)
  • > uterine perforation needing laparotomy/laparoscopy (very rare)
  • Cervical stenosis (very rare, more with cone)
  • > difficult labour/shearing forces PPROM
  • > obstruct instrumentation/menstrual flow
  • Cervical incompetence (rare, more with cone)
  • > PPROM/PROM/pre-term birth
  • > possibly monitor cervical length
  • Post op instructions
  • > avoid sex/foreign objects for 2-4 weeks
  • > follow up 6 weeks (healing and patent)
  • > if normal, co test at 6 months
  • > avoid conception for >3 months

Cold knife cone biopsy

  • Procedure
  • > general/local anaesthesia
  • > apply lugol iodine
  • > scalpel excises cone shaped piece of cervix
  • > depth/width determined by TZ type and lesion pattern
  • > endocervical curettage(TZ3/post menopausal/glandular)
  • > specimens sent to pathology
  • Indication
  • > glandular lesion
  • > TZ 3
  • > involvement of endocervical canal
  • Advantage
  • > excellent specimen quality/view of margins
  • Disadvantage
  • > higher complication rate
  • > distortion with healing

LLETZ

  • Procedure
  • > can be performed in rooms
  • > local/general anaesthesia
  • > apply lugol iodine
  • > thin wire of different sizes/passes a current
  • > depth determined by TZ type/lesion pattern
  • > endocervical curettage usually performed
  • Indication
  • > HSIL
  • > repeatedly abnormal CST with normal colposcopy
  • Advantage
  • > minimal distortion with healing
  • > less complications than cone
  • Disadvantage
  • > deep excision more difficult than cone
  • > failed excision and repeat = more morbidity
  • > thermal damage to specimen