Oncology + Vulval Disorders Flashcards
1
Q
What’s the FIGO staging of cervical cancer?
A
1 - Confined to cervix
a. Max depth of invasion <5mm
__1. Stromal invasion <3mm
__2. Stromal invasion 3 to <5mm
b. Max depth 5mm or more
__1. Stromal invasion 5mm to <2cm __2. Stromal invasion 2cm to<4cm
__3. Stromal invasion 4cm andabove
2 - Invaded upper 2/3rd of vagina + no pelvic wall involvement
a. No parametrial involvement
___1. <4cm in greatest dimension
___2. 4cm/more
b. Parametrium involved
3- Lower 1/3rd of vagina involved
a. Lower 1/3rd of vagina only
b. Extension to pelvic side wall +/ hydronephrosis or non-functioning kidney
c . Pelvic +/ paraaortic lymph nodes (irrespective of tumour size)
___1. Pelvic lymph nodes mets
___2. Paraaortic lymph node mets
- Tumour extends beyond true pelvis/ has involved bladder/rectum
a. Spread to adjacent organs
b. Spread to distant organs
2
Q
Ultrasound features in keeping with malignancy?
A
M5 rules - MAP IIN
Multilocular solid mass
Ascites
Papillary projections (4 or more)
Irregular solid contour
INcreased vascular flow
3
Q
What percentage of ovarian neoplasms are dermoid cysts/mature teratomas?
A
40%
4
Q
What percentage of dermoid cysts contain thyroid tissue/endodermal derivatives?
A
5-20%
5
Q
What percentage of dermoid cysts:
A. Undergo torsion
B. Rupture spontaneously
C. Are asymptomatic
D. Contain malignant components?
A
A. 3.5-10%
B. <5%
C. 60%
D. 2%
6
Q
What is a fibrosarcoma?
A
A fibroma with >3 mitoses per 10 high power fields
7
Q
What is Meigs syndrome?
A
Pelvic mass
Ascites
Right pleural effusion
8
Q
What percent of malignant ovarian tumours are dysgerminomas?
A
2-5%
Dysgerminomas are the commonest malignant germ cell tumour
9
Q
What percentage of patients with germ cell tumour present with stage 1 disease?
A
70%
10
Q
What percentage of patients with sex cord stromal tumour present with stage 1 disease?
A
60-95%
11
Q
T/F. Dysgerminomas are associated with gonadal dysgenesis?
A
True. Karyotyping should be offered especially in amenorrheic patients
12
Q
T/F. Dysgerminomas are usually bilateral? What percentage of ovarian dysgerminomas are bilateral?
A
10-15%
13
Q
Incidence of Endometrial cancer?
A
2/100,000 women per year :<40yrs
40-60/100,000 women per yr: >60yrs
14
Q
Median age of occurrence of endometrial ca?
A
63 years
15
Q
In general, what is the survival rate for endometrial cancer at 1 yrs, 5 yrs and 10yrs?
A
1 yr: 90%
5 yrs: 77%
10 yrs: 75%
16
Q
5 year survival rate for stage 1 vs stage 4 endometrial cancer?
A
85% vs 25%
17
Q
What is the risk of endometrial cancer in overweight/obese women?
A
2-3 times increased risk
18
Q
What are the risk factors for endometrial cancer?
A
Age - increased risk over 60yrs
Nulliparity
LMP: irregular menses/amenorrhea/
anovulatory cycles;
menopause- on HRT?
- Tibolone increases risk 80%
- oestrogen only increase 50%
Chronic illness:
*DM - hyperinsulinaemia from insulin resistance increases activity of oestrogen on uterine tissue
*Personal h/o breast ca? On tamoxifen? - triples risk of breast ca
*PCOS - obesity, hyperinsulinaemia
*Obesity/sedentary lifestyle - risk is 2-3 times higher
FHx - breast cancer, colon cancer (hereditary non-papolomatous colon cancer is seen with <5% of endometrial ca)
19
Q
How many deaths from endometrial cancer are attributed to tamoxifen therapy?
A
2/10,000 women per year!
Remember baseline risk is 2/100,000 (<40yrs) & 40-60/100,000 (>60yrs)
20
Q
What reduces the risk of endometrial cancer?
A
1.Multiparity - first pregnancy
reduces risk by 30%; 25%
for each successive birth.
– older age at last birth reduces risk
2. COCPs -6% reduction per year
of use (fewer days of unopposed oestrogen exposure).
- risk reduction continues for 20yrs after stopping use
3. More sex hormone binding globular levels - more oestrogen is bound/ less metabolically active oestrogen
4. Physical activity - healthy weight/not obese
5. Aspirin esp in obese women decreases risk 28% meta-analysis
21
Q
What is the broad FIGO classification/staging of endometrial cancer?
A
Stage 1 confined to corpus uteri
Stage 2 invades cervical stroma but
does not extend beyond the
uterus
Stage 3 local/regional spread
Stage 4 invasion of bladder/bowel/
distant mets
22
Q
What is the Stage 1 FIGO classification of endometrial cancer?
A
Confined to corpus uteri
1A - no invasion/ <50% myometrial invasion
1B - >50% myometrial invasion
23
Q
What is the Stage 2 FIGO classification of endometrial cancer?
A
Invasion of cervical stroma but no extension outside uterine corpus
24
Q
What is the Stage 3 FIGO classification of endometrial cancer?
A
think from top of uterus down
3A - invasion of serosa of corpus +/- adnexa
3B- invasion of vagina +/- parametrium
3C - Lymph node spread
3C1 - Pelvic LN spread
3C2 - paraaortic node spread +/-
PLN spread
25
What is the Stage 4 FIGO classification of endometrial cancer?
4A - invasion of bladder/ bowel mucosa
4B- distant Mets (including inguinal/intraabdominal LNs)
26
Most common type of endometrial cancer?
Endometrioid - 75%
Composed of malignant glandular epithelial elements
27
Which types of endometrial cancer are more aggressive?
Type II category endometrial cancer- aggressive, fast growing, not related to oestrogen.
*Grade III endometrioid
adenocarcinomas
*Papillary serous - 5%-10%
*Clear cell- 1%-5%
*Malignant Mixed Mullerian
tumours/ carcinosarcomas: 1-2%
*Uterine sarcomas- 3%
28
What are the categories of endometrial cancer?
There are two categories of endometrial cancer- dependent on the histology, molecular profile and clinical course.
Type I - slow growing, low-grade (I-II) adenocarcinomas
--- related to oestrogen --- therefore seen in obese patients with peripheral conversion of androstenedione to oestrone in body fat.
-- Diagnosed early and has a favourable prognosis
-- 80% of cases
Type II
- more aggressive, fast growing and unrelated to oestrogen.
- Makes up 10% of cases
- Have i) p53 mutations
ii) loss of Heterozygosity at several chromosomal loci
- less favourable prognosis
- presents at an later stage
29
Aetiology of endometrioid vs clear cell and papillary serous carcinomas?
Endometrioid goes thru the pre-malignant phase of atypical hyperplasia.
Clear cell and papillary serous arise from a series of GENETIC mutations
30
What is the risk of recurrence for endometrial cancer?
7-18%
31
Main stay of treatment for endometrial cancer with multiple or distant recurrences?
High dose progesterone therapy.
GnRH analogues may be used in progesterone refractory cases.
32
How do you manage Stage 1 endometrial cancer?
TAH & BSO - Laparoscopic or laparotomy
LND is debatable - may increase morbidity (e.g. lymphoedema) without clear benefit.
- no evidence of benefitnon overall survival or recurrence free survival
-----therefore it is NOT recommended
* If the patient is not fit for surgery (obesity, cardiac disease...) then treat with:
External beam RT &/brachytherapy
33
How do you manage Stage 2 endometrial cancer?
TAH & BSO & consider pelvic/paraaortic LND
- 20% chance of spread to PLN at this stage.
- if 1) surgical margins are attained & 2)nodes are free of disease = NO need for adjuvant RT
* If the patient is not fit for surgery (obesity, cardiac disease...) then treat with:
External beam RT &/brachytherapy
34
How do you manage Stage 3/4 (intraabdominal disease) endometrial cancer?
Stage 3: **AIM to cure!!**
- TAH & BSO + maximal surgical debulking
- pelvic RT and vaginal RT
- chemo for high grade tumours, especially if PLN disease!
- Can consider neoadjuvant chemo for large pelvic masses, followed by debulking sx.
Stage 4: If distant mets:
- Palliative hysterectomy
- may be followed by pelvic RT and or chemotherapy (for palliation and to increase the symptom-free interval)
35
Incidence of lichen sclerosus?
1/300 to 1/1000
36
What systemic disorders are associated with lichen sclerosis or erosive lichen planus?
Autoimmune disorders:
Thyroid (Graves)
Alopecia Areata
Type 1 DM
Pernicious anaemia
Vitiligo
37
Vulvar dystrophy management?
Avoid:
- irritants
- tight clothing
- soaps, shampoos, bubble bath
- condoms with spermicide
Use:
- soap substitutes (decrease irritation)
- emollients (maintain and protect skin barrier)
Counsel:
About condition and long term complications
38
Vulvar dystrophy management?
Avoid:
- irritants
- tight clothing
- soaps, shampoos, bubble bath
- condoms with spermicide
Use:
- soap substitutes (decrease irritation)
- emollients (maintain and protect skin barrier)
Counsel:
About condition and long term complications
39
Differential Diagnosis for vulval dystrophy?
There are 9:
1. Dermatitis
2. Vulval candidiasis
3. Atrophic vaginitis
4. Contact dermatitis
5. Lichen simplex
6. Lichen sclerosus or Lichen planus
7. Dermatoses
8. Infection
9. Systemic skin disorder
40
Discuss the types of vulval intraepithelial neoplasia?
- VIN are premalignant lesions of which there are 2 types:
Differentiated & Usual type
Differentiated Type
- is rare and seen in older women age 55-85 yrs
- associated with lichen sclerosus
- O/E: Unifocal ulcer or plaque
- May progress to keratinizing squamous carcinoma of the vulva
- This type of VIN is more likely to progress than the usual type
Ususal Type
- more common and seen in women 35-55yrs
- associated with smoking, HPV 16, CIN, VaIN and chronic immunosuppression
- Various presentations:
--- mutifocal and multicentric
--- papules/plaques/patches
--- red/white/pigmented
--- erosions/nodules/warts/
hyperkeratosis
- Associated with Warty or Basaloid squamous cell carcinoma of the vulva
41
What is the aim of management of VIN?
1. relieve symptoms (of intense
pruritus)
2. exclude invasive disease
3. reduce RISK of developing
invasive disease
42
Management options for VIN?
Surgical and Non-surgical
43
Outline non-surgical management of VIN?
1. Topical imiquimod cream
- used 2-3 times/wk
- has up to 81% clinical &
histological response rate
- S/Es: pain, erythema, swelling
-- can cause non-compliance
2. Cidofovir - gives clinical and
histological response
3. Laser ablation - EFFECTIVE
- Used when:
- tissue conservation is
important i.e. at glands &
hood of clitoris
- if pt refuses/is unfit for sx
- failure rate: 40%
- Not used on hair bearing
skin because of the
involvement of skin
appendages
44
Outline surgical options for VIN?
Local excision and simple/radical vulvectomy
Local excision - provides histological sample for diagnosis.
- same recurrence rates as vulvectomy
- risk lower (but still exists) if margins are disease free;
- has higher response states compared to non-surgical management
** Women should have access to reconstructive surgery**
- as larger/ mutifocal lesions when healed can lead to scarring and tension - w/ subsequent pain and psychosexual morbidity.
Simple/Radical vulvectomy
- NOT recommended
- due to adverse effects on sexual
function & female body image
45
What percentage of women undergoing excision of VIN have clinically unrecognized invasion?
12-17%
46
Surveillance for VIN
Annual
- clinical assessment
- vulcoscopy
- biopsy suspicious lesions
- colposcopy: as 4% of pts will have intraepithelial neoplasia at OTHER lower genital tract sites
- examine cervix, vagina, vulval
and perinatal skin
47
Risks recurrence for VIN?
- Increased with multifocal/multicentric disease (Usual type).
48
Risk of invasive cancer after surgical treatment for VIN?
4%
49
Risk of cancer w/in 8 years of diagnosis of VIN?
40%
50
T/F Lichen sclerosus is an autoimmune condition?
True. 40% have another autoimmune condition
51
Age of presentation for lichen sclerosus?
Any age (even children!!) but more common in postmenopausal women
52
Symptoms of lichen sclerosus?
1. Severe pruritus (worse at night)
2. Uncontrollable scratching with trauma and bleeding to area
3. Dyspareunia
4. Pain and or discomfort
5. Difficulty urinating? ( fusion one labia minora over urethra)
53
Examination findings of lichen sclerosus?
- Vulva affected in a Figure of 8 configuration
- Erythema and keratinization of the vulval skin
- Hyperkeratosis may be present
as white, thickened skin
- Atrophic skin that splits easily
- Lateral fusion and resorbtion of labia minora
- lateral fusion of clitoral hood and burying of clitoris
- Medial fusion of labia minora causing:
- Narrowing of the vaginal introitus
- Skin bridges at the fourchette
54
Treatment for lichen sclerosus?
Medical with Ultra-potent steroids.
Surgical management/CO2 laser ablation is not recommended. Disease may recur around the scar.
---- Laser may be useful to treat sequelae of scarring due to lichen sclerosus (urinary retention/narrowing of the introitus)
55
Medical management of lichen sclerosus?
Clobetasol pro-pi-onate
- MOST potent topical steroid
- 54-96% have partial/complete
symptom resolution.
- Women <50yrs have higher
response rates
84% relapse within 4 yrs
56
How is clobetosol propionate prescribed for lichen sclerosus?
Varies and no optimal regime has been identified. However,
Common dosing is:
Daily x 1mth
Alternate days x 1mth
Twice weekly x 1mth
Review at 2-3 months
57
Treatment for steroid resistant lichen sclerosus?
1. Potent topical steroid w/ antifungal/antibacterial agent to treat secondary infection (if that is a concern). E.g. Dermovate
2. Oral retinoids (aci-tre-tin) for recalcitrant disease may be prescribed by an experienced dermatologist.
3. UV phototherapy has been shown to have benefit in a small number of cases
4. Tacrolimus & Pimicrolimus
- calcineurin inhibitors
- suppress T lymphocytes response thereby reducing inflammation
- OFF License use
- 77% with full/partial response
- Avoids adverse effects of steroids
- Max effects after 120-24wks of treatment
- Do NOT use for >2yrs due to concerns about potential malignancy
58
F/U for lichen sclerosus?
2-3 after treatment to assess response
- if stable assess ANNUALLY
- If active disease, assess as clinically required.
- provide written and verbal information about:
-the risk of progression to VIN (usual type preceded by lichen sclerosus)
- malignant change (2-4% lifetime
risk)
- Advise to return for review if any change in the appearance/texture of their lesions (e.g. hardening of skin)
59
Discuss lichen planus
(Planus - planet, all over)
- affects anywhere on body, but usu affects mucosa surfaces (especially oral mucosa)
- cause unknown. ? Autoimmune
- Planus = 4 Ps of appearance:
- Polygonal and flat topped
- Purple (violaceous)
- Pruritic
- Plaques and Papules
+ with a fine, white reticular pattern (Wickham striae)
- Tends to be EROSIVE in mouth and genital region - and associated with pain rather than pruritus
- Erosive lichen planus is WELL DEMARCATED, glazed erythema around the introitus
60
Discuss lichen simplex chronic or
Chronicus vulval dermatitis.
- severe pruritus esp at night
(Lichen sclerosus has this too)
- inflammation to labia majora; can spread to inner thighs and mons pubis.
- may be areas of thickening or lichenification (hyperpigmentation and thickening due to constant scratching)
- Cause: stress, low iron stores, symptoms can be exacerbated by chemical/contact dermatitis
Treatment:
- avoid soaps and irritants
- use emollients and soap substitutes
- Antihistamines/ antipruritics for pruritus
- topical steroids (moderate/ ultra-potent) may be required to break the itch-acratch cycle
61
Discuss vulval psoriasis
- Affects vulval skin
- Vaginal mucosa NOT included
- O/E: smooth, non-scaly, red/pink discrete lesions
Exam nails and scalp for psoriasis plaques. Flexor surfaces also.
Treatment:
- emollients
- soap substitutes
- calcipo-tri-ene (vit D cream)
DO NOT is cold tar on genitals!
62
What's Bechet's disease?
- Chronic, multisystem disorder.
- causes recurrent, painful oral and genital ulcers (cervix, vagina and vulva) leaves scars
Tx: Topical/ systemic
immunosuppressants
63
Discuss Paget's disease of the vulva
-Rare
-Occurs in postmenopausal women
-Assoc. with underlying
ADENOcarcinoma
- Main symptom: pruritus
- O/E : ecezematous appearance- lichenification, erythema and excoriations
- check GIT, urinary Tract and breast
- Treatment - excision to exclude adenocarcinoma of skin appendages
- surgical margins hard to obtain due to subclinical disease.
- Recurrence is common
64
T/F VIN can be treated with laser ablation?
True, but only on hairless areas.
In pts who are unfit/refuse sx and those in whom tissue conservation is important (glans and hood of clitoris).
65
Vulval candiasis, discuss.
Irritation and soreness to vulva and anus.
Risks: DM, obesity, prolonged
antibiotic use
O/E: inflammation with satellite lesions extending from the labia majora to the inner thighs or mons pubis
Tx: Topical antifungal +/- oral preparations
66
Discuss Vulval Crohn's disease
Vulva may be involved by DIRECT spread from involved bowel OR "metastatic" granulomas.
O/E: vulva is swollen and oedematous; ulcers; draining sinuses, abscesses
Tx: Metronidazole + oral
immunomodulators
67
T/F adenocarcinomas make it 25% of vulval malignancies?
False
95% squamous cell
<5% melanomas
Adenocarcinoma is included in the rest
68
Incidence of vaginal/vulvar cancers?
<1% of all cancers
8% of gynae cancers
1.7/100,000 women
69
Death rate from vulval cancer
Almost same as the incidence:
1.2/100,000 women
70
Age group affected by vulval cancer?
70 -80's
Incidence increases with age and peaks over age 85
71
Lifetime risk of vulval cancer?
1/293
72
Risk factors for vulval cancer?
-Multifocal disease 5-90%
-Lichen sclerosus 4-7%
-VIN (Differentiated-keratinizing squamous, usual- warty/ basaloid squamous)
-Paget's disease (adenocarcinoma)
-Melanoma in situ
-HPV 16, 18, 31 - 30-40% association either vulval ca, 80% assoc w/ vin
-Immunosuppression
-Prev cervical ca or CIN
- HSV type 2 (interacts with HPV to cause vulval and other lower genital tract cancers)
- h/o radiotherapy for uterine ca
73
Clinical evaluation of vulval ca?
O/E: Vulval exam
1. Tumour size and location(90% have visible tumour)
2.Assess of vagina, urethra, bladder base or anus is involved
3. Palpate for infiltration deep to public and ischial bones
**EUA may be necessary
4. Palpate for groin LNs
Biopsy:
- Biopsy area of transition from normal to malignant tissue
- >1mm depth to asess invasion
- oriented for the pathologist
- small punch Biopsy under local for elderly patient
- excisional Biopsy for smallesions where a wide margin of normal tissue can easily be obtained
- if pt is bleeding/in pain, then biopsy can be done at time of definite sx as a frozen section PRIOR to any radical procedure
Investigations
Cbc, u&e, cxr, ecg
Pap smear (if overdue)
CT CAP if tumour >2cm to detect disease above inguinal ligament
74
FIGO staging of vulval cancer?
*Remember tumour grows from outside up into vagina/anus/urethra*
Stage 1 - localized to vulva and perineum, 2cm or less
A- tumour 2cm or less,
stromal invasion 1mm or less
B- tumour less than 2cm diameter,
>1mm stromal invasion +
neg LNs
Stage 2- tumour of any size extending to lower third vagina/urethra or anus + neg LNs
Stage 3 - tumour of any size +/- extension into adjacent perineal structures with POSITIVE inguinofemoral LNs:
A- 1 node of any size or 2 LNs <5mm
B- 2 or more LNs >5mm, or
3/more LNs <5mm
C- positive LNs w/ extracapsular
spread
Stage 4
A- tumour invades upper urethra/ Bladder mucosa/ rectal mucosa or is fixed to bone and or bilateral regional LN mets
B- distant mets/Pelvic LNs
75
What is the general population's risk of breast, ovarian and endometrial cancer?
Breast 10%
Ovarian - 1.4%
Endometrial - 1.1%
76
What is the risk of breast and invariant cancer in a BRCA 1 positive pt?
Breast - 65%
Ovarian - 39%
77
What is the risk of breast and ovarian cancer in a BRCA 2 positive pts?
Breast - 45%
Ovarian - 11%
78
What is the incidence of BRCA 1 & 2 mutations in breast and ovarian cancers in families?
52 and 32%
79
How are BRCA 1 & 2 mutations inherited?
Autosomal dominant
80
Incidence of BRCA mutations in Ashkenazi jews?
2%
81
What points in the family history would make u suspect BRCA mutation in the family?
- 3/more relatives with breast/ovarian cancer (clustering).
- esp if early onset
- bilateral breast OR bilateral ovarian ca OR breast & ovarian ca in the same woman
- serous ovarian cancers
82
What cancer surveillance or screening can be done for women with the BRCA mutation?
No screening test for ovarian ca.
For breast ca - for Annual MRI for women aged 30-49 years
- compared to mamnogram is more ideal for younger pts at risk of high grade tumours
83
Benefit of prophylactic sx in a pt with a BRCA mutation? What types of prophylactic surgery can be performed for these patients?
Allows intervention before the development of cancer.
Types of prophylactic surgeries:
1. Prophylactic BSO
2. Prophylactic mastectomy
Bilateral oophorectomy decreases the risk of ovarian cancer by 50%.
Salpingectomy decreases risk of more aggressive primary peritoneal cancer.
- cancer risk decreases from as high as 40% to 1-2%
- 20 yrs post BSO, residual risk is 4.3%
84
Benefit of prophylactic BSO?
Reduced risk of:
1. ovarian ca from 40% to 1-2%
2. primary peritoneal ovarian ca.
3. reduced risk of breast ca by 50%
85
Residual risk of primary peritoneal ca 20yrs post BSO?
4.3%
86
What are the risks associated eith prophylactic BSO?
1. Surgical - haemorrhage, damage to surrounding structures
2. Premature menopause
3. Psychological distress- loss of
fertility, early menopause
87
What age should prophylactic surgery be performed for pts with BRCA mutations?
BRCA1 - early 30's as the risk of cancer increases significantly after age 30 yrs.
BRCA2 - early 40's as risk of cancer increases after age 40yrs.
88
Which other cancers are associated ith BRCA mutations?
BRCA 2 is associated with male breast cancer (6%) and prostate cancer
89
What percentage of hereditary ovarian ca is attributable to BRCA1?
90%
90
What percentage of hereditary ovarian ca is attributable to BRCA2?
5-10%
91
What percentage of ovarian ca is hereditary?
5-10%
92
What percentage of hereditary ovarian ca is attributable to BRCA mutations?
95% of families with breast AND ovarian ca.
40-50% of families with breast ca only
93
Which hereditary conditions are assoc. With increased risk of ovarian/endometrial/breast cancer?
BRCA 1&2 mutations
Lunch syndrome/HNPCC
Peurz-Jeughers
94
What kind of inheritance is associated. With HNPCC/Lynch? What are the associated mutations?
Autosomal dominant
Mutations in mismatch repair genes:
MLH1, MSH2 & MSH6
95
What are the risks of ovarian and endometrial cancer assoc. with HNPCC?
Risks vary of which genes are affected.
MLH1 - 3.4% ovarian, 27%
endometrial
MSH2 - 10.4% ovarian, 40% endometrial
MSH6 - 71% risk endometrial
96
Is prophylactic sx an option for pts with HNPCC?
Yes, if the patient desires it.
-Prophylactic BSO for MLH1 and MSH2 mutations.
-Prophylactic hysterectomy can be done for MSH6 mutations due to the very high risk of endometrial cancer.
97
T/F. HNPCC is assoc. with breast ca?
False. They are associated with ovarian and endometrial cancer
98
Cancer surveillance for HNPCC?
2 yearly colonoscopy to reduce mortality from colorectal cancer
99
What factors make the prognosis for choriocarcinoma is worse?
1. normal pregancy or spontaneous miscarrage
2. Blood groups B or AB
3. Interval between pregnancy and chemo >12mths
*Prognosis is BETTER after:
1. a known molar pregnancy
2. Blood groups O and A
3. Interval between pregnancy and chemo is <4mths
100
In patients with HNPCC, where are the majority jmof colon cancers located?
70% are Proximal to the splenic flexure
101
Most common gynae cancer in the developed world?
Ovarian cancer, specifical epithelial ovarian
102
List the subtypes of epithelial ovarian cancers.
Serous - 68%
Clear cell - 13%
Endometrioid - 9%
Mucinous - 3%
Brenner
Mixed
Undifferentiated
103
What percentage of endometrial cancer is HNPCC associated with?
<5%
104
How are families selected for molecular testing for HNPCC?
Using the Amsterdam criteria, families most likely to have HNPCC families will fulfill all the criteria:
(Think 3, 2 , 1)
1. Colorectal ca in at least 3 first degree relatives of each other, where familial adenomatous polyposis coli has been excluded
2. Colorectal ca in 2 successive generations.
3. Colorectal ca diagnosed in at least one relative <50yrs
105
By how much does OCPs decrease the risk of endometrial ca?
40%
OCPs (progesterones) prevent proliferation of the endometrium.
- use for 12-23mths =40% reduction in risk and use for 10yrs = 60% risk reduction
106
What percentage of women with the BRCA mutation, who undergo prophylactic oophorectomy have occult ovarian tumours?
12%
12% of women who have a prophylactic oophorectomy will have occult ovarian tumours noted in histopathology.
107
By how much does prophylactic BSO decrease the risk of ovarian ca?
Prophylactic BSO decreases risk of ovarian cancer from up to 40% to 1-2%
108
What size breast tumour is suitable for breast conservation surgery?
<2.5cm
109
What is the screening schedule as per the NHS Breast Screening Programme?
<50yrs - not offered screening
50 - 71yrs - screening every 3 years
- Older pts with less breast fat makes a mammogram easier to perform.
110
What are features of a benign breast mass on ultrasound?
1. Smooth and well circumscribed
2. Hyper/iso/mildly hypoechoic
3. Thin, exhogenic capsule
4. Ellipsis shape w/ max diameter in the transverse plane
5. 3 or fewer gentle lobulations
6. Absence of malignant findings
111
What is the commonest cause of breast lumps in women 35-50 yrs? Briefly describe this lesion.
Breast cyst
- Fluid accumulation due to obstruction of extralobular terminal ducts OR fibrosis due to intraductal epithelial proliferation.
- U/S: well-defined oval or round, anechoic structure in a thin wall.
112
Which HPV types are assoc. With VIN?
16 MOSTLY
18, 31, 33, 45
They are associated with approx 30-40% of cases.
Hence HPV vaccines that cover 16 and 18 result in sig reduction of VIN in young women.
113
What percentage of women who have vulval ca present with lichen sclerosus?
25%
114
What percentage of pts with untreated VIN progress to invasive squamous cell ca (vulval ca)?
5%
115
Describe the types and presentation of VIN.
Two types: differentiayed and usual
Diffentiated
- rarer
- older pts (55-85)
- some associated with lichen sclerosus
- unifocal ulcer/plaque
- linked to keratinizing squamous cell ca of vulva
- higher risk of progression to ca
Usual type
- younger pts (35-55)
- warts, basaloid, mixed
- assoc with HPV 16, CIN, VaIN, smoking, chronic immunosuppression
- multifocal, multicentric
-varied appearance: red, white/pigmented, plaques/papules/patches
- assoc. With warty or basaloid squamous cell ca
116
T/F. VIN pts are more likely to develop CIN and AIN (anal intraepithelial neoplasia)
True
117
In pts with vulval cancer, when can groin node dissection be avoided?
- stage 1A squamous cancer
- basal cell
- verrucous tumour
- melanoma
118
In vulval cancer, what type of groin node dissection done for lateral vs central disease?
Lateral disease:
- ipsilateral GND. Contralateral GND is done if the ipsilateral node is positive.
Central disease:
Bilateral GND done via different incisions to reduce morbidity (triple incision technique)
119
What are the complications associated with surgery for vulval ca?
1. Wound infection
2. Wound dehiscence
3. DVT & PE
4. Pressure sores
5. Introital stenosis
6. Psychosocial complications
7. Urinary incontinence
8. Faecal incontinence
9. Rectocoele
10. Lymphoedema
11. Hernia
120
What is the negative predictive value of sentinel node biopsy in vulval ca?
95-100%
121
Which nodes are removed in groin node dissection (in vulval cancer)?
- superficial inguinal nodes AND
- deep femoral nodes
Higher risk of recurrence with removal of superficial inguinal LND only.
122
Preservation of which structure in groin node dissection in vulval ca will reduce both groin wound and lower limb issues?
The long saphenous vein
123
What are the categories of endometrial cancer?
Type 1 and 2 based on histopath, molecular profile and clinical course.
Type 1:
- slow growing, low-grade (I-II) adenocarcinoma
- linked to oestrogen and obesity
- 80% of cases if endometrial ca
- usu diagnosed early with good prognosis
Type 2- aggressive, faster growing
- grade III adenocarcinomas
- NOT LINKED to oestrogen
- 10% of cases
- have p53 mutations
- have loss of heterozygosity on several chromosomal loci
- present at later stages
- less favourable prognosis
124
Histological types of endometrial cancer?
1.Endometrioid - 75%
-- has malignant glandular epithelial elements
--- arises from complex hyperplasia
2. Papillary-serous - 5-10%
3. Clear cell - 1-5%
* both papillary and clear cell occur due to a sequence of genetic mutations*
4. Carcinosarcomas (MMMT)- 1-2%
5. Uterine sarcomas - 3%
6. Mucinous - 1%
7. Adenocarcinomas (with squamous differentiation)
8. Adenosquamous (malignant squamous component)
9. Adenocanthoma (benign squamous element)
10. Undifferentiated
125
What percentage of endometrial cancers are inherited?
<5%
126
What's the figo staging of vulval cancer?
Stage 1 - vulva +/- perineum, 2cm/less width
1a: no more than 1mm deep, width 2cm/less
1b: >1mm deep or >2cm wide
Stage 2: tumour of any size growing into lower 1/3rd urethra, lower 1/3rd vagina/anus. NEG nodes
Stage 3: any size +/- adjacent perineal structures with POSITIVE inguino/femoral LNs
- 3a: vulva+/- perineum; growing to anus, lower vagina/urethra PLUS POSITIVE LNS (1 nearby >5mm spread or 2 nearby <5mm each)
-3b: vulva +/- perineum + anus, lower vagina/urethra + POS nearby LNs ( 2/more >5mm or 3/more nearby <5mm)
-3c: positive LNs + extracapsular spread
Stage 4:
4a: Bladder, rectum, upper vagina/urethra, pelvic bone, regional LNs/ LN ulceration
4b: distant mets (lung, bone), pelvic LNs
Stage 4:
127
Risk of endometrial ca in overweight/obese women compared to healthy weight?
2-4 times greater risk
128
Lifetime risk of breast ca in UK?
11%
129
Most common cancer in pregnancy and puerperoum? Incidence?
Breast ca
1 in 3000 (0.03%)
130
Which HPV subtype is associated with adenocarcinoma?
HPV 18
131
Detection Rates of endometrial ca with pipelle in postmenopausal women vs premenopausal?
99% vs 91% (premenopausal)
132
What is the sensitivity and specificity of pipelle sampling?
Sensitivity 81%
Specificity 98%
133
T/F. In endometrial ca, lymphatic spread to para-aortic nodes commonly occur without pelvic node involvement.
False. Involvement of para-aortic nodes are less common if pelvic nodes are NOT involved.
134
5 year survival for endometrial cancer?
80%
Overall prognosis for endometrial ca is generally good, as most present early (Type 1 endometrial ca!!)
- prognosis varies based on histological subtype, tumour grade, depth of myometrial invasion, presence/absence of lymphovascular space invasion
135
What is the optimal surgery in early stage (Figo stage 1 - 2a) ovarian cancer?
Midline laparotomy
Tah + bso
Infracolic omentectomy
Pelvic lymphadenectomy
Biopsies of any peritoneal deposits
Random sampling of pelvic and abdominal peritoneum
Retroperitoneal LN assessment (+/- bilateral sampling of pelvic and para-aortic LNs)
Cytology from ascites/ peritoneal washings
136
What is the risk of malignancy in simple, unilocular, unilateral ovarian cysts <5cm in diameter? Management?
<1%
Premenopausal- should resolve in 3 menstrual cycles.
- if 5-7cm, yearly u/s followup.
Postmenopausal:
Manage conservatively with f/u scan in 4mths for cysts 2-5cm
137
Management of a simple ovarian cyst >7mm?
Consider MRI as u/s may not be able to fully evaluate the cyst.
Ovarian cysts that persist or increase in size are unlikely to be functional and SURGICAL management is indicated.
- no consensus of max diameter for sx but most studies use 6cm as the ULN for conservative management.
138
What are the NHS recommendations for f/u after treatment for low grade and high grade disease?
Low grade/CIN 1:
Papsmear/cytology at 6, 12 and 24mths post treatment. If all negative = return to routine/low risk f/u.
High grade/CIN 2/ 3:
- papsmeae/cytology at 6 and 12 months then yearly for the next 9 years = all normal = return to routine/high risk f/u
139
Lifetime increase in risk of breast ca after CTPA?
13.6%
140
What are borderline ovarian tumours?
- a Heterogenous group of tumours seen in younger patients
- have higher proliferative activity than benign tumours but are NOT invasive
Protective factors:
- older patients (common in young)
- multiparity
- lactation
- Unlike invasive ovarian cancer OCPs are NOT protective
- diagnosis usu made after sx for a presumed benign lesion.
Management: Surgical staging
- conservative management may be considered with patients with fertility desires.
141
8 week pregnant pt with a prev pap smear showing mild dyskaryosis. She is due for a repeat. What do u recommend?
Do not delay the test and repeat mid trimester (unless there is a clinical contraindication).
- if she had a previously normal pap smear, then it could have been deferred to after pregnancy.
142
What is the risk of contralateral LN involvement for lateral vulval tumours
<1%
In these cases the contralateral LN is resected via a separate incision (triple incision technique)
Median tumours = bilateral groin node dissection
- both superficial inguinal and deep femoral nodes are resected.
143
What are the recommendations for surgical management for borderline ovarian tumours?
- conservative management for women who wish to preserve fertility
- tah +bso+ infracolic omentectomy
- peritoneal washings (explores abdominal cavity)
- appendectomy for mucinous tumours
* treatment is similar to ideal treatment during low grade ovarian cancer, minus assessment of retroperitoneal nodes.
144
Sentinel node mapping is most established with which gynae malignancy? Benefit?
Vulval cancer
Sentinel lymphadenectomy is assoc with a lower rate of lymphoedema compared to complete groin lymphadenectomy.
145
5y.o with vulvar scratching, well demarcated white area around introitus, with the overlying skin appearing thin with extensive fissuring. Likely diagnosis?
White, thin skin with fissuring + severe pruritus = think lichen sclerosus
146
What are the histological features of lichen sclerosus?
Atrophic epidermis
Overlying hyperkeratosis
Effaced dermoepidermal junction
Superficial dermal hyalinisation
Lymphocytic infiltration
147
What is the appearance of vulval psoriasis?
Well defined, beefy red/pink, uniform/smooth and symmetrical lesions on the SKIN of the vulva.
- Vaginal mucosa not involved.
Not scaly like on the other areas of the body.
---check nails and scalp
148
What is the histological findings for vulval psoriasis?
Papillomatosis
Parakeratosis
Neutrophil exocytosis
Spongiform pustules
149
What is the treatment for vulval psoriasis?
Emollients
Soap substitutes
Topical steroids
Calcipotriene
150
What is the effectiveness of HPV vaccines in presenting cervical abnormalities assoc with HPV types 16 & 18?
>99% in women previously not infected with those serotypes
151
Factors that reduce ovarian ca?
They reduce ovulation:
Pregnancy
Breastfeeding
Multiparity
OCPs
