Gynaecological Cancers (FRANZCOG lecture 2022) Flashcards
(74 cards)
1
Q
PMB rate of benign, pre-malignant and malignant pathology?
A
benign 60%
malignant 20%
pre-malignant 20%
2
Q
Relative risk of developing endometrial cancer in post-menopausal women with tamoxifen therapy?
A
RR 4.01
- 6% 5y
- 1% 5-14y
3
Q
Lifetime risk of endometrial cancer?
A
1/36 (3%)
4
Q
Familial syndromes increasing risk of endometrial cancer?
A
BRCA (maybe uterine papillary serous in small studies not replicated)
Cowden
Lynch
5
Q
Prognostic factors for endometrial cancer?
A
patient: comorbidities, performance status, age
disease: high grade, high stage, LVSI
centre: access to treatment
6
Q
How do you pre-surgically stage low risk endometrial cancer?
A
MRI or USS +CXR
7
Q
When is laparoscopy gold standard to endometrial cancer?
A
early stage disease as per LACE and LAP 2 trials.
8
Q
What is the efficacy of sentinel lymph node biopsy in endometrial cancer?
A
sensitivity 96%
less morbidity
same oncological outcomes compared to full nodal dissection.
9
Q
What is the evidence regarding endometrial cancer screening for women with Lynch syndrome?
A
no evidence to support TVUSS screening.
studies with biopsy/TVUSS have failed to demonstrate survival benefit
10
Q
What counselling should be offered to women with Lynch syndrome?
A
TH BSO recommended from age 40yo, or 5y prior to sentinel family cancer event. ?chemoprophylaxis with COCP and aspirin.
Then give HRT
Refer urology and gastro for FU
11
Q
In what proportion of early stage and advanced ovarian cancer is Ca125 elevated?
A
early = 50% advanced = 80%
Sensitive, low specificity, low PPV.
12
Q
What studies looked at methods of ovarian cancer screening?
A
low risk population
UKCTOCS 2021
PLCO 2010
high risk population
UKFOCS
13
Q
UKTOCS OUTCOME
A
rates and mortality of ovarian outcome same between groups
14
Q
PLCO outcome
A
no difference in incidence or mortality for ovarian ca
3000 false positive results
1000 had surgical intervention
15% complication rate
15
Q
compare advantages and disadvantages of BSO and TH BSO for risk reducing surgery with BRCA.
A
BSO ad - shorter less morbidity - uterus for fertility disad: - risk of UPSC (>3%), HRT must have progesterone, ?increased risk of breast ca with progesteron - if needs tamoxifen risk of EC
THBSO ad - eliminates EC risk - treats DUB - E2 only for HRT
disad:
- longer and more morbidity
- loss of fertility options.
16
Q
Proportion of cervical cancer that is adenocarcinoma?
A
20%
17
Q
Incidence cervical cancer and mortality rate
A
4-7/100,000
1-3% mortality.
18
Q
High risk HPV
A
16 and 18 (70% cervical ca)
19
Q
intermediate risk HPV
A
31, 33, 35, 39
45,
51, 52, 56, 58, 59
20
Q
Prevalence of HPV infection?
A
80%
21
Q
Percentage of CIN 3 that persists or invades?
A
56% persist
12% invade
22
Q
Percentage of CIN 2 that persists, progresses or invades?
A
35% persist
22% progress
5% invade
23
Q
Strains of HPV covered by Gardasil-9?
A
6 & 11 (warts) 16,18, 31, 33, 45, 52, 58
- covers both high risk
- missing intermediate strains 35, 39, 51, 56, 59
24
Q
Proportion of high grade CIN and adenocarcinoma prevented with vaccination?
A
97-100% in HPV naive population
(60% general population)
Incidence risk rate if vaccinated 0.12(00-0.34)
25
What are the advantages of HPV vs. LBC?
more sensitive
| better NPV therefore longer screening interval.
26
What is the expected reduction in cervical cancer incidence and mortality with HPV testing vs. LBC?
24-36% reduction
27
Treatment CIN 2?
consider conservative management for CIN2 if under 25-30yo.
28
Relate types of TZ to depth of excision required
```
T1TZ = 8-10mm
T2TZ = 10-15mm
T3TZ= >15mm
```
29
What type of cervical abnormality would be observed in pregnancy?
CIN 2 or 3.
Colp and biopsy safe
Avoid lletz or cone
high rate of regression in pregnancy
30
Outline route of lymphatic spread of cervical cancer.
```
external iliac 43%
obturator 25%
parametrical 21%
common iliac 7%
pre sacral 1%
para-aortic 1%
```
31
Risk of pelvic lymph node spread of cervical cancer at stage
- 1A1
- 1A2-IIA
- IIB-IIIB
- IVA
- 1A1 = 0-6%
- 1A2 - IIA = 7-8%
- IIB- IIIB = 15-30%
- IVA 50%
32
Clinical examination that should be done for pre-surgical staging with cervical cancer?
assess size
assess vagina
recto-vaginal examination for parametric/pelvic sidewall involvement
inguinal and supraclavicular lymph nodes
33
What is the sensitivity of CT and sentinel lymph node biopsy for cervical cancer lymph node involvement?
CT 58% sens, 92% spec
SLN 87% sens, 92% spec
34
Treatment options IA1 or IA2 (LVSI negative) cervical cancer?
(both are microscopic disease)
cervical conization
simple hysterectomy
no lymphadenectomy required
If LVSI positive IA2 then consider trachelectomy and pelvic lymphadenectomy or simple/radical hysterectomy and pelvic lymphadenectomy.
35
What is the maximum dimension of a cervical lesion for fertility sparing surgery to be offered?
2cm. Fertility preserving treatment in adenocarcinoma remains unclear.
NB that open hysterectomy survival better than laparoscopic as per LACC trial.
36
What is radical hysterectomy?
addition of parametric and vaginal cuff in specimen.
37
Treatment of IB3 and IIA2 cervical cancer?
| both have lesions >4cm
surgery increases risk of double modality treatment. Increased treatment morbidity without survival benefit
chemoradiation therapy preferred:
- external BM RT 5x/week, 5 weeks
- Cisplatinum 1x/week 5-6 weeks during RT
- vaginal brachy therapy subsequent
38
Indications for adjuvant radiotherapy cervical cancer
Intermediate risk = 2 or more of:
- LVSI
- tumor >2cm
- deep stromal invasion (>2/3 or >15mm)
improves local control in these patients.
High risk =
- positive lymph nodes
- parametrial invasion
- positive surgical margins
High risk receive adjuvant chemo-RT. improves overall survival
39
Treatment of IB2 or IIA1 cervical cancer
| lesions <4cm
radical hysterectomy + pelvic lymphadenectomy
| radiotherapy only if surgery contraindicated.
40
Treatment options IB1 cervical cancer?
fertility preservation can be offered with up to 2cm lesion size.
Radical trachelectomy and pelvic lymphadenectomy
Radical hysterectomy and pelvic lymphadenectomy
41
Treatment of IIB and IVA cervical cancer?
| parametria, rectal, bladder, distant involvement
Depends on age, lymphatic status, performance, renal function, immunocompetence.
Curative
- external beam RT 5x/week for 5 weeks
- cisplatinum 1x per week for 5-6 weeks
- vaginal brachy therapy subsequent
Palliative
- external beam RT 10-30GY in 1-10 fractions
42
Treatment of IVB cervical cancer?
pain management
local control with external beam palliative regime
bevacizumab (angiogenesis inhibitor)
43
Prognosis at 5 yrs for cervical cancer?
```
1 = 80-95%
2= 70%
3 = 40%
4= 15%
```
44
Follow up for curatively treated patients with cervical cancer?
post surgical:
- clinical examination + yearly vault cytology, no routine imaging
post RT
= clinical examination, no vault cytology, no routine imaging
45
What proportion of ovarian cancers is Ca199 or CEA elevated?
Ca199
76% mucinous
27% serous
CEA
37% mucinous
46
LSCS intraoperative assessment for unexpected ovarian cyst/lesion?
?GONC available
Consent
Pictures
Assess: contralateral ovary, surrounding structure (adnexa, uterus, peritoneum, diaphragm, appendix, pelvic and para-aortic nodes
Stage: peritoneal cytology, omental biopsy, biopsy other suspicious lesions.
47
Recurrence of serous BOT with USO, BSO, cystectomy?
```
USO = 11%
BSO = 5%
cystectomy = 23%
```
48
Proportion of ovarian cancer with STIC's?
75%
49
Compare pro's and con's of BS vs. BSO for BRCA prevention.
BSO vs. BS
pro = eliminates ovarian cancer risk
con= surgical menopause, bone/cognitive/cardiovascular risk
50
What is stage IV ovarian cancer?
```
IVA = cytology positive pleural effusion
IVB = solid extra abdominal metastases (including inguinal lymph nodes)
```
51
What is stage III ovarian cancer?
```
IIIA1 = + retroperitoneal lymph node
IIIA2 = micro extra pelvic
IIIB = macro extra pelvic <2cm
IIIC = macro extra pelvic >2cm
```
52
5 yr survival stages ovarian cancer?
```
1 = 83-90%
2 = 70%
3 = 40%
IV = 18%
```
53
Surgery for stage I or II ovarian cancer?
```
Laparotomy
peritoneal cytology
assessment of surfaces
peritoneal biopsies of quadrants
Hysterectomy, BSO
Lymph nodes: pelvic, para-aortic
Omentectomy (infra colic + infra gastric)
```
54
When would adjuvant chemotherapy by recommended for stage 1 or 2 ovarian cancer?
clear cell
high grade
stage IC or II
paclitaxel and carboplatin
3 weekly cycle x 6 times
55
Treatment option stage III and IV ovarian cancer?
primary cytoreduction with adjuvant chemo (Paclitaxel + carboplatin 6 cycles)
neoadjuvant chemo (3 cycles), surgery, adjuvant chemo (3 cycles)
Aim for <1cm or less of residual disease. Ideal = complete excision.
56
Most common cancers in pregnancy?
melanoma: surgery GA or radiotherapy after pregnancy. risk of placental and fetal mets with advanced/distant disease.
breast- 1/3000 pregnant women. prognosis worse due to size, stage, nodal involvement, grade, hormonal receptor negative, delayed diagnosis and delays in treatment. Diagnose with USS, FNA and core biopsy. Stage for nodes with CXR+/- MRI. Breast surgery can be done in 2nd and 3d trimester. Chemo ok 2nd and 3rd trimester, but risk of IUGR and PTB. Lactation review PP.
thyroid
gynaecological
cervix
57
What mode of delivery with CIN 2-3?
vaginal ok
58
Changes to cervix in pregancy making colposcopy more difficult?
```
vaginal laxity
increased vascularisation
increased stromal oedema
glandular hyperplasia
increased mucous production
```
59
Surgical management of cervical cancer in pregnancy?
Can delay for Stage I cancer until after delivery. Can give chemotherapy during 2nd and 3rd trimesters. If excised antenatally, can have vaginal delivery. Avoid episiotomy.
LEEP or CONE from 14-20 weeks
Cone may be more appropriate later gestations.
```
Do not delay for Stage II-IV cancer.
If <26w then TOP , ChemoRT and brachytherapy. Not for vaginal delivery. Then surgical treatment.
>26 weeks then CS, surgical staging, chemo RT and brachytherapy.
Perform hysterectomy (simple or radical) or radical trachelectomy + PLND at time of CS or 6-8weeks later.
```
60
Risk of endometrial cancer or hyperplasia in premenopausal bleeding
```
Ca= 0.3%
Hyperplasia = 1.3%
```
61
False negative hyperplasia result pipelle?
2%
62
Risk of under-grading endometrial ca with pipelle?
30%
63
Risk of coexistent endometrial ca with atypical hyperplasia?
43%
64
Risk of progression to cancer endometrial ca no atypia?
5% over 20 years
65
Reduction effect of progesterone treatment for atypical hyperplasia?
5-fold reduction in progression
66
Prevalence of regression with endometrial hyperplasia with lng ius?
~80% in 6 months
67
CIN1,2 and 3 regression, persistence, progression and invasion?
```
CIN 1
- R 57%, Pe 32%, Pr 11%, In 1%
CIN2
- R 43%, Pe 35%, Pr 22%, In 5%
CIN3
- R 32%, Pe 56%, Pr--, In 12%
```
68
Cervical ca, stage IA1 disease. Possible treatments?
Cone
Hysterectomy
no Lymphadenectomy required
risk of lymph node mets 0-6%
69
Cervical cancer, stage IA2 disease, treatment options?
LVSI neg =
- cone (fertility)
- hysterectomy
- no lymphadenectomy
LVSI positive
- cone + Pelvic LND (fertility)
- trachelectomy + Pelvic LND (fertility)
- Simple/radical hysterectomy + pelvic LND
70
Treatment IB1 cervical cancer?
If <2cm
- radical trachelectomy + P LND (fertility)
- open
If 2cm or more, or no fertility desire
radical hysterectomy + pelvic LND
perform open
71
At what stages of cervical cancer would surgery not be appropriate? What would treatment be?
IB3 (>4cm)
IIA2+ (>4cm upper + 1/3 vagina)
= cisplatinum 1x per week for 5-6 weeks
= external beam RT 5x/week for 5 weeks (45-50Gy)
= subsequent vaginal brachytherapy
72
When would adjuvant RT/CT be considered after surgery for cervical cancer?
```
RT
For local control of intermediate risk patients (not overall survival)
Need 2 or more of:
- LVSI
- tumour >2cm
- deep stromal invasion >2/3 or >15mm
```
```
RT
For high risk patients
For improvement of local control and overall survival
- positive LN
- parametrial invasion
- positive surgical margins
```
no role of adjuvant chemotherapy
73
At what stages of cervical cancer would you weigh curative and palliative intent?
IIB (parametria invasion)
to
IV A (bladder/rectum mucosa invasion)
depends on stage, lymphatic status, age, performance, renal function, immunocompetence
```
curative:
Involves chemo radiation therapy:
EBRT 5x/week, 5 weeks, 45-50Gy
cisplatinum during EBRT
brachytherapy
```
palliative
EBRT 10-30Gy in 1-10 fractions
74
When is cervical cancer management definitely palliative?
Stage IVB
| Can consider angiogenesis inhibitor. Not funded NZ.
