PCB Carcinoma of the Cervix Abdominal Distension Age gt 50 years Ovarian Cancer Vulval Ulceration Age gt 60 years Vulval Cancer Government Pledges on Waiting Times Maximum Duration of Waiting ID: 687997
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Slide1
Until Proven Otherwise
PMB = Endometrial CancerPCB = Carcinoma of the Cervix
Abdominal Distension + Age > 50 years = Ovarian Cancer
Vulval
Ulceration + Age > 60 years =
Vulval
CancerSlide2
Government Pledges on Waiting Times
Maximum Duration of Waiting:62 DAYS Urgent Referral for ? Cancer to 1st
Px
31 DAYS Date of Decision to Treat to 1
st
Px
(DTT)
31 DAYS Subsequent Surgery or Radiotherapy or
Anti-Cancer Drug Regimen
14 DAYS Suspected Cancer Symptoms to Seeing a
Specialist Slide3
Gynaecological Malignancy
Growth without controlInvasion
local
distant
Diagnosis
Biopsy
Treatment
remove
destroySlide4
Surgery
RadiotherapyChemotherapySlide5
MDTGCLNSlide6
Referral to the Network(Central) MDT
Ovary/Peritoneum
Uterine
Cervix
Vagina
Vulva
Recurrent cancerSlide7
Role of CNS(Cancer Nurse Specialist)
All woman with a gynaecological cancer should have access to a CNS and is identified as the Key WorkerCNS facilitates the woman and her carer’s needs throughout the cancer pathway from diagnosis
Provision of advice, support and information. Receptive to a full range of social, physical, psychological, cultural, sexual health and spiritual needs.
Link professional who can help patients through the system.
Co-ordinator of care and services
Works closely with surgeons, oncologists, radiotherapists and other professionals
Nurse Led Clinics – Breaking bad news clinics
Cancer Follow up clinics
Holistic Assessment
Transition of care on discharge to GPSlide8
Psychosexual Issues
HRT and menopausal informationLymphoedemaSlide9
Finance
Support agenciesLocal and national support groupsHospice CareSlide10
Classification of Ovarian Malignancy
Epithelial originGerm cell originStromal cell originSlide11
Tumour Markers in Serum
CA125 αFPHCG
Epithelial Ovarian Malignancy
Yolk sac tumour
Trophoblastic tumours choriocarcinoma
Alkaline phosphatase Lactate dehydrogenase
Dysgerminoma
FSH + LH
Granulosa cell tumour
αFP + HCG
Embryonal carcinoma,
PolyembryomaSlide12
Specific HistopathologicalFeatures of Gynaecological Tumour
Call – Exener BodyPsammoma
Body
Schiller Duval Body
Reinké
crystalloids
Granulosa cell tumour
Serous papillary cystadenocarcinoma ovary
Yolk sac tumour
Leydig
cell tumour ovarySlide13
Calculation of the Risk of Malignancy Index (RMI) for a Pelvic Mass
A RMI calculation of greater than 200 indicates a high suspicion of ovarian malignancy.CA125 measurement ··········· AMenopausal statusPremenopausal Score 1
Postmenopausal Score 3
(amenorrhoea >= 1 year, or over 50 years and post hysterectomy)
BSlide14
Ultrasound Score
Multilocular lesionSolid areasBilateral lesionsAscitesIntra abdominal metastasesIf none or one of the above is present score 1, if 2-5 of
above score 3 CSlide15
RMI = A*B*CYoung premenopausal patient with a unilateral, unilocular
cyst on scan with a CA125 of 30. RMI =30*1*1=30c.f. Postmenopausal patient with bilateral solid ovarian tumour and CA125 of 300. RMI=300*3*3=2700.Slide16
SINGLE BEST ANSWER QUESTIONS (SBAs)
Author Mr S J Duthie Theme Gynaecological oncology
Domain
Treatment 1
ITEM 1
Which one of the following is the dose limiting toxicity of cis-
Platin
?
Options
A Central neurotoxicity
B
Myeolotoxicity
C Nephrotoxicity
D Ototoxicity
E Peripheral neurotoxicity
ANSWER
C Slide17
ITEM 2Which one of the following is the dose limiting toxicity of carbo-
Platin? OptionsA Central neurotoxicity B
Myeolotoxicity
C Nephrotoxicity
D Ototoxicity
E Peripheral neurotoxicity
ANSWER
B
ITEM 3
Which one of the following is the dose limiting toxicity of
Oxaliplatin
?
Options
A Aplastic anaemia
B Haemorrhagic cystitis
C Peripheral neuropathy
D Pulmonary fibrosis E Retinopathy
ANSWERC Slide18
SINGLE BEST ANSWER QUESTIONS (SBAs)
Author Mr S J Duthie Theme Gynaecological oncology
Domain
Genetics 1
ITEM 1
Which one of the following is the single most correct description of the genetic transmission of Lynch Syndrome (Hereditary non-polyposis colon cancer syndrome)?
Options
A Autosomal dominant with a high penetrance of 90%
B Autosomal dominant with a low penetrance of 20%
C Autosomal dominant with a moderate penetrance of 50%
D Autosomal recessive with a high penetrance of 90%
E Autosomal recessive with a low penetrance of 20%
ANSWER
A Slide19
SINGLE BEST ANSWER QUESTIONS (SBAs)
Author Mr S J Duthie Theme Gynaecological oncology
Domain
Genetics B
ITEM 1
Women with a mutation in the BRCA1 gene have an increased lifetime risk for fallopian tube/ovarian cancer of approximately which one of the following?
Options
A 30%
B 40%
C 50%
D 60%
E 70%
ANSWER
D Slide20
ITEM 2
Peutz-Jeghers Syndrome is an autosomal dominant condition with a penetration of which one of the following? OptionsA 10%
B 25%
C 75%
D 95%
E Variable
ANSWER
D Slide21
SINGLE BEST ANSWER QUESTIONS (SBAs)Author Mr S J DuthieTheme Gynaecological oncology
Domain Genetics 1ITEM 1In women with sporadic ovarian cancer, a co-existing endometrial tumour occurs in approximately which one of the following? OptionsA 0.1 %B 2 %C 4 %
D 9 %
E 10 %
ANSWER
B Slide22
ITEM 2In women with ovarian cancer associated with Lynch Syndrome (Hereditary non-polyposis colon cancer syndrome) a co-existing endometrial tumour occurs in approximately which one of the following?
OptionsA 5 %B 10 %C 15 %D 20 %E 40 %ANSWERD
Reference
Beirne
J.P., Irwin G.W., McIntosh S.A., Harley I.J.G. and Harkin D. P. The Molecular and Genetic Basis of Inherited Cancer Risk in Gynaecology. TOGSlide23
SINGLE BEST ANSWER QUESTIONS (SBAs)Author Mr S J DuthieTheme Gynaecological oncology
Domain Granulosa cell tumour 1 ITEM 1In a postmenopausal woman with a granulosa cell tumour of the ovary, the serum level of which one of the following is the most likely to be increased?OptionsA Cortisol B Follicle stimulating hormone
C Growth hormone
D Inhibin B
E Luteinising hormone
ANSWER
D Slide24
EXTENDED MATCHING QUESTIONS (EMQs)
Author Mr S J Duthie Theme Gynaecological oncology
Domain
Endometrial Cancer risk factors
Options
A Cigarette consumption
B Diabetes mellitus
C Early menarche
D High body mass index
E History of polycystic ovarian syndrome
F History of unopposed oestrogen therapy
G Hypertension
H Late menopause
I
Nulliparity
J Use of barrier contraception Slide25
ITEM 1A 60 year old nulliparous woman has been “fast tracked” to your clinic as her General Practitioner noted a 5 week history of postmenopausal vaginal bleeding.
You review her history and observe that the woman reached her menarche at the age of 10 years and her menopause at the age of 53 years. The woman had tried to get pregnant in the past, underwent tests which showed that she had polycystic ovarian syndrome and there was a very limited response to ovulation induction. Subsequently, the woman used barrier methods of contraception. Shortly after menopause, the woman was given a prescription for hormone replacement therapy. Inadvertently, the woman received unopposed oestrogen for 2 months, developed irregular vaginal bleeding, the HRT was stopped, assessments at the PMB clinic were reassuring and the woman decided not to use any form of HRT again.
The woman has mild hypertension, adult onset diabetes mellitus which is well controlled by dietary modification and an oral hypoglycaemic agent and she consumes 5 cigarettes daily.
On examination, the woman has a body mass index of 48 kg/ m
2
Pelvic examination shows that the uterus is bulky and histological examination of a
pipelle
biopsy of the endometrium shows adenocarcinoma of the endometrium. Which one of the factors in the list of options is the single most significant risk factor for endometrial cancer in this particular case?
ANSWER
D Slide26
EXTENDED MATCHING QUESTIONS (EMQs)
Author Mr S J Duthie Theme
Gynaecological disorders
Domain
Tumours 1
Options
A Benign cystic
teratoma
B Borderline ovarian tumour
C Borderline serous tumour
D Brenner tumour
E Chocolate cyst
F Cyst of the corpus luteum
G Follicular cyst
H Granulosa cell tumour
I Krukenburg
tumour J Metastatic breast cancer K Mucinous cystadenocarcinoma
L Ovarian fibroma
M Papillary serous cystadenocarcinoma N Theca lutein cyst
Each of the clinical scenarios listed below refers to non pregnant women with a pelvic mass. For each of the items choose the most likely diagnosis from the list of options given above. Each option may be used once, more than once or not at all. Each option may be used once, more than once or not at all.Slide27
ITEM 1
A previously healthy 23 year old woman complains of abdominal pain, abdominal swelling and tiredness. On clinical and radiological assessment the woman is found to have a solid pelvic mass with a diameter of 15 cm which is separate from a normal uterus, abdominal ascites and a left sided pleural effusion. The serum CA 125 is well within the normal range. ANSWER
L
ITEM 2
A 24 year old woman has undergone suction evacuation of the uterus for suspected molar pregnancy. Inspection of the products and histopathological examination confirm the diagnosis. The woman complains of abdominal pain and an ultrasound examination carried out 4 days postoperatively shows;
Empty normal sized uterus, bilateral adnexal masses each of which has a diameter of 8 cm. The lesions are thin walled, cystic and do not appear to contain any solid elements.
ANSWER
N Slide28
EXTENDED MATCHING QUESTIONS (EMQs)
Author Mr S J Duthie Theme Gynaecological Oncology
Domain
Tumour Histopathology 1
Options
A Barr body
B Call-
Exner
body
C Copper sulphate crystals
D Howell- Jolly body
E
Kimmelstiel
-Wilson lesion
F Lines of Zahn
G
Psammoma body H
Reinke’s crystals I Schiller-Duval body
J Sternberg-Reed cells
Select the single most correct term from the list of options for the histopathological findings in the gynaecological tumours described in the items below. Each option may be used once, more than once or not at all. Slide29
ITEM 4A 45 year old woman underwent total abdominal hysterectomy bilateral
salpingo-oophorectomy for suspected ovarian cancer. The woman had completed her family, was known to have a pelvic mass and her case had been discussed at a gynaecological multi-disciplinary team meeting. The operation specimen was examined in the pathology laboratory. The uterus was normal in size, the tubes appeared normal, the right ovary was normal in size and the left ovary contained an infiltrative mass with no obvious capsule. The lesion in the left ovary contained minute concentric
lamellated
calcified bodies visible using light microscopy. Select the term for this feature from the list of options.
ANSWER
G Slide30
EXTENDED MATCHING QUESTIONS (EMQs)Author Mr S J DuthieTheme Gynaecology
Domain Pelvic tumours 1 OptionsA Benign cystic teratoma B Choriocarcinoma C
Endometrioma
D Fallopian tube carcinoma
E Granulosa cell tumour
F
Krukenburg
tumour
G Metastasising melanoma
H Ovarian cancer
I Ovarian fibroma
J Placental site tumour K Theca lutein cyst L Uterine metastasising fibroid
M Uterine sarcoma The list of options contains tumours affecting the female genital tract. Each of the clinical scenarios listed below refers to a woman with a tumour affecting the genital tract. For each of the items choose the single most likely diagnosis from the list of options given above. Each option may be used once, more than once or not at all.Slide31
ANSWERF
ITEM 1You are called to the operating theatre by the surgical team who have just carried out emergency midline laparotomy on a 56 year old woman with a pelvic mass. The specialist trainee in Surgery has discussed the operation with his Consultant (not present) and they request you to attend. You observe that the woman has ascites, bilateral solid ovarian tumours which are not adherent to surrounding structures and peritoneal induration.The uterus is normal and the fallopian tubes are stretched over the ipsilateral ovarian tumours. You telephone your Consultant who is busy with an obstetric emergency. Your Consultant asks you to take multiple representative biopsies, send peritoneal fluid for cytological tests. close the abdomen, to return the woman to the gynaecology ward for postoperative care and
arrange referral to the Gynaecological Multi- Disciplinary team.
Three days later the Pathologist reports that histological diagnosis of the ovarian biopsies show malignant mucin containing signet cell rings.
Options
A Benign cystic
teratoma
B
Choriocarcinoma
C
Endometrioma D Fallopian tube carcinoma E Granulosa cell tumour F
Krukenburg tumour G Metastasising melanoma
H Ovarian cancer
I Ovarian fibroma J Placental site tumour K Theca lutein cyst L Uterine metastasising fibroid
M Uterine sarcoma Slide32
ITEM 2You are called to your Consultant’s office as he is away and the Secretary wants you to look at a histopathology report that has just arrived. The report is on a hysterectomy specimen. Your Consultant had supervised another trainee one week previously to carry out total abdominal hysterectomy on a 40 year old woman of Afro-Caribbean origin who had a uterine fibroid, menorrhagia and who had completed her family.
The pathology report states that there was an intramural fibroid with a diameter of 10 cm. There was a soft friable mass within the uterine fibroid and histological examination of the lesion showed local invasion, spindle cells and 10 mitoses per high- power fields ANSWERM
Options
A Benign cystic
teratoma
B
Choriocarcinoma
C
Endometrioma
D Fallopian tube carcinoma E Granulosa cell tumour F Krukenburg
tumour G Metastasising melanoma H Ovarian cancer
I Ovarian fibroma J Placental site tumour K Theca lutein cyst
L Uterine metastasising fibroid M Uterine sarcoma Slide33
COLPOSCOPY EXAMINATION - ABNORMAL
CIN1 untreatedRepeat in 12/12HR-HPV -
ve
Repeat in 36 months
HR-HPV +
ve
Cytology +
ve
Colposcopy referral
Cytology -
ve
Repeat in 12/12
HR-HPV -
ve
Repeat in 36 months
HR-HPV +
ve
Cytology -ve
Repeat in 36 months
HR-HPV +
veCytology abnormalColposcopy referralSlide34
COLPOSCOPY EXAMINATION - ABNORMAL
>=CIN2TreatmentRepeat in 6/12
HR-HPV -
ve
Repeat in 36 months
HR-HPV +
ve
Cytology normal or abnormal
Colposcopy referralSlide35
COLPOSCOPY EXAMINATION - ABNORMAL
CGIN TreatmentRepeat in 6/12
HR-HPV -
ve
Repeat in 12/12
HR-HPV +
ve
Cytology negative
Refer to colposcopy.
If normal colposcopy,
repeat in 12/12
Cytology abnormal
Refer to colposcopy.
Complete 10-yr
cytology follow-up
12/12 repeat test
Cytology negative
Refer to colposcopy.
If normal colposcopy,
repeat in 12/12
HR-HPV -
ve
Repeat in 36 months
Cytology abnormal
Refer to colposcopy.
Complete 10-yr
cytology follow-up
HR-HPV +
veSlide36
CGIN
Glandular PremalignancyHigh grade / Low gradeMost arise within 1cm of SCJCo-exists with CINNo reliable screening method
No specific
colposcopic
features
Cone biopsy – depth > 25mmSlide37
Precision Medicine
Identify and understand molecular defect Determine presenceCorrect molecular defect Slide38
The End
Thank you very much.
S. J. Duthie