what to do about gynae cancers
DESCRIPTION
Women's Health Event June 12 th 2013. What to do about gynae cancers. Peter Townsend jobbing gynaecologist. Here’s a pretty big lump. What shall we do with this one?. But not all big lumps are Cancer. Even when they look pretty nasty. But, of course, some are. - PowerPoint PPT PresentationTRANSCRIPT
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Women's Health Event
June 12th 2013
What to do aboutgynae cancers
Peter Townsendjobbing gynaecologist
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Here’s a pretty big lump
What shall we do with this one?
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But not all big lumps are Cancer
Even when they look pretty nasty
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But, of course, some are
Even when the look pretty innocent
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And they always are when they look like this
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It’s best of all if they can be avoided
So all women should Stay slender and not get diabetes Stay celibate But most don’t so have an HPV vaccine and take the
COC pill between having 3 babies Or if a bit too old for that at least have regular smears Maybe do away with the “at risk bits” And it’s always good to not smoke (or is it?) Maybe drink coffee Be affluent and Consider dying young of something quick and easy
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Second best, find it early
Stage 1a Cervix Cancer 96% at least
Stage 1b Cervix Cancer 90%
Stage 1 Endometrial Cancer 85%
Stage 1 Ovarian Cancer 92%
Stage 1 Vulval Cancer 90%
5 Year Survival Rates, Stage 1
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So pretty good if we can find it when it looks like
this
Stage 1 Endometrial Cancer
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But if we don’t the outlook is not so good
Stage 4 Cervix Cancer 15%
Stage 4 Endometrial Cancer 25%
Stage 4 Ovarian Cancer 6%
Stage 4 Vulval & Vaginal Cancer 30%
5 Year Survival Rates, Stage 4
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For example
This ovary
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With its omentum
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and peritoneum affected
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But life’s not quiet as simple as that
If only we could find them all at an early
stage and for them all to be low grade
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So how about screening?(Just to get it out of the way with one
slide)
Cervix Works well, prevents some and detects some at very early stage
Ovarian Would be very nice but it doesn’t work. Limited place
Endometrial Not practical but incidental pick up and some high risk exceptions
Vulva and vagina Only for high risk few
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What do we actually do about them & are we getting any
better at it?
So, when they do come to our attention
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Endometrial Cancers
Most seen in Fast Track Clinic
TVS, endometrial thickness Pipelle Or Hysteroscopy MRI, CXR, CA125 CT CAP if high grade Hysterectomy and BSO usually
Lap/vaginal Occasionally radical surgery Sometimes Brachy/radiotherapy Occasionally chemotherapy
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Are we getting any better at treating it?
1975 1980 1985 1990 1995 2000 20050
102030405060708090
100Endometrial Cancers,5 year survival
rates
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It looks even better if you use financial media
tricks
1975 1980 1985 1990 1995 2000 20057274767880828486889092
Endometrial Cancers,5 year survival rates
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Ovarian Cancer
Most do not come via our Fast Track Clinic
The one that they all worry about
Try to get them before anyone else does Or failing that “reclaim “ them Try to decide whether its cancer Ultrasound scan Blood tests CT chest abdomen & pelvis MRI occasionally MDT discussion Mostly Radical surgery and chemotherapy but individual
plans for each patient Occasionally palliative care from the start Sometimes too late to do anything much at all
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Things have improved here a bit too
Is it the surgery, the chemotherapy or something else that has helped with the
results?
1975 1980 1985 1990 1995 2000 20050
102030405060708090
100
Ovarian Cancers ,5 year survival rates
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Cervix cancerSome via colposcopy, some FTC others A&E
Investigations and treatment varies greatly depending mostly on stage, MDT approach
May already have been treated adequately by LLETZ in colposcopy clinic
EUA, biopsy, cystoscopy, sigmoidoscopy MRI pelvis CT/PET Chest Abdomen & Pelvis Radical surgery, sometimes staged, often laparoscopic Or Chemo-Radiation Occasionally both, neither or less
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We are getting better at this one too and it’s becoming
rarer
1975 1980 1985 1990 1995 2000 20050102030405060708090
100
Cervix cancer
5 yr Survival Incidence
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Vulva and VaginaMost seen in FTC, a few in
A&E Biopsy and histology CT CAP Vulva mostly surgery,
individually planned, with or without lymphadenectomy
Vagina mostly Chemotherapy plus Radiotherapy
Some are easy to spot
Others are a bit less obvious
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We don’t see many but we are getting steadily better
and should soon do better on morbidity
1975 1980 1985 1990 1995 20000
102030405060708090
100
Vulval & Vaginal Cancers , 5 year survival rates
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But it’s not all about statistics and big egos
(although there are plenty of both)
Treating patients as individual people, not diagnoses Listening to what they say, ask and want Being honest and realistic Gaining trust Working as a team, getting help from wherever we
can Realising that we are each only bit part players in
their cancer journeys Keeping cheery
It’s more about....
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Now,I was told that there would be 15 minutes for Questions and
Answers
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So, here is a little quiz
Questions and Answers where I ask you the Questions and you tell me the
Answers
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An interesting and unusual case
For you to help me to sort out please
Or to tell me what to do
Politely
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Here is the story Miss ST
Aged 15 years
Discomfort in her lower abdomen two weeks ago and noticed a lump
Some loss of bladder sensation
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What else shall we ask
her?
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What else shall we ask her?
Q Any other symptoms?
Q LMP?
Q Other aspects of puberty?
Q Had sex yet?
A No, but lump seems too have grown quickly
A Not yet had one, but my younger sister has
A Some breast development and sparse pubic hair growth
A No
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What does she look like?
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What does she look like?
Q Is she abnormally short, tall, fat or thin?
A No
Q Does she look normal?A Yes
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What do we find on examination?
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What do we find on examination?
No Ascites
No lymphadenopathy
No hepatomegaly
Just a large, smooth, firm, mobile mass
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What Tests shall we
do?
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What tests shall we do?
A Abdominal ultrasound scanReport:Centrally within the pelvis there
is a 12cm complex mass, with increased vascularity Not typical of a “dermoid”
Normal uterus No free fluid
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And the Blood tests, tumour markers &
hormones
CA125 46CEA <1CA19-9 5βhCG 112AFP 1LDH 2200
LH 21
FSH 77
TSH 2.47
Prolactin 316
• Estradiol 212
• Testosterone 0.5
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So what’s the diagnosis?
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So what’s the diagnosis?
Well yes of course we don’t know for sure…
But we can have an educated guess An ovarian mass… Well yes of course, but what sort? A germ-cell tumour….. Well yes of course, but what sort? A dysgerminoma….(or is it
disgerminoma?) Well yes of course, but why? And what
else? Not telling yet, all will be revealed later Life’s not always as simple as that
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Germ-Cell Tumours Classification
Benign
Mature cystic teratomasaka dermoid cysts…………..…………Malignant tumours
arisingfrom components of aDermoid
Just about anything butSCC commonest & most
>40y
Malignant germ cell tumours
Mostly young, peak early 20s
Dysgerminoma ( ≡ Seminoma)
Yolk sac (endodermal sinus) tumour
Embryonal carcinomaPolyembriomaNon-gestational
choriocarcinomaImmature teratomasMixed primitive germ cell
tumours
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Malignant germ-cell tumoursClues from tumour markers
Histology AFP hCG LDH ClueDysgerminoma - +/- + DYolk sac tumour + - Think
PregnancyEmbryonal carcinoma +/- +Polyembryoma +/- +Choriocarcinoma - + Think
PlacentaImmature teratoma +/- -Mixed germ-cell +/- +/-
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So we’ve made the diagnosis.What shall we do next?
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What shall we do next?
CT scan of chest, abdomen and pelvis:
Result: Largely solid ovarian mass
No ascites or pleural effusion
No lymphadenopathy
No lung or liver metastases
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What shall we do next?
CT scan of chest, abdomen and pelvis:Result: Largely solid ovarian mass No ascites or pleural effusion No lymphadenopathy No lung or liver metastases
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Then What?
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A long chat with patient and parents
Explain most likely diagnosis and treatment
Plan fertility sparing surgery, ASAP
Then What?
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What did I find at laparotomy?
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What did I Find?
Her right ovary, fallopian tube and uterus
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So we took out the right ovary & tube,
and it looked like this
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But this is what the left side looked
like?
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So what do we do now?
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So what do we do now?
Have a cup of tea while waiting for the frozen section.
Answer dysgerminoma so…
Omentectomy pelvic and para-aortic node sampling
Send blood for karyotype
Monitor her tumour markers
Phone Michael Seckl or Philip Savage at Charing Cross Hospital
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What happened to her tumour markers?
βhCG LDH CA125
Pre op 112 2200 46
D2 post op 5.9 816 34
D14 post op 5.0 ↑ normal normal
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What else happened?
Karyotype result:46XY in 280 of 280 cellsSwyer’s Syndrome (46XY gonadal dysgenesis)
CT scan 3weeks post op Small volume pulmonary metastases
4weeks post op. starts chemotherapy with Bleomycin, Etoposide & Cisplatin (BEP)
19 weeks post op. laparoscopic “LSO”
26 weeks post op. sits GCSEs
Now well and at University studying politics
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Swyer’s Syndrome, Complete 46,XY Gonadal Dysgenesis Several causes, usually a new mutation on X or Y chromosome, if Y usually the SRY region. Some mosaicism
Failure of gonad to progress beyond the indifferent stage, so it makes no testosterone
Embryo develops to the default position Healthy girl, normal stature, delayed puberty Elevated FSH & LH, low E2 USS, small uterus & can’t find the ovaries
(unless there is a big one)
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Other things to talk about
Hormone replacement estrogen & progestogen +/- testosterone
Sexual / body image considerations
Genetic counselling, DNA tests
Having babies
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Other things to talk about
Hormone replacement estrogen & progestogen +/- testosterone
Sexual / body image considerations
Genetic counselling, DNA tests
Having babies
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We probably shall not get here unless we
overrunThanks