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MRCOG PART 2 SBAs and EMQs

Course PAID
notes	336
EMQ	1502
SBA	2115

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Essay 329 - Gynae oncology

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		Posted by Yazmin F. Sun Jul 18, 2010 08:39 pm
a) This complex mass is likely to be malignant therefore, history examination and investigation must aim to determine the nature of diagnosis, triage patient to the relevant cancer unit and institute appropriate treatment. As Ovarian cancer has better prognosis when opertated by gynaeoncologist in a tertiary cancer centre following multidiciplinary team involvement. A 6 month history of symptoms of sudden onset, associated with weight loss and anorexia are suggestive of ovarian malignancy. This is likely to be complicated by pressure symptoms due to the size of the cyst. PV bleeding may be present if endometruium is involved, or in the presence of granulosa epithelial tumour. A family history, personal history of malignancy (breast, colorectal, ovarain) should be sought as it increases the risk of ovarian maligancy. An general examination of BMI, blood pressure, cardiorespiratory, supraclavicular lymph nodes is necessary in planning surgery and excluding secondaries. Abdominal examination may reveal distended abdomen with shifting dullness on percussion suggestive of ascites. A large ovarian mass may be solid, immoblie on palapation and a longitudinal incision mya be needed for good access during surgery. Presence of scar will suggest previous surgery and likely adhesions present during further surgery. A bimanual examination will give further information about the size and mobility of the mass and uterus. A speculum examination will ascertain whether the cervix and vagina appears healthy or identifies cause of bleeding in the presence of a positive history. Haematology, liver function, renal function tests are needed prior to surgery for suspected malignancy. Also aneamia may be present requiring correction. A ca125 can be raised in ovarian malignancy and it will provide a RMI of low, moderate and high risk allowing appropriate triage of patient. However this is also raised in beingn conditions such as endometriosis. Other tumour markers that may be of use are AFP, LDH. A CT abdomen/pelvis may give added information about this mass and help in clinical staging of the disease. A chest x ray is needed to excude lung secondaries. b) An inoperable ovarian maligancy is associated with poor prognosis and patient needs counselling by Gynae oncologist and oncology nurse folllowing MDT meetings. This should be done sensitively preferably in the presnece of a supportive family member as the patient may not rememebr all the details. Time must be given to assimilate the news and a further follow up given if required. During the counselling, the morbidity and mortality associated with the condition must be discussed fully and the options available for palliative treament to allow informed decision making. Chemotherapy , suportive treatments in the form of antimetics, analgesia, ascitic drainage to relieve symptoms can be offered if patient is agreable. However patient wishes and expectations must be respected at all times. She may benfit from consultation with the palliative team.
		Posted by Bee N. Sun Jul 18, 2010 09:36 pm
A healthy 76 year old woman with a 6 months history of abdominal discomfort and bloating has been referred to the gynaecological oncology clinic because ultrasound scan showed a 12cm complex ovarian mass. (a) Discuss your clinical assessment and investigations [10 marks]. (b) She is found to have an inoperable ovarian adenocarcinoma at laparotomy. Post-operatively, the woman states that she does not wish to have further treatment. Discuss your management [10 marks] (Bee) A). I will start my assessment by taking a history. I will ask for symptoms such as Pain, bleeding per vaginam and abdominal distention distention to have an idea of how this mass is impacting on patients quality of life. I will ask if she has bowel symptoms such as constipation, diahhoea or vomiting which may be a cause of her abdominal distention or complication of existing pelvic mass.I will then ask for risk factors associated with ovarian malignancy such as age at menarche (early menarche), age at menopause (late menopause), Parity (low parity), use of hormone treatments e.g previous contraception or hormone replacement therapy. I will ask for family history of breast, ovarian and endometrial cancer which can be associated with ovarian cancer in this patient. Family history of prostate ad colon cancer in males will also be relevant for this purpose. I will ask for her past smear test history to assess the likelyhood that this mass is related to a cervical pathology. I will then examine the patient\'s abdomen for massess and tenderness. I will palpate for ascites by doing a fluid thrill of shifting dullness. I will do a speculum examination to see if any vulval, vaginal or cervical lesions. I will then do a pelvic bimanual examination to check for adnexal masses, tenderness, mobility( fixed masses raises the suspicion of malignancy) as well as size of the Uterus for possible uterine pathology (e.g metastasis). I will then take venous blood for CA125, LDH, AFP and CEA as CA125 can be high epithelial ovarian cancers. LDH may be high in dysgerminomas and AFP-alpha feto protein high in germ cell tumours( though more unlikely in menopause).I will also take blood for full blood count, ESR, liver and kidney function tests as these may also be deranged if malignancy is present. If ascites is present, i will consider aspirating for cytology. CT/MRI is not usually indicated in initial assessment until malignancy is highly suspected (risk of malignancy index-RMI)in which case these will be done to stage the disease. Risk of malignancy is calculated from U x M x CA125. U is estimated from ultrasound characterisation of cyst. M is 3 for post menopause and 1 for premenopause and CA125 is the value of serum CA125. If RMI is <23, this is low risk with a risk of malignancy <3%. If 25-250 this is moderate risk with a risk of malignancy of 20% and if >250 is high risk of malignancy of 75%. High risks should be managed in cancer centres while moderate risk should be in cancer units. This patient with a complex ovarian mass of 12cm at 76 years (menopausal) will be at the least moderate risk. B)If she wishes not to have any further treatment after dignosis of inoperable adenocarcinoma, I will approach her sensitively and try to find out what her concerns are and what she means by no further treatment (as treatment can be offered for palliation). I will discuss issues about confidentiality and obtain permission to discuss the findings and her wish with family members. I will discuss where she will like to be observed or managed e.g home or local hospice and consider support for carers to reduce burden. She will be managed palliatively if she wishes under multidisciplinary team consisting of gynaecology oncologist, palliative team, macmillan nurses, social support services, psychologist and psychiatrists. Symptom control will aim to achieve control of her pain,hest symptoms, ascites, any intestinal obstruction, bleeding, anxiety and depression. This will be done in liason with the pain team. She may need intermittent drainage to relieve abdominal discomfort if present. Psychologists/ psychiatrists will help with symptoms of depression or anxiety. surgeons may be needed if there are symptoms of gastrointestinal obstruction. I will ensure adequate thromboprophylaxis. I will refer her to support groups locally available and discuss issues surrounding decision to resuscitate. I will ensure clear documentation of plans and arragement made. Assisted suicide is illegal in the UK and isnt an option.
		Posted by MR R. Sun Jul 18, 2010 09:44 pm
A healthy 76 year old woman with a 6 months history of abdominal discomfort and bloating has been referred to the gynaecological oncology clinic because ultrasound scan showed a 12cm complex ovarian mass. (a) Discuss your clinical assessment and investigations [10 marks]. I will take history regarding the onset of abdominal discomfort and bloating(sudden onset & short duaration might indicate underlying malignancy)I will ask if there is any associated abdominal pain and its nature,duration,radiation,aggravating and releiving factors. Acute onset of pain with associated nausea and vomiting can suggest torsion of the cyst.I will ask for any history chest pain, breathlessness,duration and its severity which can be associated with pleural effusion. I will elicit gastrointestinal symptoms including diarrhoea, constipation, passage of mucusy stools or rectal bleeding. I will ask if there is any asociated loss of weight or appetite. I will ask for symptoms related to her bladder like dysuria,haematuria,frequency or incomplete emptying.I will ask if there is excessive tiredness which might suggest underlying anaemia or yellowing of the skin suggesting jaundice.I will elicit her obstetric history as to how many children she has had and the mode of deliveries.I will ask if she has had any fertility treatments like clomiphene citrate induction. I will ask age of menopause and if she has been on HRT at any time and its duration.I will ask for past history any gynaecological surgeries like hysterectomy/treatment for endometriois/PID or ovarian cyst removal.I will ask for family history of ovarian,breast or colon cancer in 1st or 2nd degree relative.I will ask for any other medical conditions in relation to her age like diabeted,hypertension or ischemic heart disesase which might influence the treatment.I will elicit smoking and alcohol history.I will ask if she stays with family and support from her family. I will asess her height and weight and calculate her BMI.I will take her pulse rate,blood pressure and respiratory rate.In general examination I will look for anaemia,jaundice or generalised lymphadenopathy.I will examine her abdomen and identify any mass,size,nodularity & mobility.I will elicit if there is any tenderness,gaurding or rebound tenderness to rule out underlying torsion.I will palpate for any hepatomegaly.I will asess for severity of her ascites by fluid thrill and eversion of the umbilicus.I will assess if there are pressure symptoms in the bladder by ausculation of the bowel sounds.I will carry out pelvic examination to feel for the uterus,mass,its mobility and any fixity to adjoining structures.I will carry out auscultation of the CVS/RS to identify Pleural effusion. Investigations will include FBC – to identify anaemia in malignancy.Riased WBC and CRP can indicate inflammtory process.Liver funstion tests and raised transaminases can suggest hepatic metastasis if malignancy suspected.Her renal function tests to asess baseline urea and creatinine.Tumour markers CA125 and CEA can be raised 70% of ovarian malignacies and 30% of stage 1 tumours.CEA can be raised in both ovarian and GI malignancy.Urine for culture and sensitivity if there is an underlying UTI.Chest Xray – to identify if any plueral effucion and also its severuty.I will asess other USS features like solid areas,bilatreal involvement,ascites which might suggest the nature of the cyst.If suspicious features on USS CT chest ,abdomen and pelvis is done to identify metastsis.Although combined features of USS,CT,MRI,Dopplers can assist in staging its time consuming and expensive.Therfore staging can be done only by laparotomy. (b) She is found to have an inoperable ovarian adenocarcinoma at laparotomy. Post-operatively, the woman states that she does not wish to have further treatment. Discuss your management [10 marks] Patients should be dealt with in an emphathetic and sensitive manner. She should be seen by a team comprising of gynae-oncologist,specialist nurse,clinical oncologist,palliative specialist,social upport services and psycologist.Inoperable tumours can sometimes benefit with chemotherapy(taxanes & platinum).They help in improving survival rates and this should be explained to her.very advanced tumours can be managed only palliatively. Patients wishes should always be respected and taken into account for the treatment plan. Reasons as to why she declined any treatment should be explored.This could be due releigious reasons,can live with cancer than to go thro side effects of chemotherapy or other tratmnets.Her family members should be involved in the decision making and also the support process.Psycological support in the form of counselling sessions should be arranged.Symptomatic control of the cancer symtoms should be arranged if she wishes especialy to improve her quality of life.If the patient wishes hospice care then this should be arranged with local hospice. Dietician can be helpful to advice regarding foods to maintain nutritional needs.Contacts for macmillan nurses and cancer support groups should be given.The plan of management should be documented including patients wishes.Written information leaflets and also contact nos in the hospital should be given.chages her mind at any time she should be able to contact the hospital for further management.It should be explored if she wishes symptomatic control and this should be arranged.Pain can be controlled by WHO analgesic ladder pattern.This involves starting from simpler analgesics and topping up as required moving from paracetamol to morphine.Morphine can be given as subcutaneous infusion with MST for breakthrough pain.Fentanyl pathches are also available for pain control.Sometimes patients might decline this in fear of addiction and they should be reassures.Nausea and vomiting can be controlled by cyclizine/stemetil.Steroids can be useful in resistant cases.Ascites can be drained by paracentesis as a day case prosedure to releive presuure symptoms and breathlessness.Recuurence is a acommon problem and fluid management hould be done approprately.If thers is severe pleural effusion pleral tapping can be performed.Tiredness due to anaemia can be treated with top up transfusion.
		Posted by S V. Sun Jul 18, 2010 11:13 pm
SV A healthy 76 year old woman with a 6 months history of abdominal discomfort and bloating has been referred to the gynaecological oncology clinic because ultrasound scan showed a 12cm complex ovarian mass. (a) Discuss your clinical assessment and investigations [10 marks]. The ovarian mass is highly suspicious for malignancy. Symptoms may include nausea, vomiting,anorexia, weight loss,bowel symptoms or pressure urinary symptoms.Nulliparity, smoking,obesity, personal or family h/o of BRCA genes increase the risk of ovarian malignancy. On examiantion the patient may be cahectic.abdomainal examination should assess for the features of the mass- tenderness, mobility ,ascitis.A speculum examination to exclude vaginal, cervical lesions. It is recommended that postmenopausal women with ovarian masses should be assessed with serum Ca-125 and transvaginal USS. The sensitivity for Ca125 at a cut off of 30iu/ml is 81% and specificity is 75%.It can be raised in other benign conditions like endometriosis and other malignancies.The TV USS has a sensitivity of 89% and specificity 73% for ovarian cysts but can fail to differentiatie between benign and mailgnant condidtions. The RCOG states that there is no routine role yet for MRI, CT and Doppler or PET. A\' risk of malignancy index\' should be used with Ca125 and TV USS rsults to calculate the risk and to triage the patient. If the RMI risk is more than 250, as most likely in the above patient, the patient should be managed in a cancer centre by a gynaeoncologist in a multidisciplinary team. (b) She is found to have an inoperable ovarian adenocarcinoma at laparotomy. Post-operatively, the woman states that she does not wish to have further treatment. Discuss your management [10 marks] This case should be managed in a multidisciplinary team involving the gynaecologist, clinical oncologist, macmillan nurses and social services. care at home/ hospice is usually preferred. The woman\'s wishes should be respected and palliative care offered . The main aims of palliative care would be to achieve the best quality of life for the woman and her family. Adequate pain control according to the WHO priniciples is recommended. Oral analgesia is preferred and the 3 step ladder using NSAIDs, weak opiods like codeine and strong opiods like morphin should be considered. Adjuvant treatment like corticosteroids, anticonvulsants , antidepressants enhances analgesic effect.Antiemetics for nausea and vomiting. Pilocarpine for dry mouth and treatment for oral candidiasis improve mouth symptoms. laxatives to help with constipation.Corticosteroids improve appetite Paracentesis to relieve symptoms of ascities.Management of entero-cutaneous fistula with stoma bags and barrier creams should be considered.Palliative radiotherapy like can help with bone pain from metastasis. More importantly , good social, psycological and emotional support for woman and carers helps the treatment process. The decision for resuscitation status should be discussed. Assistance for suicide is illegal in the UK
		Posted by nazia M. Mon Jul 19, 2010 01:12 am
a)Most likely diagnosis is ovarian cancer.Take history about any other symptoms suchas postmenopausal vaginal bleeding,GIT symptoms like nausea, vomiting,dyspepsia,constipation,diarrhea,urinary symptoms frequency,retention of urine,chest symptom;dyspnea.Personal or family history of colon,endometrial,breast,ovarian cancers,whether she has any medical disease.Ask about parity,any intake of ovulation induction drug(clomephene),past contraceptive history-coc,ask about weight loss.On general physical examination BMI for weight loss,check pallor,lymp nodes,breast examination,abdominal examination abdominal distension,tenderness,ascites,organomegaly,any pelvic mass;site ,size,mobility,number,tenderness,consistency,regularity,bowel sound.pelvic examination;to exclude any pelvic mass.Investigations; FBC,urineanalysis,urea and electrolytes,LFT,ECG,xray chest.As ultrasound showed complex ovarian mass but want to know whether bilateral or not,multiloculated or not,solid areas,ascites present or not to calculate risk of malignancy index also liver metastasis.CA125 and CEA to exclude epithelial ovarian cancer other tumour makers are not needed as in this age group epithelial cancers are more common.CTand MRI are not routinely done if difficulty in diagnosis and to assess the extent of any intraabdominaldisease.A doppler ultrasound of ovaries shows increased vascularity is sugessitive of malignancy but not routinely done.RMI should be used to triage woman by using ultrasound findings,ca125 and postmenopausal status. b)Patient with inoperable cancer has poor prognosis.Proper counselling and support is needed and dealt sensitively as she does not wish for further treatment.Reason for this should be explored and her wishes should be respected.Her family members and partner should be involved.Patient should be managed with multidisciplinary team including gynaecology oncologist,clinical oncologist,specialist nurse,macmillan nurses,psychologist.An appointment should be made with the woman so that she may be properly counselled with advice and a subsequent management plan can be made with woman with reassurance.Management in this case is palliative with chemotherapy and releiving any symptoms such as pain, vomiting,constipation with medical treatment.
		Posted by H H. Mon Jul 19, 2010 01:48 am
hhh A sympathetic approach in managing such patient is adopted. Will ask of the effects of her symptoms on her quality of life. Will ask of her support at home and if she want anyone available with her during her clinical assessment. Will ask of her parity, age at menarche, age at menopause, use of fertility drugs during her life , type of contraception and any menopausal symptoms for which she used HRT. Will ask of family history of breast, endometrial, colon or ovarian cancer. Will ask of weight loss, anorexia , vomiting or constipation. Will ask of symptoms of metastasis as chest symptoms,(eg dyspnea, cough hemoptysis,) feeling of other swelling in the body. On examination will notice cachexia and will do BMI . Will feel lymph node enlargement specially at base of neck. Will do chest examination for pleural effusion(air entery and percussion for dullness), will do abdominal exam for ascites and feel for masses specially if firm and fixed ,will feel for enlarged liver and if tender(metastasis). Will examine the lower limbs for swelling and varicose veins specially if unilateral. Will ask permission to do a vaginal examination of such old lady , taking care of being gentle to feel the adnexal mass,its relation to uterus and fixity. Will do FBC for anemia ,group and cross match if she is scheduled for surgery, CRP for inflammatory conditions, urea and electrolytes for renal function and liver function tests. Clotting screen if liver functions affected and low platelets. Will do CA125 to assess the risk of malignancy index ,taking in consideration she is post menopausal,=3, features on the ultrasound and level of CA125 in units/ml. If risk of malignancy index is >250 she will be treated in cancer center. MRI,to use it for staging. Chest Xray ,for pleural effusion and ECG as preoperative investigation. Her wish should be respected , however she is told that there is some palliation care plans that would improve her quality of life. Care should be taken in discussing such plans as she would be in a state of depression and will need proper care and support, her relatives might help or her partner and might need bereavement counseling.The patient is given time. I will dicuss with her what palliation mean and give her written information.The Macmillan nurse can help. She is told that at a certain time she need to have it. Pain relieve is done in a step ladder protocol as WHO describes,using weak analgesics first to control pai and then shifting to stronger ones as opiates. Antiemetics used foranorexia and vomiting,as metochloropropamide and ondansteron. Chronic intestinal obstruction and abdominal distension treated by low residue diet, anti flatulents and conservation. Patient told that all medications can be used at home if she wish to be with her family. Patient is told that there are some surgical procedures that can make her final days easier as relieve of pleural effusion or ascites. If refuse,she is left to die in peace with her relatives beside her.
		Posted by Syamala H. Mon Jul 19, 2010 01:53 am
SYAMALAH ANS A: a complex ovarian mass in a 76 yr old lady is most likely to be malignant in origin. she requires urgent assesment and refferal. assesment would include a detailed h/o of symptoms,h/o nasuea ,vomitting diarhoea, constipation,anorexia,colic,pain with its duration severity and aggrevating and relieving factors any h/o postmenopausal bleeding,rectal bleeding, any chest symptoms,headach and h/o bone pain. will ask about age of menopause,parity. any h/o oral contrceptive use and hrt use and its duration.any family history of malignancy. examination will include weight,BP, signs of cachexia, breast examination, chest auscultation, per abdomen examination would include signs of ascitis, hepatospleenomegaly, palpation of mass its mobility and any tenderness. vaginal exam would include visualisation of cervix and vagina for any mass,signs of atrophy and estrogen excess. per vaginal exam to asses size of mass ,its fixity, nodularity and tenderness and whether it can be made out seperatly from uterus. per rectal exam to further confirm finding,see for any bleeding or mass. investigations include complete blood picture, urea ,electrolyte , liver function test. CA125, CEA, LDH and serum B hcg. ultrasound including tvs. chest X-ray and ECG. MRI/CT may be required if ultasound scan is inconclusive. further mangment will depend on the value if CA125 and detailed findings in tvs. Risk of malignancy index has to be calculated and patient to be traiged accordingly. A score of< 25 can be managed by general gynecologist , risk of malignacy <3%. a score between 25-250 risk of malignancy is 20% to be managed in cancer unit and finally scaore of >250 risk of malignancy is >75% and should be managed at cancer centre. ANS B:as the patient had staging laprotomy which revealed inoperable adenocarcinoma and she wishes not to have further treatment for the malignancy she will be a canditate for palliative therapy. she should along with the family should have a detailed discussion with the multideciplinary team(oncologist,palliative care team, social worker) regarding the implications of her decision. central issues of palliative care would include womens perspective of quality of life and care should aim to provide that, pain managment, managment of other complications, psycological,social and spiritual problem, and ethical issues like dicision to resucsitate, dicision making authority when she is unable to express herself. location of care(home/hospice), provision of support for carers and involments of social services and macmillan nurses. assess the degree of pain its nature and severity ,use visiual analogue pain score and to follow WHO three step ladder approach for pain managment. mild pain can be manage with NSAIDS( containdications-thrombocytopenia, upper gi bleeding , renal ad hepatic impairment), acetoamenophen and adjuvant drugs like steriods antiemetics and antidepressants. moderate pain require drugs like coedine and oxycodone and severe pain would reuire morphine and pethidine or fentanyl along with adjuvant drugs.PCA can be helpful in certain circumstances. use simlpe dose easy route and have frequent follow up for assesment of relief and adjustment.NSAIDS have cieling effect and opiods cause tolerance dependence and addiction. non pharmalogical method include cognitive behavioral hterapy,TENS, nerve ablation and acupuncture. magnaments of other symptoms include naseua, vomitting, constipation, diet and apetite(exclude drug induced ). intestinal obstruction, fistula and distressing ascitis and fractures. radiotherapy may be beneficial in certain cases of bony metastasis and bone pain. discusion regarding financial implication of decision should be done.
		Posted by millionaire2004 A. Mon Jul 19, 2010 02:45 am
A healthy 76 year old woman with a 6 months history of abdominal discomfort and bloating has been referred to the gynaecological oncology clinic because ultrasound scan showed a 12cm complex ovarian mass. (a) Discuss your clinical assessment and investigations [10 marks]. This woman may have primary or secondary pelvic malignancy and need to be approached systematically. Enquire about speed of progression because rapidly enlarging abdomen suggestive of malignancy. Ask about associated symptoms such as nausea and vomiting, loss of appetite and weight. Ask about altered bowel habits or passage of malaena or haematochezia which could suggest gastrointestinal malignancy. Ask about urinary frequency,hematuria, which could suggest bladder involvement. Ask about constipation or urinary retention which suggest compression due to pelvic mass. Ask about postmenopausal bleeding which could suggest oestrogen secreting ovarian tumour. Ask about past gynaecological or non-gynaecological malignancy. if present,ask about the stage of disease and the treatment received (surgery and chemotherapy or radiotherapy). If received chemotherapy before, ask when was the last cycle (differentiate between persistent and recurrent disease). Ask about any comorbidities such as diabetes, hypertension and past surgical history. Obtain allergy history if present. Assess her social/family support and dynamics. Assess her functional status. Do general examination looking for cachexia, lymphadenopathy, jaundice (suggest liver involvement) and pallor. Examine her breast with permission. Perform abdominal examination to assess the ovarian mass, looking specifically for site, size, consistency, ,tenderness,mobility and whether mass is separable from uterus. Look for ascitis by doing fluid thrill or shifting dullness test. Do speculum examination looking at cervix. Per rectal examination to rule out mass in rectum. An ultrasound scan can be considered to confirm ascitis and to look at uterus and other ovary if possible. Investigation ordered would be full blood count, urea and electrolytes, creatitine, liver function test. Urine for microscopy if suspicious of bladder involvement. CA 125, carcinoembryonic antigen (CEA) should be sent. Raised CA125 together with risk malignancy index (RMI) above 200 suggest ovarian malignancy. RMI has sensitivity of 85% and specificity of 97% for ovarian malignancy. Raised CEA could suggest bowel malignancy. If history suggest granulosa cell tumour, send for serum oestrogen and inhibin. Order computed tomography (CT) scan of abdomen and pelvis to assess size,site,involvement of adjacent organs and operability. It could also show metastasis to regional lymph node and liver. MRI may be better in assessing soft tissue. the choice depend on availability of service and unit protocol. CXR should be done to look for lung metastasis. (b) She is found to have an inoperable ovarian adenocarcinoma at laparotomy. Post-operatively, the woman states that she does not wish to have further treatment. Discuss your management [10 marks] This woman has an advanced disease. Manage her with a multidisciplinary team involving gynae-oncologist, medical oncologist, nurse specializes in cancer care, palliative unit specialist in conjunction with her carer and family members. Her decision need to be respected. However, explore sensitively why she refuses further treatment, preferably by a same gender doctor. Any misconception need to be clarified in order for her to make informed consent. Explain to her about stage of disease and options available ( chemotherapy and interval debulking). Explain the risk and benefit of chemotherapy. 5-year survival in the range of 20-30%. Discuss about hormonal therapy (tamoxifen, aromatase inhibitors), but their value in primary ovarian treatment unproven. Also explain about the option of no treatment and that the cancer will only worsen with complications such as bowel obstruction. Arrange family conference to discuss this. Offer formal counselling if needed. Offer another follow up meeting if the woman wishes to reconsider her decision. Offer her information about palliative care unit(PCU). Inform her that PCU intended to make her life symptom-free as possible.Discuss about place of care (home or hospice). Give her and her carer emergency contact numbers, support group informations. Offer counselling for her carers and family. Arrange follow up if she wishes to be discharged.
		Posted by leelavathi C. Mon Jul 19, 2010 02:55 am
A) complex overian mass in post menopausal women have to rule out malignancy. i will take history of abdominal swelling and any pressure symptoms like urinary frequency, constipation, pelvic pain and discomfort, and any symtom of vaginal bleeding. enquire about any history of loss of weight and loss of appetitte. find out about gynaecological history- age of menopause, uterus intact or not, and her pap smear history. enquire about family history of overian malignancy. take past history of any previous abdominal surgeries, present and past drug history to help in present management. general examination should involve to check lymphadinopathy( supraclavicular, axillary, inguinal). detail Breast examination should be done. in abdominal examination check for mass, size and its mobility, and look for ascitis. on pelvic examination include rectal examination to rule out cervical abnormality, and look for adenexal masess and its mobility. investigations should perform not only to rule out malignancy to asess fitness for anaesthesia, and surgery.blood investigations - FBS, RFT, LFT, electrolytes, CA-125 should perform. CA-125 elevates in most of overian malignancies. ultrasound findings and CA-125 helps to calculates RMI ( risk of malignancy index), so refer patient to either cancer unit or cancer center. CTscan, MRI are limited value in cases of overian tumours. B)As patient does not wish to have further treatment we have to respect her decision and advise her about palliative care. disscution should be sensitive done by senior member of oncology team. main issues in palliative care is quality of life asessment, pain control, control of other symptoms, management of psycological, social and spiritual problems. identify what women and her family perspective regarding quality of life and enquire where they prefer treament at home or hospital. pain control should be done by WHO standerds, with simple analgesics in case of mild to moderate pain, non opiates if pain increasing, or opiates in sevear pain. corticosteroids can be used to enhance analgesia and have anti inflammatory, anti emetic activity stimulates apettite. anti convulsents, anti depressents may be effective in the management of neuropathic pain. other symptoms like nausea vomitting should treat with antiemitics, dry mouth and candidiasis with hydration and drugs. paracentisis should be done in cases of ascitis causing respiratory distress. ensure the decision of palliative care as per women wishes and her family.
		Posted by A- N. Mon Jul 19, 2010 03:58 am
History includes onset, duration, progression of abdominal discomfort. Sudden onset of increase in abdominal distension indicates malignancy.History of loss of appetite, loss of weight may indicate malignancy.Associated pressure symptoms like urinary retention, constipation are important.Cough dyspnoea may suggest lung metastasis. family history of ovarian cancer personal history like use of ovulation induction drugs may be contrubuting factors. cervical smear findings as dysplasia is helpful. History of other medical and surgical co morbidities tto identify any problems that may be encountered for anaesthetic fitness. General examination findings includes to check for BMI( anaesthetic and surgical fitness) cachexia for general physical wasting seen in malignancy , palor( for anaemia), jaundice and haepatomegaly in case of metastasis is to be checked. Abdominal examination for masses, tenderness and ascitis. pllvic examination done to confirm above findings, to check uterine size, tenderness and mobility of the mass. fixed massess usually have poorer prognosis. chest is examined for signs of metastasis. Investigations include ful blood count to check haemoglobin, baseline renal and liver function tests to check for general well being, anaesthetic fitness due to co morbidities. check for tumour markers as CA125 so that it can help to calculate RMI index, this with Ultrasound scoring will helps weather the surgery can be done by general gynaecologist ( less than 25), by gynae onco lead in DGH (25-250) or be refered to gynaecology onco unit ( More than 250). PEt scanning,colour doppler are not always useful, however MRI scanning will help in clinical staging prior to surgery. The other investigations include ECG, Chest x ray to assess anaesthetic fitness. B) Her wishes is to be respected after full counselling regarding theurpeutic management by chemotheraphy. If she declines any further management, offer her pallative care so that she can live a comfortable life. She should be managed by a multidisiplinary team which is led by palliative care consultant, the including gynaecological oncologist, medical and surgical oncologist, radiotheraphisit, macmillen nurses, specialist nurse. The approach should be sensitive, sympathetic manner considering the quality of life she expects as priome consideration. Pain relief is to be offered, principles include lowest minimal effective dose should be started following WHO step ladder pattern. Non opiods like Paracetamol, NSAID\'s, should be first line of management. next step include mild opiods like codeine, then stronger opiods like morphine, diamorphine are used. Patient controlled analgesia, TENS, radiotheraphy are other options for pain relief. Vomitting and dyspepsia can be controlled by anti emetics, discomfort due ascitis can be minimised by paracentesis. laxatives help in releaving constipation which is more of a problem due to opiates. Intestinal obstruction can be managed by colostomy, in addition to symptom relief, social and ethical factors must be considered. Women\'s wishes must be fulfilled to possible extent in her last few days. Ethical issiues as decision regarding not for resuscitation should be discussed if required in the presence of family members also it is preferable to discuss about the place of her dying weather in hospital or home, people who should be present such as family members, religious support and talking about death itself by trained palliative team member is often helpful.
		Posted by L S. Mon Jul 19, 2010 04:05 am
LS: (a) Discuss your clinical assessment and investigations [10 marks]. A detailed history on her presenting compliant on onset and progression of abdominal distension, associated symptoms like pressure symptoms to bowels causing sudden change in bowel habits or feeling of incomplete evacuation. Other associated symptoms like shortness of breath which is worsening or sensation of a prolapsed asked. History of any abnormal per vaginum bleeding post menopausal are enquired. Her appetite and sudden weight loss are noted. Her previous surgical history, family history of malignancies and past history of similar conditions are documented. Her clinical examination is carried out in noting her body mass index, general examination for signs of pallor, iterus, any palpable lymph nodes at the supraclavicular area and groin area and subsequently lower limbs are examined for swelling or edema are carried out. An abdominal examination is carried out to see if there is ascites, a palpable mass and if palpable its mobility and location assessed. Any other organomegaly palpable of abdomen like liver, spleen or kidney is noted. A vaginal examination is done to note the site of origin of the mass and to see if it is palpable vaginally or not. If mass is palpable the fixation of the mass noted. Investigations should include full blood count to check for anaemia so that she can be optimized for surgery. Her liver function to assess liver infiltration and renal function test to assess her renal function. Her tumour marker CA125 are carried out to although raised in most ovarian cancer and has no prognostic value at the time of diagnosis but it can be used to monitor response to chemotherapy and for recurrence. Imaging which is useful includes a chest radiograph (CXR), pelvic and abdominal ultrasonography (USS) and computerized tomography (CT). The CXR may reveal pleural effusion. The USS as in the question confirms clinical finding of an adnexal mass and its nature (solid or cystic). CT may help in with planning the surgical resection by delineating the tumour. (b) She is found to have an inoperable ovarian adenocarcinoma at laparotomy. Post-operatively, the woman states that she does not wish to have further treatment. Discuss your management [10 marks] Immediately post operative patients are usually emotional distraught with the news and will respond in many ways. A multidisciplinary approach (gynae-oncologist, oncologist, nurse specialist, psychologist) to her care is important especially the nurse specialist involved in her care should be present when her new is broken about the outcome of the operation so that she can help in continuing her support both to the patient and her family members so that they can mentally be prepared for the future and subsequent care. She should be given time and support regarding her decision. A sensitive approach should be carried out again to enquire on the reasons why she refuses further treatment. She should be informed that the main mode of treatment for ovarian cancer is chemotherapy for which she can have an arranged discussion with the medical oncologist to inform her further on this option. Her case should be put up for discussion at the multidisciplinary meeting and a decision on further care as a group opinion should be made. Options of further care are either no treatment for cancer with only supportive care for complication symptoms and pain management with palliation, six cycles of chemotherapy only or 3 cycles of chemotherapy to assess response and if there is response to consider role of interval debulking surgery. If she refuses further care despite efforts is made she should be counselled on what to expect with time and role of palliative team informed. Her family should be encouraged to support her and role of macmillan nurses are informed.
		Posted by Chitra.s M. Mon Jul 19, 2010 05:27 am
A.The most likely diagnosis in this woman is ovarian malignancy.History of associated symptoms like nausea and vomitting ,pressure symptoms like constipation,frequency is enquired.Presence of abdominal pain is asked about.The effect of symptoms on her quality of life is enquired.Gynaecological history is taken to identify any risk factors like early menarche and late meopause,low/nulliparity.Family history of ovarian/breast cancer is enquired.Social factors like presence of family support is assessed.She is examined to note her BMI,pulse and BP.Presence of pallor,jaundice, lymphadenopathy(supraclavicular) is noted.Chest examination is done for evidence of pleural effusion.Abdominal examination is carried out to look for hepatomegaly,presence of ascites(shifting dullness),palpable mass ,mobility and tenderness.Lower limbs are examined for evidence of edema and varicosities due to pressure from the mass. Pelvic examination is performed for assessing mass fixity and tenderness. Investigations would include a full blood count for anaemia .liver function tests for evidence of secondaries(altered enzymes and bilirubin)and as preoperative assessment.Ca-125 levels are done for assessing risk of malignancy index which helps in triage.Ca-125 Chest Xray is done for presence of pleural effusion and preop investigation.A CT scan is useful for retroperitoneal assessment and detection of peritoneal and omental disease to help in planning further treatment. B. The reason for refusal of treatment is sensitively explored .The woman\'s wishes are respected when it is an informed choice.She is counselled about palliative care.She and her family are informed that, this aims to achieve the best possible quality of life for her and her family.She is offered verbal and written information about palliative team care,support mechanisms and how to access them.The aims of care -pain and other symptom control,psychological care and terminal care are discussed.Structured emotional support is provided to the woman and her carers. The place of care(home/hospice ),involvement of voluntary organisations,macmillan nurses are discussed with the woman and her family.Pain management is according to the WHO step ladder pattern using acetaminophen and NSAIDs for mild pain,weak opiates like codeine for moderate pain and opiods like fentanyl and morphine for severe pain ,with a formulated plan for breakthrough pains.Treatment outcomes are monitored using visual analogue scales.Anaesthetic interventions like coelaic plexus /neuraxial block for intractable pain and palliative radiotherapy may be required for bone pain.Other symptoms like nausea and vomitting are treated by using antiemetics like ondansetron( after excluding bowel obstruction.)Issues of terminal care,resuscitation and decision making when they cannot communicate has to be discussed and documented.Assisted death is not an option as it is illegal in the UK.
		Posted by A A. Mon Jul 19, 2010 07:33 pm
AA (a) History should include symptoms of presentation and their duration. Recent weight loss, poor appetite. Bowel symptoms like constipation diarrhea, abdominal pain and vomiting. Urinary symptoms like dysuria frequency, or retention of urine. Chest symptoms like cough dyspnea and pain are suggestive of metastasis. Family history of breast, ovarian, or uterine cancer. Any previous use of contraception, on HRT, or any previous surgery. Take social history, alcohol use or smoking. Living with family or alone .Enquire about social support. Examination should include BMI, BP, chest, CVS and CNS examination to find signs suggestive of secondaries .Per abdomen to see mass mobility, size and tenderness .Presence of Ascites, hepatomegaly or splenomegaly. Speculum examination to see vaginal walls and cervix . Rectal examination if bowel symptoms present. Investigations should include FBC to see anemia and correct it WBC, CRP to rule out infection Blood group and cross match for surgery. Liver and renal function tests and clotting profile as baseline tests Tumor marker CA125, CEA. Chest x ray for metastasis. Imaging ultrasound or CT/ MRI for secondaries in liver, extant of disease in abdomen or bowel involvement. Drainage of ascites or effusion if present for cytology. Proctoscopy or colonoscopy if Bowel symptoms. (b) Treatment should be by Multidisciplinary team including gynecologist oncologist, chemotherapist, radiotherapist, physiotherapist, trained nurses, social services and counselor in cancer centre.Take account of women wishes. Enquire about her reason of refusal of treatment. Need counselor for counseling and explore her fear and anxiety. Explore her wishes for use of chemotherapy and radiotherapy as palliative care. Decision to abandon treatment and care for her symptoms should include MDT, woman’s family and herself. Treatment should center on women’s perception of quality of life. Decide location of care and death Provide support to careers as desire. Palliative care for her symptoms. Thorough history and examination required for clinical assessment of pain and symptoms such as constipation, nausea, vomiting headache anxiety and depression. After diagnosis of type and severity of pain, treatment goals are set and explained to woman and her family. There are pharmacology and non pharmacology treatment for pain including WHO three step ladders which include NSAIDS in step 1, weak opiod in Step 2 and strong opiod in step 3. Non pharmacological methods include exercise, acupuncture and TENS. GI Symptoms like mouth dryness can be treated by hydration and saliva production medications. Nausea vomiting and constipation are treated by antiemetic +/- Corticosteroids. Use of antibiotics for infection. Bowel obstruction by conservative treatment or by use of corticosteroids or by surgery percutaneous gastostomy. Paracentecic for ascites may be needed. Palliative radiotherapy can be used for bleeding and bone pain from metastasis. Give psychological and spiritual sport and manage depression and anxiety with help of counselors. There is need for regular follow yup and reassessment of treatment goals. Discuss ethical issues associated with palliative care in circumstances where woman is unable to express herself use of surrogate decision maker. Decision on resuscitation. Keep in mind assisted suicide is illegal.
		Posted by sonu P. Mon Jul 19, 2010 08:28 pm
a) This is most likely a malignant pathology. I will take a history of severity of symptoms and association with loss of appetite and weight and their effect on quality of life.I will also try to rule out causes of secondary ovarian tumor like any history of breast cancer in the past or any ongoing investigations for breast lump,any personal or family history of stomach or bowel cancer. On examination I will look for signs of cachexia, pallor, jaundice, supraclavicular lymphadenopathy in general examination. Systemically, chest and abdomen are examined to look for signs of distant metastasis e.g hepatomegaly and ascitis. A breast examination may reveal a primary carcinoma of breast.A large mass which is either hard or of variable consistency due to degeneration is highly suggestive of malignant pathology. I will perform a FBC,U&E,LFT to assess general anesthetic fitness. I will order a CT- chest, abdomen and pelvis to look for the extent of disease e.g liver metastasis, pelvic and paraaortic LN involvement, any evidence of pressure effects like hydronephrosis. A mammography,upper GI endoscopy or colonoscopy may be advisable if there is suspicion of non ovarian primary cancer. Serum CA-125 levels would help to get a RMI score which can be used to decide the most appropriate place for management and to monitor the therapy and recurrence in the future. b) The patient must be very anxious and upset and should be counselled by the most senior member of the team, ideally the gynecological oncology consultant who performed the operation. She should be given the bad news in a quiet area in the presence of partner or close family member if she agrees; ideally, with no interruptions.She will be told about the operative findings in detail, and I will make sure that she recovers as smoothly as possible from the laparotomy. She should be advised to wait for full histopathology report. She will be advised that the team will respect her wishes and should be told about the multidisciplinary care she should expect involving oncologist, McMillan nurses, the pain management team, GP, the health visitor and surgeons if complications like bowel obstruction anticipated. I will explore her reasons of refusing treatment and reiterate that even though its not curable but quality of life can be much improved if surgery, CT are used for palliation. She should understand that palliative care is an active management of people with terminal and incurable illnesses. She should be assured that even if she declines treatment, all effort will be made to relieve the symptoms of pain, constipation, vomiting, loss of appetite, and ascitis which are the most common reasons for presentation to the hospital. If she makes an informed decision of DNR,it should be respected and revised with every hospital admission and change in circumstances,if any.She can be cared in a hospice or home according to her wishes.I will emphasise on the need for repeated drainage of ascitis, if symptomatic.
		Posted by NIRMALA M. Tue Jul 20, 2010 06:16 am
Nirmala a. My clinical assessment includes eliciting history and examination. History to include onset, progression of disease whether slow or rapid, site of pain or discomfort, whether any associated pressure symptoms on bladder or bowel. Rapid onset and rapid progression denotes more of a malignant lesion. Loss of weight and loss of appetite should be ruled out as these favour towards malignancy. Any comorbid conditions such as diabetes, hypertension should be noted. Examination includes general and systemic to include respiratory, cardio vascular and abdominal. General examination to look for anaemia, jaundice, generalized lymphadenopathy, to measure BMI, BP, and pulse rate. Respiratory system assessment to look for equal air entry and to exclude hydro thorax. Cardio vascular assessment to look for normal rhythm. Abdominal examination should be followed by pelvic internal examination. Abdominal examination to assess the extent and size of the mass, origin of the mass whether abdominal or abdomino-pelvic, fixity of the swelling, surface whether smooth or lobulated, consistency of the swelling whether cystic or solid, presence of any tenderness, presence of any ascites and presence of any other organomegaly. Internal examination to confirm the above findings and to know whether the mass is fixed to the uterus and the surrounding structures, any palpable swelling on the other adnexa. Investigations include general, specific and pre operative investigations. General investigations to include FBC, LFT, UEC to exclude anaemia and metastasis Specific investigations to include Tumor markers like ca 125, CEA, CA 19-9 as these are elevated in epithelial ovarian malignant tumors in 80%. CT abdomen, pelvis, chest to know the extent and spread of the disease. In cases of fixed ovarian mass, IVP can be considered to know the course of the ureter and pre op stenting can be decided. Pre op investigations like ECG, CXR and group and save. Based on risk of malignancy index (depending on USS, (3 IN THIS PATIENT) X post menopause(3) X CA 125 values, cutoff normal < 30) if > 250,assessed as high risk and referred to cancer centre. If between 25-250 she is intermediate risk and referred to cancer unit. If < 25, she should be managed by Gynaecology team. b. Patient must be approached sensitively with sympathy. She has to be managed by multi-disciplinary team involving Gynae oncologist, Medical Oncologist , Oncology nurse specialist, Pain team and Macmillan support workers following MDT review. Patients relatives should be involved in her further care and discussion. Patients mental capacity to understand and retain information about her condition and treatment should be assessed before judging on patients\' decision not to have further treatment. If patient has good mental capacity, reasons should be explored. If not, decision should be made by MDT in patients’ best interest. If patient does not have supporting family for further treatment if patient decided for treatment, then nursing care home and social support services should be involved. Patient and family should be clearly explained about the survival rate by Senior Gynae Oncologist or Medical Oncologist with and without treatment (neoadjuvant chemotherapy X 3 cycles which may be followed by relook laparotomy and 3 more cycles of chemotherapy) and quality of life. If patient decides not to have treatment even after this, her decision should be viewed with respect. Her concerns regarding pain relief, nausea, abdominal discomfort should be addressed by appropriate palliative care team. She can be managed either as outpatient and inpatient depending on her co existing symptoms and admisiion as and when necessary. Pain relief should be stepwise starting with regular paracetamol, NSAIDS, Opioid derivatives, PCA, TENS with regular anti emetics. Regular paracentesis should be done to aid comfort. Future bowel obstruction should be managed with colostomy and bladder obstruction should be managed with suprapubic catheterisation. Total parenteral nutrition should be considered as part of palliative care. Her wishes to be explored with respect to resuscitation after death and to include it in her care of dying pathway if she is deteriorating.
		Posted by zara A. Tue Jul 20, 2010 07:55 am
a]The most likely diagnosis in this woman is ovarian malignancy.She needs prompt assessment.She should be approached empathetically ,explain most likely diagnosis,and need for further assessment and investigations to confirm it.Her history should be taken,ask about if she has pain ,severity.She should be asked about weight loss,anorexia.She should be asked about cough,breathlessness[metastasis] .SHE should inquired about nausea,vomiting ,constipation[ intestinal obstruction].urinary symptoms voiding problems,hematuria.ASKaboutPARITY, age of menopause ,post menopausal bleeding.She should be inquired about drug historyHRT.History of any previous surgery should be taken.family history of ca breast,colon,ovarian cancer should be taken.Social history of smoking and alcohal should betaken .Ask about family support social problems.Examination carried out to look for pallor,jaundice .BMI AND blood pressure recorded.LOOk for lymphadenopathy [supraclavicular ].Breast examination done.CHESTexamination for plueral effusion.Abdominal examination done for hepatomegaly,ascites ,mass tenderness. bimanual examination to assesssize, mobility,consistency,Rectal examination if bowel symptoms .INvestigations performed to look for likehood of malignancy ,extent of disease,and for fitness for surgery.FULLblood count and blood group and save [asneeded for surgery].LFTS AND SERUM electrolyte s should be done.CHEST xray [pleural effusion] and ECG for fit ness carried out.CAI25 CARRIED out and trans vaginal USG done to look features of mass solid components ,bilaterality,ascites metastasis,multilocular .RMI IS CALCULATED from cai25 level xmenopausal statusx ultrasound features[ultra sound U =1 for [ultrasound score 1 and u=3 for 2 to5 ,TO triage woman which need surgery in cancer unit [RMI 25 -250]AND in cancer centre [RMI >250].Trans abdominal USG DONE TO LOOK for liver metastasis .ROLE of CT scan and MRI not proven for evaluation of cyst.CT SCAN AND MRI can be carried out tolook for extent of disease[BOWEL INVOLEMENT.Further investigation like barium enema can be planned depending on GIT SYMPTOMS .B]The patient should be treated sympathetically and reason for her refusal explored ,her concerns noted [misconception ,fear from treat ment ,psyclogical problem].She should be managed by multi disciplinary team involving gynaecologist oncologist,palliative teammacmillian nurses ,dietician,pshycologist ,pain specialist,Counseller.Family and social services involved depending on need of patient .patient should be told about that aim of treatment is to improve her quality of life .THE manage ment options should be dis cussed depend ing on physical problems[pain ;constipation,intestinal obstruction,]and psycological problems,should disuss role of palliative chemotherapy and surgery,she should be told that we will respect her wishes ,ask her what treatment acceptable to her.if she changes her mind we can offer her treatment.She and her family offered support and counselling ,and discuss place of care hospice or home.S he should be offered palliative care ,explain her it will give relief from distressing symptoms, individualised according to her problems.IF she has pain ,assess by visual analogue score ,if pain mild start according to WHOanalgesic ladder first start NSAID [EXclude contra indication],if not controlled then morphine if not controlled,then give dimorphene.assess type of pain if neurological tricyclic anti depressent can be given .REVIEW her plan further according to pain.If not terminal ill advice her life style changes like mobility ,hydration and soft diet laxatives to relieve constipation.nausea an vomiting can be controlled by anti emetics and small meals and steroids.FOR ascites offer her paracentesis. SHE should be given information leaflets,support group addressss.
		Posted by Mohamed D. Tue Jul 20, 2010 09:47 am
Mohamed A) History of the condition with onset, course and duration would indicate the severity of the problem to plan her further management. Any family history of ovarian, breast or bowel cancer especially in first degree relatives, would indicate a heriditary famillial cancer condition like BRCA mutaion of NPCC. Histiry of rapid weight loss which is a sign of malignancy. Any history of vaginal blleding to role out uterine malignancy as well. Cervical slear history to role out cancer cervix. Past history of HRT usage as there is a small increae in risk of endometrial and breast cancer with its usage. Blood should be checked for tumour markers asCA125 which is associated with serous epethelial tumours, CEA which is associated with mucinous tumours and HCG which is associated with adenocarcinoma. Tumour markers like CA19.9 and alfa fetoprotein are usually associated with tumours common at younger age. Tumour markers are not specific as it could be raised with many benign conditions, but it help in follow up as well. MRI for accurate assessment of the ovaries and LNs. B) Woman\'s wishes should be respected, but she needs time to absorb the shock with this diagnosis. A gynae OPD appointment should be aranged with consultant to discuss about her management. Her case and management plan should be discussed in the MDT meeting with the medical oncologist if chemotherapy is accepted. She shouls see the Macmillan nurse to discuss further management issues. Her GP should be informed about the condition and future plans. Written information should be provided about different management strategies as wll as risks and benifits. She should be informed that ovarian maligancy usually sensitive ti platinum chemotherapy and possibility of further debulking surgery after that if possible which is still under trial in the CHORRUS trial. She needs to have an informed consent about any further step. Palliative care should be offered and pain management strategiers if she opt for that with support of community nurse and her GP. She should be provided with support groups and hospice if needed.
		Posted by Mohamed D. Tue Jul 20, 2010 09:47 am
Mohamed A) History of the condition with onset, course and duration would indicate the severity of the problem to plan her further management. Any family history of ovarian, breast or bowel cancer especially in first degree relatives, would indicate a heriditary famillial cancer condition like BRCA mutaion of NPCC. Histiry of rapid weight loss which is a sign of malignancy. Any history of vaginal blleding to role out uterine malignancy as well. Cervical slear history to role out cancer cervix. Past history of HRT usage as there is a small increae in risk of endometrial and breast cancer with its usage. Blood should be checked for tumour markers asCA125 which is associated with serous epethelial tumours, CEA which is associated with mucinous tumours and HCG which is associated with adenocarcinoma. Tumour markers like CA19.9 and alfa fetoprotein are usually associated with tumours common at younger age. Tumour markers are not specific as it could be raised with many benign conditions, but it help in follow up as well. MRI for accurate assessment of the ovaries and LNs. B) Woman\'s wishes should be respected, but she needs time to absorb the shock with this diagnosis. A gynae OPD appointment should be aranged with consultant to discuss about her management. Her case and management plan should be discussed in the MDT meeting with the medical oncologist if chemotherapy is accepted. She shouls see the Macmillan nurse to discuss further management issues. Her GP should be informed about the condition and future plans. Written information should be provided about different management strategies as wll as risks and benifits. She should be informed that ovarian maligancy usually sensitive ti platinum chemotherapy and possibility of further debulking surgery after that if possible which is still under trial in the CHORRUS trial. She needs to have an informed consent about any further step. Palliative care should be offered and pain management strategiers if she opt for that with support of community nurse and her GP. She should be provided with support groups and hospice if needed.
		Posted by Mohamed D. Tue Jul 20, 2010 09:47 am
Mohamed A) History of the condition with onset, course and duration would indicate the severity of the problem to plan her further management. Any family history of ovarian, breast or bowel cancer especially in first degree relatives, would indicate a heriditary famillial cancer condition like BRCA mutaion of NPCC. Histiry of rapid weight loss which is a sign of malignancy. Any history of vaginal blleding to role out uterine malignancy as well. Cervical slear history to role out cancer cervix. Past history of HRT usage as there is a small increae in risk of endometrial and breast cancer with its usage. Blood should be checked for tumour markers asCA125 which is associated with serous epethelial tumours, CEA which is associated with mucinous tumours and HCG which is associated with adenocarcinoma. Tumour markers like CA19.9 and alfa fetoprotein are usually associated with tumours common at younger age. Tumour markers are not specific as it could be raised with many benign conditions, but it help in follow up as well. MRI for accurate assessment of the ovaries and LNs. B) Woman\'s wishes should be respected, but she needs time to absorb the shock with this diagnosis. A gynae OPD appointment should be aranged with consultant to discuss about her management. Her case and management plan should be discussed in the MDT meeting with the medical oncologist if chemotherapy is accepted. She shouls see the Macmillan nurse to discuss further management issues. Her GP should be informed about the condition and future plans. Written information should be provided about different management strategies as wll as risks and benifits. She should be informed that ovarian maligancy usually sensitive ti platinum chemotherapy and possibility of further debulking surgery after that if possible which is still under trial in the CHORRUS trial. She needs to have an informed consent about any further step. Palliative care should be offered and pain management strategiers if she opt for that with support of community nurse and her GP. She should be provided with support groups and hospice if needed.
		Posted by KWASI RICHARD A. Tue Jul 20, 2010 05:54 pm
KRA A. Any history of anorexia and weight loss, has she noticed any abdominal distension. Exclude bowel and bladder symptoms, specifically enquiring about altered bowel habits, constipation alternating with diarrhoea and symptoms of frequency urgency and incontinence which may be due to the pressure effect of the mass. enquire about personal history of cancer and family history of cancers of the bowel, breast and the endometrium. Any vaginal bleeding or chest symptoms. Enquire about medical cormobidities like hypertension, diabetes, and lung diseases because of anaesthetic implications. Abdominal examination to elicit any tenderness guarding and assess whether the mass is regular or irregular, irregularity may be suggestive of omental cake. Elicit shifting dullness to confirm presence of ascitis. Bimanual pelvic examination to assess whether the mass is mobile or fixed and the adnexal mass and tenderness. Palpate for lymphnodes in the groins and the supraclavicular region. I would arrange blood tests including full blood court (FBS) Urea and electrolytes (U+E) and liver function test (LFT), and tumour markers such as cancer antigen 125 (Ca125), Cancer antigen 19-9 (Ca 19-9) and cancinoembrynic antigen (CEA). The FBC is important as she may be anaemic. U+E to assess renal function and LFT\'s help exclude liver infiltration. Ca-125 is raised in majority of patients, with ovarian cancer, and while it has no prognostic value when measured at the time of diagnosis it is used to monitor response to chemotherapy. If it normalises and the subsequently begins to rise again, this associated with tumour recurrence, Ca 19-9 is raised in mucinous tumours including pancreas. CEA high levels indicate possible colorectal primary. Imaging which is useful include chest xray, computerised tomography scan (CT scan) of abdomen and pelvis. The chest xray may reveal a pleural effusion and a CT scan help to assess metastatic speed and help with planning surgical resection by delineating the tumour. Paracentesis of ascities of pleural tap for cytology. B. Her wishes should be respected. She needs to be approached with empathy and sympathy, she has terminal cancer. Her further management will include a multidisciplinary team of Gynaecological oncologist, her general practitioner, social services and Macmillian nurses. Central issues in her further management that need to be discussed include her quality of life, identify what she and family wants, location of her care, either at home or a hospice and support for her careers. Other issues are pain control and management of other symptoms like nausea and vomiting, constipation, diarrhoea and mouth symptoms. Management of psychological, social and spiritual problems and ethical issued like decision on resuscitation status need to be discussed. She may wish to consider assisted suicide which is illegal the United Kingdom.
		Posted by Arun D. Tue Jul 20, 2010 09:25 pm
answer.. a de a) i will enquire about her pain, any need of analgesia or not.i will also ask her about presence of any bowel problem like constipation or blood with stool. i will also enquire about presence of any hematuria.history of weight loss, loss of appetite should also be asked for.any prevvious surgical history should also be asked, especially caesarean and hysterectomy.any previous history of breast carcinoma should also be asked.i will enquire about any family history of ovarian carcinoma. during examination, i will note the BMI of the patient.presence of ascites,mobility or fixity of mass, consistency of the mass should also be assessed. evidence of distant metastasis should also be noted in trms of presence of pleural effusion or left supra clavicular node.during internal examination, involvement of vulva and vagina should be ruled out.in P/R examination, i will look for any fixity of rectal mucosa or any parametrial involvement.i will request for the serum level of the tumour markers like CA125,CEA,AFP,b HCG.CT scan should be requested to assess the exetnt of the lesion and to diagnose lymph nodes are involved or not.MRI scan may also be requested to assess the invasion of the lesion.proper anesthetic referral should be made before planning for staging laparotomy.her case should be referred to be discussed in gynae oncology MDT meeting. B) If the lady feclines any further treatment, we have to assess her capacity to judge her understandability of the situation.i will explain her that prognosis will be far more poor if she is not willing for any more treatment.i will discuss the options of palliative treatment with her. i would like to respect her wish but at the same time, i would like to involve other family members in the decision making process.i will involve the oncology specialist nurse in her care and provide the patient with all necessary phone numbers and contact details.i will give her the details of the mcmillan group.written information should be provided.i will also reassure her that if she changes her mind in due course of time, she can contact the relevant person as soon as possible.
		Posted by Penelope T. Tue Jul 20, 2010 10:28 pm
a) Clinical assessment of this lady needs to establish firstly her diagnosis, and secondly her general health. Given the ultrasound findings in this age group the most likely diagnosis (even prior to further assessment) is ovarian cancer, so assessment should be geared towards clarifying this and presence of metastasis, and ascertaining fitness for anaesthetic. Of importance in her history is other symptoms (weight loss, anorexia, breast lumps, breathlessness), pre-existing medical conditions (including degree of severity and treatment), prior surgery (particularly abdominal), previous anaesthetic problems, family history of breast, ovarian, bowel cancers, venous thromboembolism, or other relevant conditions. Her current social circumstances and support persons should also be clarified, and she should be encouraged to bring a supportive family member with her to future visits. Examination should include habitus, general appearance, cardiovascular and respiratory systems (for anaesthetic purposes), and examination of breasts/axillae, abdomen (including for mass, hepatomegaly, ascites), and pelvis. Pelvis examination is important particularly to determine size and fixedness of the mass. The presence of lymphadenopathy (supraclavicular, inguinal ) should be sought. A risk of malignancy index should be calculated based on her on postmenopausal status, serum ca125 level and transvaginal suspicious ultrasound features (bilaterality, presence of internal septae, solid areas, ascites, metastasis). This will categorise her level of risk of malignancy. This lady is likely to fit a high risk category with a risk of cancer of >70%. Additional investigation should include FBC, ELFT, Ca 19-9, CEA. She will also require a chest xray and CT of abdomen and pelvis for staging purposes. Due to her age a pre-op ECG should also be performed. b) This woman\'s wishes and autonomy should be respected and she should be supported in whatever decision she makes for her future care. However, it is important to clarify her understanding of her disease and the likely progression and prognosis of this. This is best done through a multidisciplinary setting, including a gynaeoncologist, oncology nurse specialist, palliative care physician, psychologist, social worker. It may also be necessary to confirm her capacity to make decisions. She should be encouraged to discuss her wishes, clarify any advance health decisions, and involve her close family. It should be explained to her that whilst her disease is inoperable there are still options involving degrees of treatment, including chemotherapy. Palliative measures may also include analgesics, antiemetics, assisted feeding (eg. nasogastric), comfort measures such as therapeutic drainage of ascites, and treatment of complications (eg.DVT). She should understand the potential side effects and benefits of these, but also the implications of declining treatments.
		Posted by Kiran J. Tue Jul 20, 2010 10:57 pm
A healthy 76 year old woman with a 6 months history of abdominal discomfort and bloating has been referred to the gynaecological oncology clinic because ultrasound scan showed a 12cm complex ovarian mass. (a) Discuss your clinical assessment and investigations [10 marks]. (b) She is found to have an inoperable ovarian adenocarcinoma at laparotomy. Post-operatively, the woman states that she does not wish to have further treatment. Discuss your management [10 marks a : I will take history of increasing abdominal girth,abdominal or pelvic pain,anorexia,wight loss,nausea and vomiting.I will ask her regarding vaginal bleeding,any recent changes in her bowel habit(constipation) urinary symptoms such as freqency, incomplete evacuation or retention.and other non specific symtopms such as fatigue.Medical history of co-morbities and cancer such as breast, ovarian or colorectal cancers.I will ask regarding nulliparity or multiparity,and family history of breast, ovarian endometrial and colorectal cancers. I will do clinical examination which will constitute a general physical examination assessing for her pallor,lymphadenopathy, chest auscultation, abdominal examination to assess for ascites by percussion and fluid thrill/shifting dullness.If not than examin abdomen for hepatomegaly,splenomegaly anf pelvic organomegaly.I will clinically assess if the ovarian mass is palpable,for its tenderness, solid or cystic consistancy and mobility.A pelvic examination to assess size of the mass and mobility. Investigations include FBC U&e and LFTS to assess if patient aneamic,her organ functions to assess her health and if there is suspicion of metasteses or if capable to tolerate chemotherapy.CXR to assess for metasteses,CA125 as it can be raised in 80% of avanced epithelial ovarian cancers of ovary and be helpful in risk assessment scoring(RMI).CT scan to assess peritoneal,omental or retroperitoneal disease.If acites is clinically/ultasonicaly evident then an ascitic tap. b> Her case should be Discussed in Multidisiplinary team including Gynae oncologist,Oncologist,Histopathologist and palliative care consultant.Her wishes should be respected and options explored.She should be informed regarding chemptherapy and that there is a survival advantage in all stages of ovarian cancer. and neo adjuvant chemotherapy with interval debulking as these options are available should she choose.Her social set up is explored whether she wishes to stay at home, in a hospice or in the hospital.Main aim is to controle cancer pain,controle of GIT symptoms and her phycological needs.A palliative care consultant and team would be in close liason.In case of pain it is controlled with step ladder fashion model presented by WHO.Oral medications are preffered and given as a regular basis.Dose is given accoding to individual needs and mild to moderate pain managed with Non opiods like NSAIDS.If pain increase then weak opiods like coedine used and for severe pain strong opiods like fentanyl patches, oromorph,oxycodone and PCA used.Her bowel symptoms can be controlled with Buscopan and maxalon/cyclizine. In cases of signs of obstruction ttreat with oral medications(Buscopan and morphine with laculose) for 2 days and if not resolved then defunctioning colostomy performed. If she has ascites and is in severe discomfort due to that then palliative parcentesis done for that.Mcmillan support can also be used and individualize her care according to her needs,her wishes and her beliefs.
		Posted by Dr Dyslexia V. Thu Jul 22, 2010 12:51 am
X a) History of other symptoms apart from abdominal distention and bloating, such as any presence of respiratory difficulty or presence of orthopnea could suggest large mass or excessive ascites. Presence of any constitutional symptoms such as acute weight loss or loss of appetite could be suggestive of malignant disease. Bowel symptoms such as constipation or altered bowel habit could indicate any bowel extension or due to excessive ascites. Presence of pain on the abdomen could indicate ovarian accidents such as torsion, hemorrhage or rupture. History of personal breast cancer which could have been treated, family history of breast or ovarian cancer, usage of talcum powder in the perineal region, nulliparity, the use of HRT increase the risk of ovarian cancer in this patient. Examination of general nutritional status, if cachexic could suggest malignant disease. Presence of any supraclavicular lymph notes could suggest metastasis. General breast examination to detect any mass should also be done to detect undiagnosed breast lump. Abdominal examination should be done to detect presence of clinical ascites, or mass. The mass if fixed tender and solid in nature could suggest malignancy. Pelvic examination done to detect the origin, the mobility and tenderness is important to determine origin of mass and complexity of surgery. Investigation would generally include a full blood count to check hemoglobin status prior to a major surgery. Renal profile and liver function test to see if any renal or liver involvement in advance diseases. Tumour marker such as CA 125 for epithelial cancer , alpha feto protein raised in some germ cell tumours and beta HCG in primary ovarian choriocarcinoma. The tumour markers could be used to monitor the disease post surgery or treatment. Imaging should be done by trans vaginal scan to assess the origin, the ultrasounds features which could be complimented with trans abdominal scan in large masses. A computer tomography scan of the pelvis abdomen to plan the surgery, the plane of entry and also presence of any lymph notes prior to surgery. b) The patient’s wishes should be respected but she should be fully informed of all the modalities which are available and it’s availability if she were to change her mind later. She should be offered counseling to cope with her tragic diagnosis and thought to cope and manage it. She should be informed on the debulking surgery by gynae oncologist with complimented with adjuvant chemotherapy. She should be informed that chemotherapy could prolong her survival period. She should be offered symptomatic surgery such as colostomy, if bowel obstruction occurs, or urinary standing if ureteric involvement occurs. She should be managed by a multi disciplinary team of gynaecologist, oncologist, macmillan nurses or hospice nurses. She should be given pain relief medication in step wise fashion such as NSAID’s, weak opiods and narcotics. Issues in regards to autonomy such as resuscitation should be discussed and respected. Her family members should be involved in order for support and coping with the disease. She could be referred to support group such as Macmillan cancer support group as well.
		Posted by Bgk H. Thu Jul 22, 2010 09:51 am
bgk a. The aim of my clinical assessment and investigation is to stratify this lady into high and low risk of malignancy index. I will ask about the onset of her symptoms and its severity. Acutely onset and rapid progression suggest malignancy. Associated symptoms such as constant abdominal pain, nausea and vomiting may alarm cyst torsion, infected ruptured. I will ask about her urinary or bowel symptoms to rule out non gynecological origin such as bowel malignancy. Association with loss of weight and loss of appetite may suggest malignancy. I will ask her regarding any abnormal per vaginal bleeding as this may cause by estrogen secreting tumor. Family history of gynaecological malignancy is important. I will also ask about her past surgical history that may influence the type of surgery to be performed. I will examine this lady regarding her general condition and her performance status. Chacexia and emaciated lady may suggest malignancy. I will calculate her BMI. I will measure her blood pressure and pulse rate. I will then examine her abdomen to rule out any abdomino pelvic mass and ascites. Present of ascites may suggest malignancy. I will do respiratory examination to rule out any pleural effusion. I will then undertake vaginal examination to determine the origin and involvement of other genital tract. Per rectal examination needed to rule out any rectal involvement I will perform routine full blood count, urea and electrolytes to rule out anemia . I will perform tumour marker and calculate her malignancy index. b. I will respect her decision, however I will inform the consequences. I will explore her wish either she is not able to withstand the therapeutic effect of the chemotherapy or the fear of side effect of the chemo. I will address accordingly and will bring this up to multidisciplinary team meeting to get a joint decision of her further management. The role of palliative therapy is very important as patient now refuse further treatment. Palliative care nurse and cancer nurse specialist need to review her and treat her symptomatically with adequate analgesia, antiemetics and iron therapy. I will inform her that not getting any further treatment may worsen her condition. She may have recurrent symptoms such as ascitis, pleural effusion hat may need to drain from time to time. All the discussion and decision need to be made with the patent and her choice should be respected. Her family member need to be explain regarding the management.
		Posted by Bobey B. Thu Jul 22, 2010 02:42 pm
Detailed history of symptoms including abdominal pain, vomiting , constipation , bleeding per rectum , dyspnea , weight loss and anorexia should be obtained. Severity of symptoms and effect on quality of life should be identified. Menstrual history should be taken regarding age of menarche , menopause to identify risk factors of ovarian tumors . Regularity of cycles, associated dysmenorrhoea should be elicited. Parity , past history of ovulation induction treatment and its duration of use as increasing risk of ovarian cancer. Contraception history should be taken. COCP reducing risk of ovarian cancer.HRT use should be asked. HRT is increasing the risk of ovarian cancer. Family history of ovarian and breast cancers must be taken. General examination including BMI .Abdominal and pelvic examination should be performed for abdominal mass , tenderness and mobility. Examination should be done for presence of ascites , enlarged lymph nodes and hepatomegaly. Ultrasound scan finding of ascites , evidence of metastasis in other organs should be confirmed by another ultrasound scan. Tumour markers such as CA-125 and CEA should be done. Blood sample to be taken for FBC , LFT , urea and serum electrolytes. Chest X-ray should be done for metastasis. RMI should be calculated for the risk of ovarian cancer, as ultrasound score – one point for each of multilocular cyst, evidence of solid areas , ascites , bilateral lesions and metastasis. Postmenopause = 3 and CA-125 level in u/ml. It is effective for categorizing her risk of malignancy. RMI = U X M X CA-125. There is no current role for the use of colour-flow Doppler , C T or MRI scanning or PET in the assessment of ovarian mass. b) The management should be discussed with the patient and family. Early involvement of the primary care team , social service , Macmillan nurses is essential prior to leaving the hospital . There should be watertight arrangements for family to gain rapid assistance in case of deterioration. If the woman and her family are ready to make decisions regarding the location of terminal care , then preliminary arrangements can be made such as care at home or referral for hospice place. Care should largely be determined by symptom relief. Adequate pain relief is important and should be initiated and increased in accordance with WHO analgesia ladder , until the patient is pain-free. The patient should receive education about range of pain control interventions available to her. She should be the prime assessor of her pain. She should have treatment outcomes monitored regularly using visual analogue pain scales ( VAPS ), verbal rating scales (VRS) or numerical rating scales (NRS). Treatment of pain should be individualized . Oral administration is preferred as has rapid onset, with fewer side effect and usually effective . Medication should be administered round –the clock- rather than on an as-needed basis. Simple ,non-opioid analgesic such as acetylsalicylic acid, paracetamol , NSAIDs and acetaminophen should be prescribed in mild to moderate pain , unless contraindicated. If pain is persisting or increasing , weak opioid analgesic such as codeine , dihydrocodeine plus non-opioid drug along with adjuvant analgesic should be prescribed. If the pain still persisting or increasing , strong opioid analgesic such as morphine , diamorphine , oxycodone and fentanyl patches plus non-opioid drug along with adjuvant analgesic should be used. Neuropathic pain due to damage to the nervous system is relieved by adjuvant analgesics such as antidepressants ( TCA ) and anticonvulsants. In cases of troublesome vomiting , the rectal , transdermal , subcutaneous or parenteral route can be used. If there are difficulties experienced in obtaining satisfactory pain control , the advice of the pain control clinic should be sought . Antiemetic can be used as prochlorperazine and (5HT antagonist ) ondansteron . In intractable vomiting , an intravenous infusion will need to be started and electrolytes correction performed. Constipation is a common problem particularly with opiate administration and pre-empted by regular laxative administration. Hyoscine and octreoide are used to relieve intestinal colic and reduce secretions. Abdominal discomfort and dyspnea is common secondary to ascites and palliative paracentesis is often indicated. Help from well-trained social worker and religious lead is may be invaluable. Psychological support and counseling should be offered regarding the decision on resuscitation status. The woman \'s wishes and her family should be considered with every point of care.