MRCOG PART 2 SBAs and EMQs
| Course PAID | ||
| notes | 336 | |
| EMQ | 1502 | |
| SBA | 2115 | |
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ESSAY 211 - Ovarian cyst
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Posted by Srivas P. |
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| The feature which are likely to be associated with malignancy include clinical features like sudden and rapid growth of tumor, pressure symptoms, sudden and rapid change in menstrual pattern with amenorrhea, appearance of masculising and virilising symptoms, significant loss of weight and cachexia. Clinical examination which could be suspicious for malignancy are firm, irregular feel of the mass, bilateral involvement, presence of ascitis, large veins seen on abdomen, enlarged liver, pleural effusions, leg varicosities and lymph adenopathy. RMI is effective in differentiating between benign and malignant lesions. The Ca 125 levels along with USG features are used to calculate RMI. USG features which suggest malignancy are bilaterality, presence of ascitis, multilocular cysts, papillary excrescences and solid areas. Sensitivity of RMI is 85% and the specificity is 97%. Other markers like Ca 15-3, 19-9 is also being used to screen for cancer. Increased CEA (Carcino embryonic Antigen) may point to mucinous adenocarcinoma. High serum AFP is seen in endodermal sinus tumors while HCG is raised in non gestational chorio carcinoma and LDH may be raised in metastatic disease. Management depends on her fertility needs, histological type of malignancy, staging, grading of the tumor and the woman?s views. On this nulliparous woman aim would be to preserve her fertility if it is possible, without compromising on her long term survival. If she has germ cell tumors which are usually unilateral, fertility sparing surgery can be done even if she has metatstatic disease and can be combined with adjuvant chemotherapy depending on staging. The cure rates are almost 95 % in early cancers, and are more than 75% even in advanced disease and most recover their fertility following conservative surgery. Dysgerminomas are radiosensitive but is not advocated for this woman with need to preserve fertility. Unfortunately conservative and fertility preserving surgery is not recommended even for stage 1a granulose cell tumors because of high risk of recurrence and also because the chances of cure is very high, up to 95% with radical and complete removal of the uterus and both ovaries and maybe as low as 60% or even none with conservative surgery. This calls for a detailed discussion with the woman. Fertility sparing surgery can be offered in borderline ovarian tumours and unilateral adenexectomy can be done though cystectomy alone is not appropriate. Similarly in stage1a and 1b early stage epithelial cancers unilateral salpingo-oopherectomy can be done after exploration to rule out metastatic disease and do not require adjuvant therapy. For the later stages maximum cytoreductive surgery with post operative chemo-irradiation is done. In these late stage malignancies her only chances of fertility is with ovum donation and embryo-freezing preoperatively and would need surrogacy and this is not advocated in view of only 26% 5 year survival in late stage cancers. All these issues should be discussed with her and her partner and a concerted opinion should be taken, after taking into account her own survival chances which is foremost, followed by chances of preserving the fertility. |
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Posted by neera B. |
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| Older women specially post menopausal are more likely to have malignancy. History of sudden increase of size of mass, family or previous history of ovarian, breast or colon cancer and carriers of BRCA 1 & 2 have higher likelihood of malignancy. On examination fixity of tumour , ascites, nodules in POD are suggestive of malignancy. Risk of malignancy index, comprises patients age , serum Ca 125 levels, and ultrasound findings. 50 % of StageI epithelial cancers have high serum CA 125 levels. On ultrasound bilateral tumours , solid areas or septae within the cyst , ascites, tumour on external surface of cyst, raise suspicion of malignancy. Peroperatively, bloody ascites , bilaterlity, papillary excescences on external surface, capsular invasion, solid tumours, paraortic lymphnode enlargement, or nodules on liver, are suspicious of malignancy. RMI of > 250 is associaed a very high likelihood of malignancy. Principles of management in young women is to conserve fertility and sexual function without compromising on survival. But patient must be compliant for follow up , so that recurrences can be picked up early and treated adequately. Conservative management with unilateral oopherectomy is an option for stage I a well differentiated epithelial or germ cell tumour. Alternatively chemotherapy may be given for germ cell tumours. Biopsy of normal looking ovary is not recommended at the time of conservative surgery because it is assosiated with adhesion formation which can compromise fertility, thereby defeating the very purpose of conservative surgery.The place of frozen section is uncertain. Radiotherapy is avoided in young women due to risk of premature ovarian failure, vaginal stenosis causing dyspraeunia , radiation induced leukemia, long side effects like fistulae. No increase in recurrence has been seen with conservative management . If histopathology reveals more advaned malignancy , chemotherapy or a second surgery of total abdominal hysterectomy with oopherectomy, infracolic omentectomy and peritoneal fluid cytology would be needed ; for which the patient should have been counselled preperatively. Tretment in cancer unit or centre with MDT involving gynae oncologist gives better results. Patient must be involved in decision making and informed written consent taken. The discussion should be documented. Follow up is essential. Involvement of GP in detecting recrrrence and counselling the lady to report if pain, abdomen mass, bloating sensation or discomfort is important. |
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Posted by Vinayak B. |
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| Features associated with increased likelihood of malignancy are ultrasound features of tumour such as mixed / solid echogenicity, . multiple thick septae. With presence of ascites. Size of the tumour more than 5cm and bilateral nature of tumour. Papillary excrescences. It is supported with history of weight loss, decresed apetite. Family history of heriditory cancers, or first degree relative with cancer ovary at young age. Tumour marker assay is unreliable at young age esp Ca125 as it increases inpelvic inflammatory condition and endometriosis , only 50% cases of stage 1 ca 125 shows increased titres . carcino embryonic antigen levels are raised in mucinous adenocarcinoma. Principles underline in the management of apparently malignant tumour are risk analysis by Risk malignancy index by which chance of malignancy can be scored by considering pre/ post menopausal status ,usg findings and ca 125 levels if less than 25 risk is 3% 25_ 250 risk is 20% and if greater than 250 risk is high upto 75% . Surgery should be done by gynecologist/ at cancer centre or cancer centre as per the risk . Preoperative assessment with CT/ MRI scan to reconfirm the diagnosis and assess lymph node involvement and spread will decide place of operation whether cancer centre or unit. Route of surgery depend on size of tumour. And avialbility of expertise.for laparoscopic surgery. With consent of laparotomy. IF required . Aspiration tumour should not be advocated in suspected malignancy.spillage of tumour cells should be avoided as leads to spread of malignancy and psuedomyxoma peritonii. Prior to surgery informed consent , explaination and possible surgery and its outcome discussed and patient wishes considered . Conservative / fertility sparing surgery considered at young age if patient not completed family. Other ovary should be assessed but biopsy of other ovary is not advocated as may affect function of the other ovary .Surgical staging done by taking ascetic fluid samples , suspicious nodes, omentum and undersurface diaphragm and liver.which will help in staging and further follow up and reference to cancer centres if required. If stromal cell tumours such as granulose cell tumour detected radical surgery needed with prolonged follow up. Follow up and need of repeat laparotomy / chemotherapy in advanced sugicopathological staging should be discussed . Especially if radical surgery or chemotherapy is required . Preservation of ovarian tissue f or IVF and surrogacy discussed. and documented . |
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Posted by Ismatara B. |
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| Features that increase the likelihood of malignancy include a history of rapid weight loss, anorexia, cachexia, sudden rise and rapid growth of a mass making pressure symptom to surrounding structures, change in menstrual pattern- amenorrhoea/abnormal bleeding, rapid onset of virilization, masculinization. Personal or family history in first degree relative of ovarian, breast or colon cancer or carriers of BRCA I or II are at increased risk of ovarian cancer. On clinical examination fixed, firm, irregular, solid or partly solid partly cystic mass with bilateral mass, ascities, nodules in POD, large vein on abdomen, palpable enlarged liver, pleural effusion, presence of metastasis deposit in other organ, lymphadenopathy also increased likelihood of malignancy. On investigation risk malignancy index (RMI) is important to detect malignancy by patient age (more risk for menopausal women), serum Ca-125 level and USG features including multilocularity with septation, papillary formation, evidence of solid areas with metastases, presence of ascities and bilateral lesions. Risk of cancer is <3% if RMI is <25, 20% if 25-250 and 75% if >250. RMI has 70% sensitivity and 90% specificity. Other tumour marker also may increase in ovarian malignancy. Serum AFP increased in endodermal sinus tumour, serum B hHCG increased in non gestational choriocarcinoma, CEA may increase in mucinous cystadenocarcinoma. Principles that underlie for the management of malignant ovarian cyst include involvement of a multidisciplinary team, staging of the disease, various method of treatment according to staging and other profiles, preservation of fertility if possible and wishes fertility, follow up and palliative care where necessary. The patient should be referred as soon as possible to a specialist cancer centre under a MDT with involvement of surgical, gynae and medical oncologist, pathologist, radiologist, clinical nurse specialist, radiation therapists. Investigation includes U & Es, LFTs and CXR (to exclude pleural effusions). CT is not essential but may help to assess retroperitoneal disease, lymphnode status in advanced disease before surgery. Staging imaging (MRI) is limited by its resolution but necessary to detect or exclude intrahepatic disease and or distant metastasis which cannot be detected at laporotomy. A pleural effusion should be tapped before surgery for staging. The best prognosis can be achieved by staging laporotomy by a trained gynaecological oncologist through an extended midline incision. This will confirm diagnosis by cytology of ascitic fluid or peritoneal washing and biopsies from adhesions and suspicious areas. Laporotomy with clear documentation will influence in subsequent treatment (chemotherapy, further surgery after conservative surgery. And finally definitive surgery includes TAH with BLSO and infracolic omentectomy. It may include bilateral selective pelvic and para-aortic lymphadenectomy. Surgery also determine prognosis and provides data for research. The advantage of surgery is maintaining fertility in early stage and preservation of sexual function. If fertility is desired in stage Ia with well differentiated tumour (confirmed by histology or cytology) and then conservative surgery by unilateral salpingoophorectomy-intraoperative frozen section may help in this decision. But the patient should compliant for close follow up is needed as there is risk of tumour in conserved ovary or new tumour and definitive surgery after family complete. Conservative surgery may require immediate second laporotomy if histology shows more advanced or high grade tumour. Value of laporoscopic surgery is not yet proven. If there is advanced stage of the disease primary cytoreductive surgery (debulking) is appropriate. Because this will improve quality of life, by treating complication caused by tumor (pressure, ascities, obstruction), improve response to chemotherapy, prolong remission, increase median survival (unproven) and provide psychological benefit. But this is associated with surgical morbidity and may delay to start chemotherapy and little benefit where tumour is inoperable. Adjuvant chemotherapy (postoprative) is given within 8 wks of surgery. RCT shows that this will improve survival and reduced relapse with carboplatin. For more advanced disease primary chemotherapy-carboplatin is first line therapy with or without taxane. Carboplatin is preferable to cisplatin as it has less toxicity and easier to give the patient. The combination of carboplatin and paclitaxel improves survival but more toxicity (neurotoxicity, alopecia, and allergy) than carboplatinum alone. Cyclophosphomide is not used at present as first line therapy. Neoadjuvant chemotherapy (Chemotherapy before surgery) is also improve quality of life, prolong remission, and increase median survival. Benefit of second look procedure and secondary cytoreductive surgery are unproven. Follow up after ovarian cancer is life long with clinical assessment, pelvic imaging and ca-125. In terminal malignancy, palliative care is essential with pain control by analgesic and frees from other trouble some symptoms (nausea, vomiting, constipation etc). |
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Posted by Aroosha B. |
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| The features associated with increased likelihood of malignancy in history includes the symptoms like, pain lower abdomen, GIT symptoms, loss of appetite, weight loss, increased tiredness are all associated with increased likeliness of malignancy. A family history of ovarian cancer increase the risk but the incidence of familial cancer is 1 % and even in this group the cancer occurs less likely before the age of 45 or 50. Age of the patient is also important as incidence of ovarian cancer increases with the age. Nulliparity is also a risk factor. Features suggestive of malignancy on examination are general condition of the patient as an advanced stage will result in ascilis, legodema, enlarged lymph node on per abdomen examination a fixed, firm tumor. Ascitis palpable lymph nodes increase the risk of malignancy. On bimanual examination the consistency, size, whether the mass is separate from uterus, immobility all increases the risk. On USG features suggestive of malignancy are bilaterality, presence of solid areas, papillary projection inside tumors, ascites are all associated with increased likelihood of malegancy. Although an MRI is no more a better predictor of malignancy but it helps in assesing the spread. The principles underlining the management of an apparently malignant tumor are the conservation of fertility. But the conservation of fertility is only possible it the tumor is at early stage like 1a1. At this stage the tumor is limited to one ovary with capsule intact, no tumor on the surface. In these patients with careful counselling fertility preserving surgery can be performed with sample also taken from the other ovary and fresh frozen samples seen for the evidence of no malignancy on the other side. However if on laparatomy the tumor appear to be advanced more than 1a1, present on both ovaries ascites infertility sparing surgery is not recommended. In this case the principles of surgery are same as in any other patient and it is carried out in the form of debulking surgery with the aim to leave the areas of less than 1.5 cm behind. Surgery in this young patient is followed by chemotherapy in form of Cisplatin and Pacletaxeal. If on laparotomy the tumor appears to be granules cell tumor even than conservative surgery is not recommended because it is associated with high rate of recurrence and 5 years, 10 years and 20 years mortality is high in those with conservative surgery. In case the tumors are Germ cells tumors then if it is involving only one ovary then conservative surgery is an option in young patient as the incidence of centralatral ovary is involved very less and there is good prognosis of these tumors in higher cancer center where chemotherapy is offered. |
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Posted by Vinayak B. |
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| A 37 year old nulliparous woman is found to have a 10cm ovarian cyst. (a) Which features are associated with an increased likelihood of malignancy? (8 marks). (b) Which principles underlie the management of apparently malignant ovarian cysts in young women? (12 marks Principles of management apparantly malignant ovarian cyst in young age. except role of conservative surgery all principles are same as managing malignant tumour. WHY apparantly malignat tumour is included in question another doubt is as u said suspected cancers to be managed in cancer units . THen why RCOG guideline on postmenopausal tumour based there management on RMI index scoring . or there is difeerence in postmenopausal / premenopausal age groups should we comment on harmone replacement therapy at young age if requires radical surgery. thanks |
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