1. What to do about gynae cancers
Women's Health Event
June 12th 2013
What to do about gynae cancers
Mostly I will talk about what we do in our cancer network, with a few more personal thoughts and anecdotes thrown in
Peter Townsend
jobbing gynaecologist

2. Here’s a pretty big lump
41 yr old nulliparous Nigerian lady, who would like to have a baby.
Sort of makes your heart sink
What shall we do with this one?

3. But not all big lumps are Cancer
Even when they look pretty nasty
Big worm like vessels inn adherent omentum.
Just pretty big fibroids, still more still inside

4. But, of course, some are Even when the look pretty innocent
Another 41 year old nulliparous lady who would have liked to have had babies but having had time to think about options decided on radical surgery. This was a stage 1a serous papillary ovarian adenocarcinoma
Even when the look pretty innocent

5. And they always are when they look like this

6. It’s best of all if they can be avoided So all women should
Stay slender and not get diabetes
Stay celibate
But most don’t so have an HPV vaccine and take the COC pill between having 3 babies
Or if a bit too old for that at least have regular smears
Maybe do away with the “at risk bits”
And it’s always good to not smoke (or is it?)
Maybe drink coffee
Be affluent and
Consider dying young of something quick and easy
Like most unpleasant things, they are best avoided or prevented
BRCA 1&2 mutations - ovary
Lynch syndrome, hereditary non polyposis colorectal cancer – ovary and endometrium

7. Second best, find it early
5 Year Survival Rates, Stage 1
Stage 1a Cervix Cancer % at least
Stage 1b Cervix Cancer %
Stage 1 Endometrial Cancer %
Stage 1 Ovarian Cancer %
Stage 1 Vulval Cancer %
If we don’t prevent them then 2nd best would be to catch it at an early stage
If only that were possibly
All pretty good and similar if confined to were they started

8. So pretty good if we can find it when it looks like this
The lumpy bits on the outside are just fibroids, not as big as the previous ones
A few years ago staging changed
Stage 1 Endometrial Cancer

9. But if we don’t the outlook is not so good
5 Year Survival Rates, Stage 4
Stage 4 Cervix Cancer %
Stage 4 Endometrial Cancer %
Stage 4 Ovarian Cancer %
Stage 4 Vulval & Vaginal Cancer %

10. For example
This ovary
Whereas most endometrial cancers are early stage most ovarian cancers are late stage

11. With its omentum

12. and peritoneum affected

13. But life’s not quiet as simple as that
If only we could find them all at an early stage and for them all to be low grade
But life’s not quiet as simple as that
Although the numbers relate to a single anatomical site, each has several different diseases with in it and varying degrees of differentiation which greatly affect outcome

14. So how about screening? (Just to get it out of the way with one slide)
Cervix Works well, prevents some and detects some at very early stage
Ovarian Would be very nice but it doesn’t work. Limited place
Endometrial Not practical but incidental pick up and some high risk exceptions
Vulva and vagina Only for high risk few
In a nutshell...
BRCA 1&2
HNPCC
Incidental pick up of endometrial on smear e.g. Mrs M’s serous papillary endometrial Ca anecdote and the Ca breast lady that had a PET CT for no good reason and found a uterine hot spot

15. What do we actually do about them & are we getting any better at it?
So, when they do come to our attention
What do we actually do about them & are we getting any better at it?

16. Endometrial Cancers Most seen in Fast Track Clinic
TVS, endometrial thickness
Pipelle
Or Hysteroscopy
MRI, CXR, CA125
CT CAP if high grade
Hysterectomy and BSO usually Lap/vaginal
Occasionally radical surgery
Sometimes Brachy/radiotherapy
Occasionally chemotherapy
I had had enough of nasty pictures by this point so does anyone recognise this?
Hoare frost
Most of our patients come though the TWR clinic with PMB but about 10-15% are premenopausal, so must be suspicious. Many much too short for their weight.....

17. Are we getting any better at treating it?
Just from when I qualified and started to learn my craft
Age standardised survival rates take into account the age distribution in the population at risk, which changes with time
Our network is better than this. I think it is the only NHS league table that ESH tops.

18. It looks even better if you use financial media tricks
And change the vertical axis start point

19. Ovarian Cancer Most do not come via our Fast Track Clinic
The one that they all worry about
Try to get them before anyone else does
Or failing that “reclaim “ them
Try to decide whether its cancer
Ultrasound scan
Blood tests
CT chest abdomen & pelvis
MRI occasionally
MDT discussion
Mostly Radical surgery and chemotherapy but individual plans for each patient
Occasionally palliative care from the start
Sometimes too late to do anything much at all
Hieronymus Bosch detail from The Last Judgement, one of his depictions of hell. Alte Pinakothek Munich
Just to remind you that only 50% of ovarian cancer patients start of with a gynaecologist
Lots come fro gastroenterology or colorectal other for chest or COE physicians

20. Things have improved here a bit too Is it the surgery, the chemotherapy or something else that has helped with the results?
Probably several factors including greater specialisation both in surgery and oncology
Whether supra-radical surgery will help who knows, may do more harm in some cases. Maybe there will be a RCT oneday.
Maybe better understanding of the tumour biology and drug development is more likely to improve success

21. Cervix cancer Some via colposcopy, some FTC others A&E
Investigations and treatment varies greatly depending mostly on stage, MDT approach
May already have been treated adequately by LLETZ in colposcopy clinic
EUA, biopsy, cystoscopy, sigmoidoscopy
MRI pelvis
CT/PET Chest Abdomen & Pelvis
Radical surgery, sometimes staged,
often laparoscopic
Or Chemo-Radiation
Occasionally both, neither or less
The very early Stage 1a cases where can't be seen come through the colposcopy clinic
The clinically obvious tend to come with abnormal bleeding and no recent smear
A lady with PCB is very unlikely to have Ca Cx if here Cx looks normal. PCB is very common Ca Cx is pretty rare

22. We are getting better at this one too and it’s becoming rarer
We are diagnosis lots of very early cancers on LLETZ biopsies that in the days of laser vaporisation may have gone undetected. Most of the more advanced ones have not had a recent smear.

23. Vulva and Vagina Most seen in FTC, a few in A&E
Some are easy to spot
Biopsy and histology
CT CAP
Vulva mostly surgery, individually planned, with or without lymphadenectomy
Vagina mostly Chemotherapy plus Radiotherapy
Others are a bit less obvious
Sentinel node biopsy will help

24. We don’t see many but we are getting steadily better and should soon do better on morbidity

25. But it’s not all about statistics and big egos (although there are plenty of both)
It’s more about....
Treating patients as individual people, not diagnoses
Listening to what they say, ask and want
Being honest and realistic
Gaining trust
Working as a team, getting help from wherever we can
Realising that we are each only bit part players in their cancer journeys
Keeping cheery

26. Now, I was told that there would be 15 minutes for Questions and Answers

27. So, here is a little quiz
Questions and Answers where I ask you the Questions and you tell me the Answers

28. An interesting and unusual case
For you to help me to sort out please
Or to tell me what to do
Politely

29. Here is the story Miss ST Aged 15 years
Discomfort in her lower abdomen two weeks ago and noticed a lump
Some loss of bladder sensation

30. What else shall we ask her?

31. What else shall we ask her?
Q Any other symptoms?
Q LMP?
Q Other aspects of puberty?
Q Had sex yet?
A No, but lump seems too have grown quickly A Not yet had one, but my younger sister has A Some breast development and sparse pubic hair growth A No

32. What does she look like?

33. What does she look like? Q Is she abnormally short, tall, fat or thin?
A No
Q Does she look normal?
A Yes

34. What do we find on examination?

35. What do we find on examination?
No Ascites
No lymphadenopathy
No hepatomegaly
Just a large, smooth, firm, mobile mass

36. What Tests shall we do?

37. What tests shall we do?
A Abdominal ultrasound scan Report: Centrally within the pelvis there is a 12cm complex mass, with increased vascularity Not typical of a “dermoid” Normal uterus No free fluid

38. And the Blood tests, tumour markers & hormonesLH
FSH
TSH
Prolactin
Estradiol
Testosterone 0.5 CA
CEA <1 CA
βhCG
AFP
LDH

39. So what’s the diagnosis?

40. So what’s the diagnosis?
Well yes of course we don’t know for sure…
But we can have an educated guess
An ovarian mass…
Well yes of course, but what sort?
A germ-cell tumour…..
A dysgerminoma….(or is it disgerminoma?)
Well yes of course, but why? And what else?
Not telling yet, all will be revealed later
Life’s not always as simple as that

41. Germ-Cell Tumours Classification
Malignant germ cell tumours
Mostly young, peak early 20s
Dysgerminoma ( ≡ Seminoma)
Yolk sac (endodermal sinus) tumour
Embryonal carcinoma
Polyembrioma
Non-gestational choriocarcinoma
Immature teratomas
Mixed primitive germ cell tumours
Benign Mature cystic teratomas aka dermoid cysts …………..………… Malignant tumours arising from components of a Dermoid Just about anything but SCC commonest & most >40y

42. Malignant germ-cell tumours Clues from tumour markers
Histology AFP hCG LDH Clue Dysgerminoma - +/- + D Yolk sac tumour + - Think Pregnancy Embryonal carcinoma +/- + Polyembryoma +/- + Choriocarcinoma - + Think Placenta Immature teratoma +/- - Mixed germ-cell +/- +/-

43. So we’ve made the diagnosis. What shall we do next?

44. What shall we do next? CT scan of chest, abdomen and pelvis:
Result: Largely solid ovarian mass
No ascites or pleural effusion
No lymphadenopathy
No lung or liver metastases

45. What shall we do next? CT scan of chest, abdomen and pelvis:
Result: Largely solid ovarian mass
No ascites or pleural effusion
No lymphadenopathy
No lung or liver metastases

46. Then What?

47. Then What? A long chat with patient and parents
Explain most likely diagnosis and treatment
Plan fertility sparing surgery, ASAP

48. What did I find at laparotomy?

49. Her right ovary, fallopian tube and uterus
What did I Find?
Her right ovary, fallopian tube and uterus

50. So we took out the right ovary & tube, and it looked like this

51. But this is what the left side looked like?

52. So what do we do now?

53. So what do we do now?
Have a cup of tea while waiting for the frozen section.
Answer dysgerminoma so…
Omentectomy pelvic and para-aortic node sampling
Send blood for karyotype
Monitor her tumour markers
Phone Michael Seckl or Philip Savage at Charing Cross Hospital

54. What happened to her tumour markers?
βhCG LDH CA125 Pre op D2 post op D14 post op 5.0 ↑ normal normal

55. What else happened? Karyotype result: 46XY in 280 of 280 cells
Swyer’s Syndrome (46XY gonadal dysgenesis)
CT scan 3weeks post op
Small volume pulmonary metastases
4weeks post op. starts chemotherapy with Bleomycin, Etoposide & Cisplatin (BEP)
19 weeks post op. laparoscopic “LSO”
26 weeks post op. sits GCSEs
Now well and at University studying politics

56. Swyer’s Syndrome, Complete 46,XY Gonadal Dysgenesis
Several causes, usually a new mutation on X or Y chromosome, if Y usually the SRY region. Some mosaicism
Failure of gonad to progress beyond the indifferent stage, so it makes no testosterone
Embryo develops to the default position
Healthy girl, normal stature, delayed puberty
Elevated FSH & LH, low E2
USS, small uterus & can’t find the ovaries (unless there is a big one)

57. Other things to talk about
Hormone replacement
estrogen & progestogen +/- testosterone
Sexual / body image considerations
Genetic counselling, DNA tests
Having babies

58. Other things to talk about
Hormone replacement
estrogen & progestogen +/- testosterone
Sexual / body image considerations
Genetic counselling, DNA tests
Having babies

59. We probably shall not get here unless we overrun Thanks