1
Q
What is the lifetime risk of vulval cancer?
A
1 in 232
2
Q
What is the average age of diagnosis of vulval cancer?
A
65
3
Q
What are the different kinds of epithelial vulval cancer?
A
SCC (>90%), adenocarcinoma (pagets), BCC, Merkel cell, bartholins, verrucous carcinoma
4
Q
What are the non epithelial cancers of the vulva?
A
melanoma
sarcoma
5
Q
What are risk factors for vulval cancer?
A
lichen sclerosus
hrHPV - smoking, HIV, immunosuppression
6
Q
what is the risk of progression to SCC in dVIN?
A
30%
7
Q
What is dVIN?
A
VIN developed secondary to lichen sclerosus
8
Q
What is the risk of progression from uVIN to SCC if untreated?
A
9-16%
9
Q
if uVIN is treated what is the progression to SCC risk?
A
3%
10
Q
What is the hart line?
A
the border between the vulval keritinised epithelium and the non keratinised mucosa on the vulva
11
Q
Which part of the female genital tract will have lymphatic drainage to the superficial inguinal node group?
A
distal 1/3 of the vagina and vulva
12
Q
What is the lymphatic drainage of the vulva?
A
superficial inguinal to deep inguinal (including the node of cloquet) and then the pelvic nodes
13
Q
What is the node of cloquet?
A
the highest and most proximal node of the deep inguinal lymph nodes, just inferior to the inguinal ligament
14
Q
Which lesions can cross to contralateral lymph nodes vulva?
A
within 2cm of the midline
15
Q
Which type of VIN is more common in the midline?
A
dVIN
16
Q
How is P16 useful in VIN/SCC?
A
it is associated with HPV related disease
17
Q
How is p53 useful in VIN/SCC?
A
p53 wild type - HPV
p53 abnormal/mutated - non HPV
18
Q
When do you do lymph node sampling in vulval SCC?
A
when depth of stromal invasion if >1mm
19
Q
When examining vulval lesion what should you do?
A
check the rest of the vagina and cervix for synchronous lesions
20
Q
How long does 3% acetic acid take to work on the vulva and why?
A
5 minutes because of the keratin
21
Q
what investigations are done for for vulval cancer?
A
punch biopsy
consider HIV test in HPV assoc lesions
CT CAP - staging
FNA of suspicious nodes
PET CT or MRI can be considered
22
Q
what is stage I vulval SCC?
A
confined to the vulva
23
Q
what is stage II vulval SCC?
A
extension to the lower 1/3 vagina, or urethra, lower 1/3 anus, no nodes
24
Q
what is stage III vulval SCC?
A
extension to the upper 2/3 of vagina or urethra, bladder, rectum or regional lymph node metastases
25
what is stage IV vulval SCC?
tumour fixed to bone, ulcerated lymph node mets, distant mets including pelvic LN
26
What is stage 1A vulval SCC?
<2cm diameter and <1mm deep invasion
27
What is stage 1B vulval SCC?
>2cm diamater or >1mm deep invasion
28
what is vulval stage 3A SCC?
extension into structures or LN <5mm
29
what is vulval stage 3B SCC?
LN >5mm
30
what is vulval stage 3C SCC?
LN with extra capsular spread
31
what is vulval stage 4A SCC?
tumours fixed to bone or LN ulcerated
32
what is vulval stage 4B SCC?
distant met including pelvic LN
33
what are the 5 year survival rates for stage 1A vulval SCC?
86%
34
what are the 5 year survival rates for stage 1B vulval SCC?
77%
35
what are the 5 year survival rates for stage 2 vulval SCC?
64%
36
what are the 5 year survival rates for stage IV vulval SCC?
18-25%
37
What is the most important prognostic factor in vulval SCC?
nodal involvement
38
What are the five important prognostic factors in vulval SCC?
1. nodal involvement - one, bilateral
2. FIGO stage
3. grade of the tumour
4. depth of invasion
5. age and performance status of the patient
39
If depth of vulval SCC is <1mm what is the risk of nodal involvement
little to no risk
40
If depth of vulval SCC is 1-2mm what is the risk of nodal involvement
8%
41
If depth of vulval SCC is 3-5mm what is the risk of nodal involvement
30%
42
What are the aims for margins for surgical resection of vulval SCC?
clear margins confer no extra risk of recurrence even if close to disease (used to be 10-20mm)
43
What side nodes should you remove if primary lesion in vulval SCC is midline?
both sides
44
when should you go back and do a LN dissection on the other side in vulval SCC?
if the ipsilateral side has positive node and the lesion is >1cm from the midline
45
What are the risks with inguino femoral lymphadenectomy?
wound infection, dehiscence, lymphocyst, lymphodema, immobility, prolonged hospital stay
46
What have the GROINS-V studies looked at?
safety of omitting IFL in early stage cancer is SNLB is negative
if micromet in SLN can have radiotherapy, if macro mets should have surgery for IFL
47
when is radiotherapy given in vulval SCC?
to the vulva if - margins positive and not possible to re-operate
to the groin if - SLN mets 2mm or less
extracapsular sprread of node
two or more positive groin nodes
48
When should RT be started for vulval SCC?
within 8-10 weeks of surgery
49
which vulval SCC patients may benefit for sensitising chemotherapy with RT?
node positive cancer
50
How is advanced vulval cancer managed?
chemo RT if not amenable to surgery
then can reassess at 12 weeks ? resectable then
51
How frequent is follow up after treatment for vulval cancer?
first 2 years 3-4 monthly
next 3 years 6-12 monthly
dVIN patients need follow up life long for LS
multifocal disease or recurrent - life long
52
What kind of cancer can a bartholins gland carcinoma be?
adenoc, SCC, transitional cell
53
When is peak age for barts Ca. diagnosis?
mid 60s
54
What is the common first complaint with barts ca?
dyspareunia, become quite large
55
When should you biopsy a barts to check fro cancer?
if recurrence of gland enlargement >40
56
Which LN does a barts ca spread to?
inguinal and pelvic, travels to ischiorectal fossa.
57
what is extramammary pagets disease?
heterogenous group of intraepithelial neoplasia
58
how does extramammary pagets present on the vulva?
eczematoid, red, weepy, often labia majora, perineal body or clitoris
59
In extramammary pagets how often is there an underlying cancer or invasive pagets?
10-20%
60
What needs to be considered in a patient with extramammary pagets disease?
screen for secondary tumour on breasts, GI, genitourinary tract
61
What is the difficulty with excision of extramammary pagets?
often have involved margins meaning high risk of recurrence, needing repeat surgery
need long term surveillence
62
What proportion of vulval cancer is a met?
8%
63
Where can vulval cancers be a met from?
bladder, urethral, rectum
breast, lung, kidney, stomach
chioriocarcinoma
64
What are the most common types of vaginal cancer?
SCC 70-80%
adenocarcinoma 13%
65
What is the most common age for vaginal cancer?
>80y
66
What is the way that vaginal cancer spreads?
direct and lymphatic
67
why is the lymphatic drainage from the vagina complicated?
due to the embryologic development of the vagina coming from different parts (mullerian ducts and the urogenital sinus)
68
What is the LN drainage from the posterior vagina?
inferior gluteal, pre sacral and peri rectal nodes
69
What is the LN drainage from the distal vagina?
deep and superficial inguinal nodes
70
What is the LN drainage from the proximal vagina?
external, internal and common in iliac nodes
71
What is the most common cause of vaginal SCC?
HPV 16
72
What are the most common symptoms with vaginal cancer?
bleeding, pain, discharge
73
What is the risk of VaIN progressing to cancer?
3%
74
Where do most vaginal cancers develop?
upper 1/3 of the vagina
75
How is staging done for vaginal SCC?
clinically
76
what is stage I vaginal cancer?
confined to the vagina
77
what is stage II vaginal cancer?
involves the subvaginal tissues but has not extended to the pelvic wall
78
What is stage III vaginal cancer?
extends to the pelvic wall
79
What is stage IVA vaginal cancer?
extends to the rectal or bladder mucosa or direct extension beyond the pelvis
80
What is stage IVB vaginal cancer
spread to distant organs
81
What is the treatment for vaginal cancer?
radical surgery with negative margins and pelvic lymphadenectomy for upper 1/3 of the vagina
radiation if unable to get negative margins EBRT and brachy
82
What is added for stage III and IV vaginal cancer treatment?
cisplatin
83
What is clear cell ca of the vagina related to?
in utero DES exposure
84
What can vaginal adenocarcinoma arise from?
endometriosis, vaginal adenosis, wolffian duct remnants, skene glands, most commonlly, mets
85
How do you treat vaginal adenocarcinoma?
the same as SCC
86
What is GTD?
gestational trophoblastic disease
A group of placental related disorders derived from pregnancy spanning from premalignant to malignant
87
What are the malignant forms of GTD?
choriocarcinoma, invasive mole, placental site trophoblastic tumour, epithelioid trophoblastic tumor
88
What is the origin of complete mole vs partial mole?
complete - empty egg and paternal genes (one replicates or two) 46XX, XY, 46YY
partial - 2 sperm + one egg 69 XXX, XYY, XXY
89
What is more common in complete molar pregnancies mono sperm or di sperm?
mono 75% eg haploid
90
what are other possibilities other than triploid in partial molar?
tetraploid or mosaic
triploid in 90%
91
how common in complete and partial molar pregnancy?
1 in 1000 complete
3 in 1000 partial
RANZCOG says 1 in 200-1000 pregnancies
92
which types of GTD has fetal RBC and tissue?
partial only
93
What do you see on ultrasound in partial molar?
enlarged placental tissue or cystic changes in the decidual reaction, empty gestation sac or delayed incomplete miscarriage
94
What USS changes to you see in complete molar pregnancy?
polypoid mass with multiple sonolucent areas aka a snow storm appearance.
no gestation sac
theca lutein cysts
95
What do you see on histology for partial molar pregnancy?
Focal trophoblast hyperplasia (just partial molar feature)
focal villous hydrops with scattered abnormally sized or scalloped villi
fetal tissue
trophoblastic pseudo inclusions
96
What is the histology for a complete molar pregnancy?
diffuse villous hydrops
diffuse trophoblast hyperplasia
macroscopically the cystic villi appearance looks like the 'clusters of grapes'
no fetal tissue
97
What is p57 expressed on and how is this helpful in GTD?
maternal alelle on cytotrophoblast. so only present in partial not complete mole
98
What does FISH show for complete and partial mole?
complete diploid
partial triploid
99
What is the risk of complete and partial mole pregnancies progressing to GTN and needing chemo?
complete 15-25%
partial 0.5-4%
100
what is the most common sign that people present within GTD?
irregular vaginal bleeding 60%
101
What are other symptoms of molar pregnancy?
HG
excessive uterine enlargement
abdo distension from theca lutein (complete)
hyperthyroid
early onset PET
rarely - seizures or haemoptysis from mets
102
what HCG level is common with a complete mole?
HCG >100 000
103
is pelvis uss sensitive for molar preganncies?
no, will only detect 56%
Much more for complete 95%
vs
partial 20%
104
How do you diagnose molar pregnancy?
histology
105
What is the risk with medical management of molar pregnancies?
increases risk of GTN 16x in complete
106
should you give anti D in molar pregnancies?
yes, as RBC can be on partial molar and it is hard to tell the difference prior
107
What groups are molar pregnancy more common in?
asian and extremes of age <15 >45
108
What is included in GTD?
hydatidiform mole (complete and partial moles), invasive
mole, gestational choriocarcinoma, placental site trophoblastic tumour (PSTT) and some include Epithelioid
Trophoblast Tumour (ETT)
109
What is GTN?
describes GTD that requires chemotherapy or excisional treatment because of persistence of HCG or the presence of metastases
110
What can you get GTN from?
molar pregnancy 60%
miscarriage or TOP 30%
regular pregnancy or ectopic 10%
111
What are symptoms of gestational choriocarcinoma?
PVB, pelvic mass, distant mets symptoms from liver, brain, lungs
112
What can occur with a newborn in gestational choriocarcinoma?
mets, should be assessed, with a urinary HCG
113
after what kinds of pregnancy can you get gestational choriocarcinoma?
complete molar pregnancy (25-50 per
cent), within 12 months of a non-molar abortion (25 per cent), or after a term pregnancy (25-50
per cent).
114
What is always present in gestational choriocarcinoma?
raised HCG
115
What are the characteristic of placental site trophoblastic tumour?
slow growing, low HCG compared to volume of disease, metastasises late, lymphatic spread, relatively chemoresistant
116
How does placental site trophoblastic tumour present?
bleeding or gynae symptoms as mets are rare
117
when should you consider PSTT?
in cases of relapse of GTD
118
How do you treat PSTT and why?
hysterectomy and pelvic lymphadenectomy (LN spread) chemo insensitive
119
What are the rare presentations of PSTT?
nephrotic syndrome or hyperprolactinaemia
120
What cells are involved in a epithelioid trophoblast tumour?
intermediate trophoblast cells
121
What are the differentials for a epithelioid trophoblast tumour?
PSTT, SCC of cervix, choriocarcinoma
122
What is the characteristics of a epithelioid trophoblast tumour?
long interval between antecedant pregnancy, usually after a term pregnancy
HCG is lower than molar
less aggressive the choriocarcinoma
some metastatic potential
lymphatic spread
123
How do you treat epithelioid trophoblast tumour?
surgery, relatively chemo resistant (chemo plays a part in ext metastatic disease)
124
What are the common places for vaginal GTN to grow?
vaginal fornices and suburethrally
125
Why shouldn't you biopsy GTN?
highly vascular
126
What should you do if you are considering an second surgical evacuation for GTD?
consultGTD registry and use hysteroscope to locate focus to reduce risk of perforation
127
When is a repeat evacuation not recommended in GTD?
if mets of HCG >5000
128
If a second procedure is needed for GTD what is the risk of perofrstion and needing chemo?
perf 8%
chemo 70%
129
Can you use prostaglandins in GTD?
yes
130
can you use oxytocin in GTD?
after the evacuation only
131
When can you consider a IUD after GTD evacuation?
6 weeks and hCG has returned to normal
132
Who should be reported to the GTD registry?
all cases
133
How long do you monitor a partial molar for as per RANZCOG?
until three of the weekly levels are negative in a row , then stop
All bloods through the same provider
134
How long do you monitor a complete molar for as per RANZCOG?
after you have three weekly normal levels consecutive levels in a row, go to monthly until HCG has been negative for 6 months total
All bloods through the same provider
135
What diagnoses persistent GTD eg a form of GTN?
a rise of 10% over two weeks (3 tests)
A fall of 10% over three weeks (4)
136
What should be done with persistent GTD?
complete a metastatic screen and a WHO risk score and refer to a specialist centre/GONC
137
What is a metastatic screen in GTD?
Mets screen - CT head, CAP, and MRI head if chorio ca. or neuro symptoms
138
How long should women with GTN receiving chemo wait until they TTC?
12 months after completion of chemo due possible chemo teratogencitiy, not due to relapse
139
What is the risk of subsequent GTD event for women?
1 in 70
fertility not effected
140
What is should be done following any future pregnancies as per RANZOG after GTD?
HCG at 6 weeks and early uss in future pregnancies
141
Who in T2 would you suspect a molar pregnancy in?
large for dates, hyperthyroid, hyperemesis, PET, pulmonary or neurological symptoms
142
What investigation should be done for ERPOC for molar?
G+H FBC beta HCG
if clinically indicated TFT, LFTs, coag, CXR
143
Which patients in GTD should be immediately referred to GONC?
ETT, PSTT, chorio carcinoma or evidence of mets
144
What should a patient be informed of when telling them about their histology in a molar?
diagnosis
follow up plan and risk of persistent disease
to avoid getting pregnant
counselling - when can get pregnant, 1:70 risk, HCG at 6 weeks, fert un effected
145
What is classified as GTN?
ETT PSTT chorioca. persistent GTD
eg GTD needing chemo
146
What is the FIGO 2000 risk score for GTN?
age, antecedent pregnancy, interval months from index pregnancy, pretreatment HCG, large tumour size, site of mets, number of mets, previous failed chemo
147
What is FIGO 2000 used for in GTN and what is low or high?
to decide chemo regime
low is <7
high is 7 or higher
148
What is the low risk protocol for chemo in GTN?
either MTX and folinic acid or
actinomycin D
149
What is the foilinic acid and MTX regime in GTN?
alternating injections IM of 1mg/kg MTX and 0.1mg/kg for 8 days then repeat every two weeks until normal HCG level.
repeat for 6 more weeks
then follow up with monthly HCG for 12 months after chemo completion.
150
What meds are given for high risk GTN?
EMACO protocol repeated every 14 days
D1
etoposide
MTX
actinomycin D 0.5mg
D8
cyclophosphamide
oncovin (vincristine)
After HCG normalises, treat for 6 more weeks
151
In a woman with persistent vaginal bleeding after pregnancy what should you consider?
GTN, do a beta HCG
152
What are the characteristics of PSTT
HCG is low compared to volume of disease
about 1/3 of patients present with mets
human placental lactogen is seen on cells
153
how frequently does ETT present as mets?
1/3
usually to the lungs
154
What is the half life of HCG?
24-36 hours
155
In GTD what is 5iu/L of hCG equivalent to in tumour cells?
about 100
156
If a patient requests a hysterectomy as treatment of mole what should be done?
staging imaging, still need follow up, 3-10% still need chemo
157
in a coexsisting molar and viable pregnancy what is the chance of viable birth?
40-50%, high risk of PTL, T2 loss and PET
158
How long should people be follow up after GTN chemo?
12 months with monthly hcg after low risk chemo
24 months with high risk chemo
159
How long should people wait before conceiving in GTN?
12 months after chemo - recurrence risk and abnormal pregnancy
160
What is the risk of relapse and the average time for GTN?
3.5% will
average 4 months
161
What is the risk of molar after GTD or GTN?
1 in 70
162
what is the cure rate of low risk GTN?
100%
163
What is the cure rate of high risk GTN?
94%
164
What part of the cell cycle are cells protected from chemo?
G0
165
why is combinatino chemo used?
better at targeting a heterogenous population of cells
166
What does chemo do when combine with radiation?
sensitises cells ot the RT and alos treats micromets outside the radiation field
167
What is the problem with chemotherapy for an area previously irradiated?
scarring and capillary destruction stops the chemo working as effectively
168
What is the order of the cell cycle?
G0 - quiescence
G1 - protein synthesis, DNA repair
S phase - DNA replication
G2 - pre mitotic, 2 x normal DNA
M phase - mitosis and division
169
What is different about the cell cycle of a cancer cell?
same time duration for each phase
just more cells in the active phases and dysfunctional apoptosis
170
What are example of antimetabolite chemo therapy drugs and what part of the cell cycle do they target?
MTX, gemcitabine, mercaptopurine, 5FU
S phase (DNA replication)
171
How do antimetabolites work?
interfere with metabolic pathways which produce building blocks of DNA
172
What are the side effects of MTX?
myelosuppression, mucositis, renal toxicity, hepatotoxicity
173
What are topoisomerase inhibitors and what part of the cell cycle do they inhibit?
doxorubicin, etoposide
G2 - inhibits DNA repair
174
What are the side effects of doxorubicin?
cardiac failure (dose related)
175
What are the side effects of etoposide?
secondary haematological malignancies
176
how do platinum based chemotherapy work?
forms covalent bonds between purine bases of DNA inhibiting DNA replication and repair
177
Which platinum chemo needs IV hydration and adequate renal function?
cisplatin
178
What are the adverse effects of cisplatin?
nephrotoxic, ototoxic, highly emetogenic
less myelosuppression
179
What are the adverse effects of carboplatin?
peripheral neuropathy, more myelosuppreion
less emetogenic, no ototoxicitiy, less nephrotoxic
180
Can you given carboplatin in renal impariment?
yes, a calculation is done for dose (calvert formula)
181
How do taxanes work?
bind to tubulin and inhibit mitosis in M phase
182
what are the side effects of paclitaxel ?
neurotoxic, myelosuppression, alopecia, alopecia, arthralgia, myalgia
183
What premedications do you give with paclitaxel
corticosteroids, antihistamines, H2 receptor agonist
184
What part of the cell cycle does antitumour antibiotic work on and an example of a drug?
bleomycin
G2 phase (premitotic)
185
what are the side effects of belomycin?
pulmonary fibrosis 10%
nail and skin changes
186
What are example of PARP inhibitors?
olaparib niraparib
187
Who can benefit from a PARP inhibitor?
patients with germline BRCA mutation
somatic mutations
about 50% of ovarian cancer patient
188
What is germline vs somatic?
germline is a mutation inherited at conception, somatic is one developed after conception and not usually passed on to future generations
189
how does a PARP inhibitor work?
polyp-ADP-ribose polymerase inhibitor selectively causes cell death in BRCA deficient cells
190
What are side effects of PARP inhibitor?
N+V, anorexia, fatigue, diarrhoea
rare pneumonitis, myelodysplastic, syndrome /AML
191
How does Bevacizumab work?
binds to VEGF and inhibits angiogenesis
192
What are the rare but serious side effects of Bevacizumab ?
GI perforation 2% worse with IBD or peritoneal involvement
bowel fistulae 2%
haemorrhage
arterial thromboembolism
193
What are symptoms with tamoxifen?
menopausal symptoms, fluid retentions, VTE risk
194
What are the side effects with megestrol acetate
weight gain, fluid retention, appetite increase, VTE rare
195
What is ECOG 2 performance status?
active more than 50% of the day cannot do light tasks
196
what is ECOG 4 performance status?
active less than 50% of the day, needs help with all ADLS
197
What is the chemo for ovarian germ cell tumours?
3-4 cycles of BEP as inpatient
bleomycin
etoposide
cisplatin
198
What chemo is given to uterine sarcoma patients?
not usually given
199
What chemo is given for cervical cancer?
usually cisplatin with RT
bevacizumab when combined with chemo beneficial
carbooplatin and pacli can be of benefit prior to cisplatin RT in advanced disease
200
What chemo is given in vulval cancer?
5 FU and cisplatin
201
when in early stage ovarian cancer should chemo always be offered?
stage 1C and greater or if haven't had optimal surgical staging
202
When should carboplatin alone be considered in ovarian cancer?
if wanting to avoid alopecia and enuropathy or poor ECOG status
or early ovarian cancer
203
Who does bevacizumab benefit overall survival for?
Stage IV ovarian cancer and some cervical cancer
204
Which chemotherapy agents are highest risk for infertility?
platinum drugs, etoposide
205
What is a gray in RT?
joukes/kiogram, amount of radiation absorbed by tissue
206
What is ionising radiation?
radiation with sufficient energy to cause the ejection of an orbital electron from an atom
207
How does RT work?
indirect and direct
indirect - production of free radicals which cause DNA damage and cell death
direct - xray photon absorption directly breaks DNA bonds
208
what is the principle of brachy therapy?
shorted distance, higher dose, lower dose to surrounding normal tissues
can be interstitial or intercavity
209
What is the cause of acute RT toxicity?
irradiation to rapidly dividing cell systems
210
What is the time frame for acute RT symptoms?
during and up to 8 weeks after
211
What are the acute and late symptoms you get from RT for bowels?
acute nausea, diarrhoea, cramps and bloating
late chornic colitis, stircture, fistulae, bile salt malabsorption, altered bowel habit
212
What are the acute and late symptoms you get from RT for bladder?
acute hyperactivity dysuria, pain, urinary urgency
late same, fistulae, contractures, telangietasia
213
What are the acute symptoms you get from RT for skin?
erythema, moist desquamation
214
What are the acute and late symptoms you get from RT for vagina?
acute soreness and discharge
late shortening, stenosis, dryness, atrophy
215
What are the acute and late symptoms you get from RT for MSK?
hip and lower back pain
late sacral insufficiency #
216
What is the cause of late RT symptoms?
depletion of normal tissue stem cells and injury to chronic microvasculature
217
What proportion of patients will get late RT adverse effects?
50% mild
10% serious
218
What are the ovarian symptoms from RT?
infertility and premature menopause
219
what lymphatic symptoms can occur with RT and what can be done to maage?
lymphoedema, elevation, massage, compression stocking, clinics
220
What psychological symptoms can occur with RT?
tiredness, irritability, low mood, anxiety, sexual dysfunction
221
What is the difference in palliative RT vs curative RT?
curative - high total dose, multiple fractions, small dose per fraction
pallative - low overall dose, small number fractions, high dose per fraction
222
What are risk factors for HPV related disease?
high parity, COCP use, smoking, immunosuppression, higher number of sexual partners, high viral load, persistent infection, low SES
223
After what time frame of bleeding after pregnancy should you be investigate with an HCG?
if still bleeding 8 weeks Post pregnancy
224
How common in choriocarcinoma?
1 in 50 000 pregnancies
225
What are risk factors for GTN after molar?
age >40
uterus >20 weeks
HCG >100 000
theca lutein cysts >6cm
repeat molar pregnancy
aneuploid mole
medical complications eg PET, hyperthyroid
evidence of distant disease
226
How do you diagnose metastatic GTN?
clinically, DO NOT biopsy
can be considered for choriocarcinoma?
227
What imaging should be done for persistent GTD?
CXR, if mets then CT body and MRI head
228
What are the most commonplaces for GTD to mets to?
Lung and vagina
229
What are the cure rate with low risk GTN?
eg score of 6 or less
100%
230
What are the cure rate with high risk GTN?
94%
231
What does a FIGO score for GTN of over 13 mean?
high risk of death in 4 weeks from bleeding into organs of drug resistance
232
What is stage I GTN?
confined to uteruse
233
What is stage II GTN?
extends outside of uterus but limited to genital structures eg vagina, broad ligament, adenexa
234
What is stage III GTN?
spread to lungs
235
What is stage IV GTN?
all other mets (apart from lungs)
236
How long should one prevent pregnancy after chemo for GTN? What contraception should be avoided during this time?
12 months - due to toxic effects
and to allow follow up HCGs.
avoid mirena
237
What proportion of choriocarcinoma presents with mets symptoms?
1/3
238
What is the prognosis in choriocarcinoma?
10-15% die, highly malignant
239
what pregnancies do PSTT arise from mostly?
term, non molar pregnancies
240
What is the difference in growth pattern of PSTT vs ETT?
ETT nodular
PSTT infiltrative
241
why are PSTT and ETT low HCG secreting vs choriocarcinoma and invasive mole being high HCG secreting?
PSTT and ETT - non villous trophoblast cells
CC and IM - villous trophoblast cells
242
What can atypical placental site nodules progress to?
Epithelioid trophoblastic tumour
PSTT
243
What should be recommended for atypical placental site nodule?
hysterectomy when family complete as 10-15% will turn into GTN
referral to a GTD centre
244
Why is theory don't you need anti D in complete molar pregnancy?
poor vascularisation of the chorionic villi and absence of the D antigen by the trophoblastic cells
245
When is repeat procedure considered in molar with RPOC?
if HCG is <5000, reduces need for chemo by 40%
246
Why is oxytocin avoided in GTD?
risk of tissue embolisation which can cause an AFE like response and mets
247
when should miscarriage tissue be sent?
all POC if no fetal parts are identified at any stage of the pregnancy.
248
what kinds of HCG can GTD make?
any - nicked, free beta subunit, HCG, core fragment
249
How common is choriocarcinoma?
occurs after 1 in 50 000 pregnancies
250
Why is the prognosis worse for GTN after a normal pregnancy?
delay in diagnosis
251
what can be considered for confirmation of a twin molar?
invasive genetic testing
252
What are the risks of molar twin pregnancy?
PET 4-20%
PTB 40%
Early fetal loss 36%
no increase in GTN or needing chemo
253
What % if GTD is ETT or PSTT?
0.2%
254
What is the most important prognostic factor with ETT or PSTT?
time from causative pregnancy
if >48 months the prognosis is poor eg 100% die (reduced with intensive chemo)
but <48 month they survive
255
What are different about GTG and RANZCOG GTD guidelines
GTG - don't send placenta or follow HCG after each pregnancy with molar (only GTN)
and follow up duration is different for molar
256
What can occur with multiple agent chemo for GTN?
premature menopause
13% by 40 and 36% by 45
257
Are HRT and fertility drugs okay after GTN or GTD?
yes after hCG nromalised and follow up complete
258
What is the advised fetal dose of radiation to remain under in pregnancy?
50mGy
100 thought to be deterministic
259
Ellen's flashcards
flashcards
Decks in class (27)
# Cards
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Week 419
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Week 585
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Autoimmune medications and pregnancy11
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Landmark trials to date13
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Week 6253
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Week 7259
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Week 8232
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Week 9206
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Week 10364
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Week 258
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week 371
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Week one136
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Week 11237
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Week 12314
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Week 13381
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GONC 1395
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GONC 2259
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Week 16134
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Week 17410
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Week 18266
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Week 19347
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Week 20307
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Week 21430
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Week 22370
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Week 23298
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Week 24325
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Week 261
