Gynaecological Oncology Cases

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Russell Nicholson
5 years ago
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1 Gynaecological Oncology Cases 1. Tamoxifen and the endometrium 2. Cancer and the older woman Dr Julie M Lamont Consultant Gynaecological Oncologist Epworth Freemasons Hospital 21 st April 2015

2 Mrs FS 66 year old G3P3 Post-menopausal (55yrs) No PMB, USS ET 11.3mm, cystic appearance Cervical smears - up to date, normal History Bilateral breast cancer Diagnosed 18 months prior Bilateral Mastectomies, Adjuvant XRT Adjuvant Tamoxifen - 1 year Congenital absence right kidney, depression Family Hx Breast Cancer - Mother, Sister, Maternal Aunt Genetic testing inconclusive, No BRCA mutation found

3 Mrs FS USS Uterus normal size Endometrial thickness 11.3mm, cystic changes Ovaries normal Examination BMI 23 No significant findings

4 Pelvic ultrasound

5 Pelvic ultrasound

6 Hysteroscopy + D&C

7 Histology Benign Endometrial Polyp No further treatment needed Continued surveillance with medical oncologist

8 Tamoxifen and the endometrium Selective estrogen receptor modulator (SERM) Antagonist (anti-oestrogenic) Breast Reducing cell proliferation Breast cancer chemopreventive agent Agonist Endometrium Oestrogen like effect Stimulates cell proliferation Polyps, fibroids, endometrial hyperplasia/malignancy, sarcoma Due to variable gene expression in different cell types

9 Tamoxifen and the endometrium P-1 study RR 3.28 developing endometrial cancer 2/3 cancers localised FIGO Stage 1 Most - present with PV bleeding - post-menopausal women No difference in risk for premenopausal women Risk endometrial cancer - increases with longer treatment durations ATLAS trial cumulative risk (years 4-15) 3.1% (tamox 10yrs) vs 1.6% (tamoxifen 5yrs) Risk decreases after treatment stops

10 Screening of Asymptomatic women Difficult Tamoxifen-induced subepithelial stromal hypertrophy USS/Pathology correlation is poor Endometrial biopsy Not sensitive (asymptomatic) High-risk women Other risk factors for endometrial cancer

11 Surveillance of women taking tamoxifen Pre-menopausal No increased risk of cancer Post-menopausal Annual gynaecologic examination Monitor/Educate for symptoms PV bleeding, discharge, leukorrhoea, spotting Investigate abnormal symptoms No evidence to support USS or regular sampling Unless patient is symptomatic (or high-risk) Protection with LNG-IUD (Mirena) not recommended Reduces polyps Increased risk of recurrence of breast cancer

12 Cancer and the older women

13 Ms K 78 year old G0 Presentation Post-menopausal bleeding 2/52 prior Heavy, lasted 1 day First episode No associated pain No bloating, bowel, bladder symptoms 1-2 year history of minor PV discharge Thought to be associated with urinary leakage

14 Ms K Fit and well Painful periods in the past Cervical smears previously normal Hypertension, Hypercholesterolaemia Colonoscopy 6 months prior benign polyps No previous surgery Father prostate cancer, Sister Bowel cancer at 74yo, 3x maternal relatives stomach cancer Lives alone on her farm Managed livestock until 2-3 years ago Independent with ADLs, IADLs Non-smoker Social support Nephew and his wife

15 Ms K Normal general appearance, BMI 22 Normal Respiratory, Thyroid examination Palpable abdominal mass Mobile, non-tender PV examination Exophytic tumour upper 1/3 of vagina Serum Tumour Markers Ca19.9 Normal, Ca , Hb 120, WCC 7.1, Neut 4.6, Plt 445, Na 141, K 4.0, Creatinine 69, Albumin 41 CT Examination under Anaesthetic (EUA)

22 EUA Vaginal mass 4cm exophytic, necrotic extending from the left vaginal fornix and into left para-rectal space Separate from the cervix. Cervix appeared normal Biopsy of vaginal mass Hysteroscopy, D&C Normal intrauterine cavity

23 EUA Results Vaginal mass High-grade serous carcinoma Consistent with ovarian origin Currettings/Cervical polyp Benign MRI

30 PET Scan

31 Discussion with patient Primary cytoreductive surgery vs chemotherapy and interval surgery Primary Surgery would involve: Hysterectomy Bilateral salpingoopherectomy Omentectomy Upper vaginectomy Ultralow-Anterior bowel resection +/- stoma formation Increased risk post-op morbidity Possible delayed recovery Delay to adjuvant chemotherapy

32 Treatment Neoadjuvant ( Up front ) chemotherapy Carboplatin/Weekly paclitaxel (ICON8 trial) 3 cycles (3 months) Interval debulking surgery Ca Laparotomy, TAH, BSO, Omentectomy Large fibroid uterus, 5cm right ovarian mass (adherent to Pouch of Douglas), omentum appeared normal. No gross residual tumour seen in Vagina. Histology High-grade serous carcinoma of the ovary

34 Treatment Neoadjuvant ( Up front ) chemotherapy Carboplatin/Weekly paclitaxel (ICON8 trial) 3 cycles (3 months) Interval debulking surgery Ca Hb 101g/L, Hct 0.30, WCC 6.5, Neut 4.2, Albumin 36 Laparotomy, TAH, BSO, Omentectomy Large fibroid uterus, 5cm right ovarian mass (adherent to Pouch of Douglas), omentum appeared normal. No gross residual tumour seen in Vagina. No residual tumour at the end of surgery Discharged home, day 5 following surgery Histology High-grade serous carcinoma of the ovary

35 Treatment - contd Completed final 3 cycles of chemotherapy. Ca125 5 Moved into supported residential housing during chemotx Independent with ADLs, IADLs Type 1 peripheral neuropathy Continuing under ongoing review

36 Ovarian Cancer and the older patient Ovarian cancer 10-15% diagnosed before menopause Average age of diagnosis 60 years What constitutes older? >60 years, >70 years, >80 years? Increasing age Comorbidities Polypharmacy Functional dependence Cognitive impairment Depression Poor nutrition Limited social support Frailty Physical vs physiological Older patients often received less aggressive treatment Not always based on physiological assessment

37 Ideal approach to the older patient Geriatric assessment Formal way to evaluate functional status Comorbidities Cognition Psychological state Social functioning/support Nutritional status Predictive value for estimating the risk of severe toxicity from chemotherapy Survival outcomes

38 Pre-operative assessment No specific tool for ovarian cancer Pre-operative Assessment of Cancer in the Elderly (PACE) ADLs, IADLs, PS associated with extended hospital stay Age itself NOT associated with post-op complications

Frailty Physical frailty Weight loss, weakness,

Correlated with post-op complications and increased

comorbidities, reduced function/nutrition/cognition,

39 Frailty Physical frailty Weight loss, weakness, exhaustion, low physical activity, slow walking speed Correlated with post-op complications and increased length of stay Physiologic frailty Multiple comorbidities, reduced function/nutrition/cognition, low Hct, low albumin, impaired renal function Associated with 6 month mortality

40 Ovarian Cancer and the older patient All patients should be considered for optimal treatment, regardless of age If appropriate Treatment should be individualised for the older Treatment should be individualised for the older patient Doesn t mean compromised treatment Physiologically robust Need to consider all aspects of recovery Not just survival rate Early palliative care involvement Prolong survival (especially socially isolated)

41 Ovarian Cancer and the older patient Management Multifaceted Physical/Rehabilitation Psychological Social/Family GP/Primary care physician Gynaecological oncologist Medical Oncologist Physician Palliative Care Nutrition

42 Thank you!

43 Gynaecological Oncology Cases 1. Tamoxifen and the endometrium 2. Cancer and the older woman Dr Julie M Lamont Consultant Gynaecological Oncologist Epworth Freemasons Hospital 21 st April 2015

Gynaecology Cancer Red Flags. Dr Dina Bisson Consultant Obstetrician and Gynaecologist Southmead Hospital North Bristol NHS Trust 27 April 2017

Gynaecology Cancer Red Flags. Dr Dina Bisson Consultant Obstetrician and Gynaecologist Southmead Hospital North Bristol NHS Trust 27 April 2017 Gynaecology Cancer Red Flags Dr Dina Bisson Consultant Obstetrician and Gynaecologist Southmead Hospital North Bristol NHS Trust 27 April 2017 Gynaecological Cancers Endometrial Cancer Ovarian Cancer Cervical