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Cancer care (Y4) > 3- Reproductive cancer > Flashcards

3- Reproductive cancer Flashcards

1
Q

Cervical cancer background

A
  • 3rd most common gynae in England
  • More common in developing
  • Bimodal age distribution
  • Low socioecomic groups
  • 50% with cervical cancer have never had a smear
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2
Q

types of cervical cancer

A
  • 2/3 squamous cell carcinoma
  • 15% adenocarcinoma
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3
Q

Pre- cancerous condition of cervical cancer

A

Cervical intraepithelial neoplasia (CIN)

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4
Q

cervical cancer risk factors

A
  • HPV- believed to be exclusively caused by this virus
  • Young age at first intercourse
  • Multiple partners
  • Exposure
  • Smoking
  • COCP
  • Immunosuppression/ HIV
  • Non-compliance with cervical screening
  • Family history
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5
Q

cervical cancer metastasis

A

lymph nodes, liver, lungs and bones.

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6
Q

refferal cervical cancer

A

An individual must be referred to colposcopy and should be seen within 2 weeks of referral (≥93% of cases) if the appearance of the cervix is suspicious or they have symptoms consistent with cervical cancer e.g. intermenstrual (post coital) bleeding

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7
Q

Protective factors for cervical cancers

A
  • HPV vaccine
  • Cervical screening compliance
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8
Q

Presentation of cervical cancer

A
  • Post coital bleeding
  • PMH
  • IMB
  • Dyspareunia
  • Blood stained vaginal discharge
  • If advanced
    o Fistulae
    o Renal failure
    o Nervous root pain
    o Lower limb oedema
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9
Q

examination findings for cervical cancer

A

Ulceration, inflammation, bleeding, visible tumour

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10
Q

Red flags for cervical cancer

A
  • Intermenstrual bleeding including post-coitally
  • Changes to vaginal discharge
  • Pain during sex
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11
Q

HPV background

A
  • Most women will be infected at some time
  • HPV infection is common in late teens and early twenties
  • Infection lasts on average 8 months
  • Prevalence 5% by age 50
    o Immunological clearance of virus
    o Reduced opportunities for re-infection
  • HPV is an accepted necessary (but not sufficient) cause of cervical cancer
  • Cervical cancer could be viewed as a rare complication of a common infection
  • A vaccine can reasonably be expected to prevent most cases of cervical carcinoma
  • Biggest implication is in developing nations
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12
Q

types of HPV

A
  • Oncogenic types: 16 and 18
  • Low risk HPV types (warts): 6 and 11
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13
Q

pathophysiology of HPV

A

HPV (esp subtypes 16 & 18): produce proteins (E6&7) which suppress the products of ‘p53’ tumour suppressor gene in keratinocytes

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14
Q

presentation of HPV

A

Presentation
* Asymptomatic
* Can be cleared or persist or cause CIN

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15
Q

HPV vaccine

A

The HPV vaccine is ideally given to girls and boys before they become sexually active. The intention is to prevent them contracting and spreading HPV once they become sexually active. The current NHS vaccine is Gardasil, which protects against strains 6, 11, 16 and 18:
* Strains 6 and 11 cause genital warts
* Strains 16 and 18 cause cervical cancer

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16
Q

Cervical intraepithelial neoplasia (CIN) background
.

A
  • pre- cancerous condition
  • Is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix

CIN is diagnosed at colposcopy (not with cervical screening). The grades are:

  • CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
  • CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
  • CIN III: severe dysplasia, very likely to progress to cancer if untreated
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17
Q

CIN III is sometimes called

A

cervical carcinoma in situ.
* Asymptomatic and pre-malignant
* Can regress, persist or progress to cancer
* Best Estimates
* 60% CIN1 regress spontaneously
* 30% of CIN3 progress to invasion over 5-10 years

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18
Q

cervical screening

A

Smear test
Aim: to pick up precancerous changes

  • Starts at 25 years old
  • Every 3 years from 25-50
  • 5 years from 50-65
  • After 65 selected patients only
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19
Q

cervical screening: what happens

A
  • Speculum examination
  • Cells collected from cervix (transformation zone) and exfoliated morphology examined
  • Samples initially tested for high risk HPV and then Liquid based cytology- UK

Classification / reporting
* Normal
* Inadequate
* Borderline- HPV test
* Mild Dyskaryosis- HPV test
* Moderate Dyskaryosis- coloscopy
* Severe Dyskaryosis- coloscopy
* Possible Invasion

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20
Q

Management of smear results

A
  • Inadequate sample – repeat the smear after at least three months
  • HPV negative – continue routine screening
  • HPV positive with normal cytology – repeat the HPV test after 12 months
  • HPV positive with abnormal cytology – refer for colposcopy
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21
Q

investigations for cervical cancer

A

colposcopy + stains
biopsy

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22
Q

Colposcopy

A

If HPV positive and abnormal cytology

  • Involves inserting a speculum, and using a colposcope to magnify the cervix.
  • During stains such as acetic acid and iodine are used to differentiated between abnormal areas

Acetic acid
- Causes abnormal cells to appear white. This appearance is described as acetowhite. This occurs in cells with an increased nuclear to cytoplasmic ratio (more nuclear material), such as cervical intraepithelial neoplasia and cervical cancer cells.

Schiller iodine test
- Involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour.
- Abnormal areas will not stain.

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23
Q

types of biopsy

A

large loop excision of transformational zone (LLETZ)

punch biopsy

cone biopsy for CIN

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24
Q

Large loop excision of transformational zone (LLETZ)

A

o Under local anaesthetic during colposcopy
o Loop of wire with electrical current (diathermy) used to remove abnormal tissue
o Risk of infection and preterm labour

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25
Q

cone biopsy for CIN

A
  • For treatment of CIN and early cervical cancer
  • Surgeon removes a cone-shaped piece of the cervix using a scalpel (pain, bleeding, infection, stenosis of cervix)
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26
Q

cone biopsy for CIN

A
  • For treatment of CIN and early cervical cancer
  • Surgeon removes a cone-shaped piece of the cervix using a scalpel (pain, bleeding, infection, stenosis of cervix)
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27
Q

Staging of cervical cancer

A

The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage cervical cancer:
* Stage 1: Confined to the cervix
* Stage 2: Invades the uterus or upper 2/3 of the vagina
* Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
* Stage 4: Invades the bladder, rectum or beyond the pelvis

28
Q

Management of cervical cancer

A

Screening very important- management and prognosis depends on the stage of the disease

  • Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy
  • Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
  • Stage 2B – 4A: Chemotherapy and radiotherapy
  • Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
29
Q

management of advanced cervical cancer

A
  • Pelvic exenteration: involves removing most or all of the pelvic organs including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum
  • Significant implications on QoL
30
Q

metastatic cervical cancer management

A

Metastatic cervical cancer
- Bevacizumab (Avastin): monoclonal antibody
- Targets VEGF-A- reducing development of new blood vessels

31
Q

prognosis of cervical cancer

A
  • Early detection= better outcomes
  • 98% survival with stage 1A, 15% with stage 4
32
Q

complications of cervical cancer treatment

A
33
Q

ovarian cancer

A
  • 2nd commonest gynae cancer
  • Incidence rising
  • Peak age 70-74
  • No pre-malignant stage
    o THEREFORE NO SCREENING PROGRAMME
34
Q

ovarian cancer metastasis

A
  • Peritoneal
  • More than 70% of patients with ovarian cancer present after it has spread beyond pelvis
35
Q

ovarian cancer risk factors

A

Risk factors
- Obesity
- Nulliparity
- Factors which increase no. of ovulations: Early men/ late men
- Unopposed oestrogen
- Family history
o BRCA1/2
- Endometriosis
- Clomiphene recurrent use

36
Q

protective factors for ovarian cancer

A
  • COCP
  • Pregnancy
  • Breastfeeding
  • Hysterectomy
  • Oophorectomy
  • Sterilisation
37
Q

presentation of ovarian cancer

A

Presentation- late due to non specific
- Abdominal swelling and ascites
- Pelvic mass
- Pain
- Anorexia
- N and V
- Weight loss
- Vaginal bleeding
- Bowel/urinary symptoms
- Hip/groin pain- mass pressing on obturator nerve

38
Q

Referral for ovarian cancer

A

Referral
Refer directly on a 2-week-wait referral if a physical examination reveals:
* Ascites
* Pelvic mass (unless clearly due to fibroids)
* Abdominal mass

39
Q

ovarian tumours can be

A

benign
borderline
malignnat

Named according to cell line

40
Q

most common ovarian tumours

A

Epithelial
* Serous (most common)
* Mucinous
Germ cells
* Teratoma (dermoid)
Sex cord-stromal tumours
* Benign or malignant
* Arise from connective tissue or sex cords
* E.g. Sertoli-leygid cell tumours and granulosa
Metastasis
* Krukenberg tumour– usually from GI cancer
* Signet ring cells on histology

41
Q

staging of ovarian cancers

A
42
Q

investigations for ovarian cancer

A
  • H and E
  • FBC and U&E
  • Tumour marker
    o CA125 >35 IU/mL
    o AFP/LDH/ HCG (<40 years)
  • Pelvic US
  • Pelvic CT
  • Paracentesis
  • Surgical exploration
  • Histopathology
43
Q

tumour markers for ovarian cancer

A

o CA125 >35 IU/mL
o AFP/LDH/ HCG (<40 years)

44
Q

Ca125

A

This is particularly important in women over 50 years presenting with:
o New symptoms of IBS / change in bowel habit
o Abdominal bloating
o Early satiety
o Pelvic pain
o Urinary frequency or urgency
o Weight loss

45
Q

causes of raised Ca125

A

Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy

46
Q

Tumour markers for women under 40 years with complex ovarian mass which could be a germ cell tumour

A
  • Alpha-fetoprotein (α-FP)
  • Human chorionic gonadotropin (HCG)
47
Q

The risk of malignancy index (RMI)

A

estimates the risk of an ovarian mass being malignant, taking account of three things:
* Menopausal status
* Ultrasound findings
* CA125 level

48
Q

Staging of ovarian cancer

A
  • CXR
  • CT to assess peritoneal, omental and retroperitoneal disease
  • Cytology of ascitic tap (paracentesis)
49
Q

management: eptihelial ovarian cancer

A
  • Surgery + chemotherapy
  • Staging laparotomy, TAH PLUS BSO and debulking
  • Platinum (Cisplatin, carboplatin) and Taxane (paclitaxel)
  • In women of reproductive age, where the tumour is confined to one ovary, oophorectomy only may be considered
50
Q

Management non-epithelial ovarian cancers:

A

often occur in young women and can be extremely chemo-sensitive (e.g. germ cell). Often treated with combination of ‘conservative’ surgery and chemo

51
Q

management of recurrent ovarian cancer

A

palliative chemotherapy

52
Q

Endometrial cancer

A
  • Commonest
  • Rare before 35 and rare after 80
  • More common in postmenopausal
  • Common in western world
  • Types of endometrial cancer
    o Endometrial hyperplasia (pre-cancerous)
    o Endometrial carcinoma (adenocarcinoma)
    o Sarcoma
53
Q

endometrial metastases

A
  • Rare at presentation of type 1 cancers
  • Intraperitoneal, lung, bone, brain
54
Q

causes/RF for uterine cancer

A
  • Obesity huge risk- adipose is source of oestrogen
    o Primary source of oestrogen in postmenopausal women
    o Adipose contain aromatase -> converts androgens such as testosterone into oestrogen
    o Unopposed in women not ovulation e.g. PCOS or post-men
  • T2DM due to increased insulin resistance
  • Early menarche/ late meno
  • Nulliparity
  • PCOS- increased exposure to unopposed oestrogen due to lack of ovulation (due to less likely to ovulate and form CL, which produces progesterone)
  • Unopposed oestrogen e.g. tamoxifen
    o Anti-oestrogenic in breast, opposite in uterus
  • Previous breast or ovarian cancer (BRCA ½)
  • Endometrial polyps
  • Diabetes- due to increased production of insulin in T2
55
Q

uterine cancer protective factors

A

Protective
- Continuous combined HRT
- COCP/ mirena
- Multiparety
- Smoking- antiestrogenic- WHATTT
- Coffee/ Tea
- Healthy lifestyle/ PT

56
Q

Presentation of uterine

A
  • Post menopausal bleeding
  • PCB/ intermenstrual bleeding
  • Abnormal discharge
  • Haematuria
  • Anaemia
  • Raised platelet count
57
Q

Referral for uterine cancer

A
  • 2-week wait urgent cancer referral
    o Postmenopausal bleeding (>12 months after LMP)
  • Transvaginal US in women >55 with
    o Unexplained vaginal discharge
    o Visible haematuria
58
Q

staging of uterine cancer

A
59
Q

Investigations for uterine cancer

A

One stop postmenopausal bleeding clinic
- H and E
- FBC, UEs, LFT
- Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
- Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer (quicker and less invasive than hysteroscopy)
o <4mm and normal pipelle biopsy -> discharge patient
- Hysteroscopy with endometrial biopsy
- CT CAP
- MRI pelvis

60
Q

Transvaginal ultrasound for endometrial thickness

A

normal is less than 4mm post-menopause

61
Q

pipelle biopsy

A

Pipelle biopsy

It involves a speculum examination and inserting a thin tube (pipelle) through the cervix into the uterus. This small tube fills with a sample of endometrial tissue that can be examined for signs of endometrial hyperplasia or cancer. Pipelle biopsy is a quicker and less invasive alternative to hysteroscopy for excluding cancer in lower-risk women.

62
Q

management of uterine cancer depends on

A
  • Stage
  • Age
  • Fitness
63
Q

management of uterine cancer

A

Preferred treatment: Surgical
Non surgical
- progestagens
- primary radiotherapy

64
Q

surgical management of uterine cancer

A

Surgical treatment 80% of patients have primary surgery
- Hysterectomy PLUS bilateral salpingo-oophorectomy, peritoneal washings
- Laparoscopic / Open

**
Adjuvant Radiotherapy if high risk of recurrence**
* External beam
* Brachytherapy

65
Q

Advanced uterine cancer /inoperable disease/unfit for surgery

A
  • Chemotherapy
  • Radiotherapy
  • Hormones
  • Palliative Care

Cancer care (Y4) (30 decks)

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