Cancer Flashcards
When is the peak incidence of cervical cancer?
reproductive years
What are the most common types of cervical cancer?
squamous cell carcinoma (80%)
adenocarcinoma
What is the most common cause of cervical cancer?
HPV type 16 and 18
How does HPV promote the development of cancer?
p53 and and pRb are tumour suppressor genes
HPV produces two proteins - E6 and E7
E6 protein inhibits p53
E7 protein inhibits pRb
What are the risk factors for cervical cancer?
increased risk of catching HPV = early sexual activity, increased number of sexual partners, sexual partners who have had more partners, not using condoms
non-engagement with cervical screening
smoking
HIV
COCP for >5 years
increased number of full-term pregnancies
family history
exposure to diethylstilbestrol during foetal development (used to prevent miscarriages before 1971)
What presenting symptoms should make cervical cancer be considered as a differential?
abnormal vaginal bleeding - intermenstrual, postcoital or post-menopausal bleeding
vaginal discharge
pelvic pain
dyspareunia
What cervical appearances may suggest cancer?
ulceration
inflammation
bleeding
visible tumour
What is the next step in a patient whose cervix has an appearance suggestive of cancer?
urgent cancer referral for colposcopy
What are the grades of cervical intraepithelial neoplasia?
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/cervical carcinoma-in-situ = severe dysplasia, very likely to progress to cancer if untreated
What women or trans men with cervixes get cervical screening?
every three years aged 25-49
every five years aged 50-64
patients with HIV are screened annually
over 65 may request a smear if they have not had one since aged 50
When should pregnant women due a routine smear test have it?
wait until 12 weeks postpartum
What is the management of smear results?
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
What stains can be used to identify abnormal areas during colposcopy?
acetic acid = abnormal cells appear white
Schiller’s iodine test = abnormal areas will not stain (normal areas stain brown)
What types of biopsy can be performed during colposcopy?
punch
large loop excision of the transformational zone (LLETZ)
How can the risk of infection after a LLETZ procedure be reduced?
avoiding intercourse and tampon use
What can a LLETZ procedure increase the risk of?
preterm labour
What is a cone biopsy
surgeon removes a cone shaped piece of the cervix using a scalpel under GA
What are the risks of a cone biopsy?
pain
bleeding
infection
scar formation with stenosis of the cervix
increased risk of miscarriage and premature labour
What strains of HPV cause genital warts?
6
11
What strains does the HPV vaccine protect against?
6
11
16
18
What is the most common type of endometrial cancer?
adenocarcinoma (80%)
What hormone is endometrial cancer dependent on?
oestrogen
What does any woman presenting with postmenopausal bleeding have until proven otherwise?
endometrial cancer
What are the two types of endometrial hyperplasia?
hyperplasia without atypia
atypical hyperplasia
What is the treatment of endometrial hyperplasia?
progestogens:
intrauterine system (e.g. mirena coil)
continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
What are the risk factors for endometrial cancer?
(think of what increases exposure to unopposed oestrogen)
increased age
earlier onset of menstruation
late menopause
oestrogen only HRT
no or fewer pregnancies
obesity
PCOS
tamoxifen (anti-oestrogenic effect on breast tissue but an oestrogenic effect on the endometrium)
additional (unrelated to unopposed oestrogen) = T2DM, hereditary nonpolyposis colorectal cancer (HNPCC)/Lynch syndrome
What are the protective factors against endometrial cancer?
COCP
mirena coil
increased pregnancies
cigarette smoking
Is smoking protective against oestrogen dependent cancer?
protective against endometrial cancer in postmenopausal women by being anti-oestrogen
not protective against breast cancer - increases the risk
How may smoking have anti-oestrogenic effects?
oestrogen may be metabolised differently in smokers
smokers tend to be leaner - less adipose tissue and aromatase enzymes
smoking destroys oocytes (eggs), resulting in an earlier menopause
What is the presentation of endometrial cancer?
main symptom = postmenopausal bleeding
other symptoms:
postcoital bleeding
intermenstrual bleeding
unusually heavy menstrual bleeding
abnormal vaginal discharge
haematuria
anaemia
raised platelet count
What is the criteria for a 2 week wait urgent cancer referral for endometrial cancer?
postmenopausal bleeding (>12 months after the last menstrual period)
What patients should be referred for a TVUS for suspected endometrial cancer?
unexplained change in vaginal discharge
visible haematuria + raised platelets, anaemia or elevated glucose levels
What are the three investigations for diagnosing and excluding endometrial cancer?
TVUS for endometrial thickness (normal is less than 4mm post-menopause)
pipelle biospy (highly sensitive making it useful to exclude cancer)
hysteroscopy with endometrial biopsy
What are the stages of endometrial cancer?
stage 1 = confined to the cervix
stage 2 = invades the cervix
stage 3 = invades the ovaries, fallopian tubes, vagina or lymph nodes
stage 4 = invades bladder, rectum or beyond the pelvis
What is the management of endometrial cancer?
stage 1 and 2 = total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH and BSO)
other options:
radical hysterectomy (removing the pelvic lymph nodes, surrounding tissues and top of the vagina)
radiotherapy
chemotherapy
progesterone to slow progression of the cancer
What is a Krukenberg tumour?
metastasis in the ovary, usually from a GI tract cancer
What is the histological appearance of Krukenberg tumours?
signet-ring cells
What are the risk factors for ovarian cancer?
BRCA1 and BRCA2 genes
increased number of ovulations = early menarche, late menopause, no pregnancies (nulligravidas)
obesity
smoking
recurrent use of clomifene
At what age is the peak incidence of ovarian cancer?
60 years
What are the protective factors against ovarian cancer?
factors that stop ovulation or reduce the number of lifetime ovulations:
COCP
breastfeeding
pregnancy
What are the symptoms of ovarian cancer?
abdominal bloating
early satiety
loss of appetite
pelvic pain
urinary symptoms (frequency, urgency)
weight loss
abdominal or pelvic mass
ascites
hip or groin pain (ovarian mass may press on the obturator nerve)
What patients should have a two week referral for suspected ovarian cancer?
ascites
pelvic mass (unless clearly due to fibroids)
abdominal mass
What are the initial investigations for suspected ovarian cancer?
CA125 blood test (>35 IU/ml is significant)
pelvic US
How is the risk of an ovarian mask being malignant calculated?
risk of malignancy index = menopausal status, US findings, CA125 level
What are the tumour markers for an ovarian germ cell tumour?
alpha-fetoprotein
HCG
What are the causes of a raised CA125?
epithelial cell ovarian cancer
endometriosis
fibroids
adenomyosis
pelvic infection
liver disease
pregnancy
What are the stages of ovarian cancer?
stage 1 = confined to the ovary
stage 2 = spread past the ovary but inside the pelvis
stage 3 = spread past the pelvis but inside the abdomen
stage 4 = spread outside the abdomen (distant metastasis)
What are the most common types of vulval cancer?
squamous cell carcinomas (90%)
malignant melanomas
What are the risk factors for vulval cancer?
> 75 years
immunosuppression
HPV infection
lichen sclerosus
What are the types of vulval intraepithelial neoplasia (VIN)?
high grade squamous VIN (associated with HPV infection, occurs ages 35-50)
differentiated VIN (associated with lichen sclerosus, occurs ages 50-60)
What are the treatment options for VIN?
watch and wait
wide local excision
imiquimod cream
laser ablation
What are the symptoms of vulval cancer?
vulval lump
ulceration
bleeding
pain
itching
lymphadenopathy in the groin
labia majora appearance:
irregular mass
fungating lesion
ulceration
bleeding
What is the FIGO staging of cervical cancer?
IA = confined to the cervix, only visible by microscopy, <7mm wide:
A1 = <3mm deep
A2 = 3-5mm deep
IB = confined to the cervix, clinically visible or >7mm wide:
B1 = <4cm diameter
B2 = >4cm diameter
II = extension of tumour beyond cervix but not to the pelvic wall:
A = upper two thirds of vagina
B = parametrial involvement
III = extension of tumour beyond the cervix and to the pelvic wall:
A = lower third of vagina
B = pelvic side wall
(any tumour causing hydronephrosis or a non-functioning kidney is considered stage III)
IV = extension of tumour beyond the pelvis or involvement of bladder or rectum:
A = involvement of bladder or rectum
B = involvement of distant sites outside the pelvis
What is the management of cervical cancer?
gold standard = hysterectomy +/- lymph node clearance
fertility preserving = cone biopsy with negative margins if stage IA1, radical trachelectomy (removal of cervix, upper part of vagina and surrounding tissue) if stage IA2
chemo and/or radio
What are the potential complications of radiotherapy for cervical cancer?
short-term = diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness
long-term = ovarian failure, fibrosis of bowel, skin, bladder and/or vagina, lymphoedema
What is the management of a patient with two inadequate smear results?
colposcopy
What lymph nodes do the ovaries drain to?
para-aortic
What lymph nodes does the uterus drain too?
fundus = para-aortic, inguinal
body = iliac
What lymph nodes does the cervix drain to?
external iliac
presacral
internal iliac
