Cancer Flashcards
Ctype of epithelium in cervical cancer
s.c.c (most common)
adeno
associations of cervical cancer
Human papilloma virus
when vaccinated against HPV
12-13 yrs
if HPV +ve increased risk of what other cancers
anal
vulval
vaginal
penis
mouth and throat
2 important strains of HPV
type 16 and 18
what tell pt with HPV +VE
no treatment for infection with HPV. Most cases resolve spontaneously within two years, while some will persist.
pathophysiology of HPV causing cervical cancer
P53 and pRb are tumour suppressor genes. They have a role in suppressing cancers from developing. HPV produces two proteins (E6 and E7) that inhibit these tumour suppressor genes. The E6 protein inhibits p53, and the E7 protein inhibits pRb. Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.
risk fx of cervical cancer
Increased risk of catching HPV
Later detection of precancerous and cancerous changes (non-engagement with screening)
Other risk factors
Smoking
HIV (patients with HIV are offered yearly smear tests)
Combined contraceptive pill use for more than five years
Increased number of full-term pregnancies
Family history
Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)
increased risk of catching HPV
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
presentation of cervical cancer
asx - screening
Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
Vaginal discharge
Pelvic pain
Dyspareunia (pain or discomfort with sex)
ix for cervical cancer
examine cervix with speculum and swab
if abnormal - urgent referral for colposcopy
cervical appearance requiring 2WW
Ulceration
Inflammation
Bleeding
Visible tumour
grading system for dysplasia in cervical cancer
CIN
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/carcinoma in situ
how screening for cervical cancer
The cells are deposited from the brush into a preservation fluid. This fluid is transported to a lab where the cells are examined under a microscope for precancerous changes (dyskaryosis). This way of transporting the cells is called liquid-based cytology.
tested for high risk HPV, if -ve, cells not examined and smear is negative
when attend cervical screening
Every three years aged 25 – 49
Every five years aged 50 – 64
cervical screening additional testing circumstances
Women with HIV are screened annually
Women over 65 may request a smear if they have not had one since aged 50
Women with previous CIN may require additional tests (e.g. test of cure after treatment)
Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
Pregnant women due a routine smear should wait until 12 weeks post-partum
infections found on smear
BV
candidiasis
trichomoniasis
IUS infection associated
Actinomyces-like organisms are often discovered in women with an intrauterine device (coil). These do not require treatment unless they are symptomatic. Where the woman is symptomatic (e.g. pelvic pain or abnormal bleeding), removal of the intrauterine device
Summary of mx from 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 is colposcopy
inserting a speculum and using equipment (a colposcope) to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail. During colposcopy, stains such as acetic acid and iodine solution can be used to differentiate abnormal areas
If abnormal - white with acetate, not stain wirh iodine
How get tissue sample during colposcopy
Punch biopsy
Large loop excision of transformation zone
Large loop excision of the transformation zone how work
Local anaesthetic
using a loop of wire with electrical current (diathermy) to remove abnormal epithelial tissue on the cervix. The electrical current cauterises the tissue and stops bleeding.
S/e - bleeding and abnormal discharge, increases risk of pre term labour
C/i - using tampons or sex after
Cone biopsy how work
Indications - can be used for tx for CIN and very early stage cancer
General anaesthetic
Sent for histology
Risks -Pain
Bleeding
Infection
Scar formation with stenosis of the cervix
Increased risk of miscarriage and premature labour
Staging cervical cancer
FIGO
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
Mx of cervical cancer
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
Survival cervical cancer
The 5-year survival drops significantly with more advanced cervical cancer, from around 98% with stage 1A to around 15% with stage 4.
Mx of advanced cervical cancer
Pelvic exenteration - removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum.
Chemo Tx of cervical cancer
Bevacizumab (avastin) - targets vascular endothelial growth factor A (VEGF-A), which is responsible for the development of new blood vessels. Therefore, it reduces the development of new blood vessels. You may also come across this medication as a treatment for wet age-related macular degeneration
HPV strains causing genital warts
6 and 11
When HPV vaccine given?
Before sexually active
Type of epithelium endometrial cancer
Adenocarcinoma
Typical presentation of endometrial cancer
any woman presenting with postmenopausal bleeding has endometrial cancer until proven otherwise
Key risk fx for endometrial cancer
Obesity
DM
Endometrial hyperplasia types
Hyperplasia without atypia
Atypical hyperplasia
How endometrial hyperplasia tx
Intrauterine system (e.g. Mirena coil)
Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
Risk fx endometrial cancer
Unopposed oestrogen
stimulates the endometrial cells and increases the risk of endometrial hyperplasia and cancer
Risk fx of unopposed oestrogen
Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen
PCOS unopposed oestrogen
Usually, when ovulation occurs, a corpus luteum is formed in the ovaries from the ruptured follicle that released the egg. It is this corpus luteum that produces progesterone, providing endometrial protection during the luteal phase of the menstrual cycle (the second half of the menstrual cycle). Women with polycystic ovarian syndrome are less likely to ovulate and form a corpus luteum.
Main cause of unopposed oestrogen in postmenopausal women
Obesity - Adipose tissue contains aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen. Androgens are produced mainly by the adrenal glands. In women with more adipose tissue, and therefore more aromatase enzyme, more of these androgens are converted to oestrogen
Also not ovulating so no corpus luteum to produce progesterone
Drug that increases risk of endometrial cancer
Tamoxifen
Risk fx of endometrial cancer unrelated to unopposed oestrogen
Type 2 diabetes
Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome
Protective fx against endometrial cancer
Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking
Presentation of endometrial cancer
Post menopausal bleeding!
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
Referral for endometrial cancer
a 2-week-wait urgent cancer referral for endometrial cancer is:
Postmenopausal bleeding (more than 12 months after the last menstrual period)
NICE also recommends referral for a transvaginal ultrasound in women over 55 years with:
Unexplained vaginal discharge
Visible haematuria plus raised platelets, anaemia or elevated glucose levels
Ix for endometrial cancer
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
Hysteroscopy with endometrial biopsy
Stages of endometrial cancer
FIGO
Stage 1: Confined to the uterus
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
Mx of endometrial cancer
stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa
radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer
Types of ovarian cancer
Epithelial cell tumours
Dermoid cysts
Sex cord stromal tumours
Mets
Types of epithelial cell tumours
Serous tumours (the most common)
Endometrioid carcinomas
Clear cell tumours
Mucinous tumours
Undifferentiated tumours
Dermoid cysts clinical do
tissue types, such as skin, teeth, hair and bone.
Associations of Dermoid cysts
Ovarian torsion
Germ cell tumours markers
alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG)
Types of sex cord stromal tumours
Sertoli–Leydig cell tumours and granulosa cell tumours.
Term for metastatic ovarian cancer
Krukenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach
Krukenberg tumours on histology
Signet ring cells
Risk fx for ovarian cancer
Age (peaks age 60)
BRCA1 and BRCA2 genes (consider the family history)
Increased number of ovulations
Obesity
Smoking
Recurrent use of clomifene
Protective fx of ovarian cancer
Combined contraceptive pill
Breastfeeding
Pregnancy
Ovarian cancer clinical fx
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
may press on the obturator nerve and cause referred hip or groin pain.
Referral criteria ovarian cancer
2-week-wait referral if a physical examination reveals:
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
Ix for ovarian cancer
Ca125
(>35 IU/mL is significant)
Pelvic ultrasound
Further:
CT
Histology
Paracentesis
Risk scoring of ovarian mass being malignant
Risk of malignancy index
Menopausal status
Ultrasound findings
CA125 level
When germ cell tumours more likely
<40 with complex ovarian mass
Other causes of raised ca 125
Non specific -
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
Staging of ovarian cancer
FIGO
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)
Mx of ovarian cancer
gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.
Types of epithelium vulval cancer
S.c.c
Malignant melanoma
Risk fx for vulval cancer
Advanced age (particularly over 75 years)
Immunosuppression
Human papillomavirus (HPV) infection
Lichen sclerosus
Premalignant vulval cancer
VIN :
High grade squamous intraepithelial lesion is a type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years.
Differentiated VIN is an alternative type of VIN associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years).
Diagnosis of VIN
Biopsy
Tx of VIN
Watch and wait with close followup
Wide local excision (surgery) to remove the lesion
Imiquimod cream
Laser ablation
VIN clinical fx
Vulval lump
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in the groin
O/E vulval cancer
Labia majors - Irregular mass
Fungating lesion
Ulceration
Bleeding
Mxof vulval cancer
Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy
