Cancer Flashcards
Why is ovarian cancer frequently diagnosed at an advanced stage?
often diagnosed at an advanced stage due to non-specific symptoms, which can result in the disease being widely metastatic within the abdomen by the time it is detected
State the most common type of ovarian cancer and give 4 subtypes
epithelial cell tumours
* serous adenocarcinoma (mc)
* endometroid carcinoma
* clear cell carcinoma
* mucinous adenocarcinoma
How does the number of ovulations relate to the risk of ovarian cancer?
Factors that increase the number of ovulations increase the risk of ovarian cancer.
* Early menarche
* late menopause
* nulliparity
What are some risk factors for ovarian cancer?
- increase age
- FHx - BRCA1 & 2 gene
- obesity
- many ovulations - early, late menopause, nulliparity
Give 3 factors that are protective against ovarian cancer
- combined contraceptive pill
- breastfeeding
- pregnancy
What are some symptoms that may indicate ovarian cancer?
- persistent abdo distension (bloating)
- early satiety (feeling full)
- loss of appetite
- pelvic/abdo pain
- urinary symptoms (frequency/urgency)
- weight loss
- abdominal/ pelvic mass
- ascites.
When should a 2-week-wait referral for suspected ovarian cancer be made based on physical examination findings?
- ascites
- pelvic mass (unless clearly due to fibroids)
- abdominal mass
What are the initial investigations for ovarian cancer in primary care?
- CA125 blood test
- pelvic ultrasound: ascites and/ or mass = urgent referral
What investigations are done in secondary care for suspected ovarian cancer
- CT pelvis/ abdo: establish disease extent
- calculate risk of malignancy index
What factors does the Risk of Malignancy Index (RMI) use to estimate the risk of an ovarian mass being malignant?
- menopausal status
- ultrasound findings
- CA125 level.
When calculating the Risk of Malignancy Index (RMI), how is the ultrasound result scored?
the ultrasound result is scored 1 point for each of the following characteristics:
* multilocular cysts
* solid areas
* metastases
* ascites
* bilateral lesions
U=1: 1pt
U=3: 2-5pts
What tumour markers are required for women under 40 years with a complex ovarian mass to assess for a possible germ cell tumour
- Alpha-fetoprotein (α-FP)
- Human chorionic gonadotropin (HCG)
What are the stages of ovarian cancer according to the International Federation of Gynaecology and Obstetrics (FIGO) staging system?
- Stage 1: Confined to the ovary.
- 2: Spread past the ovary but inside the pelvis.
- 3: Spread past the pelvis but inside the abdomen.
- 4: Spread outside the abdomen (distant metastasis).
How is ovarian cancer managed surgically
- total hysterectomy, bilateral salpingo-oophrectomy and partial omentectomy
- mid line laparotomy - assess abdo and pelvis
How is ovarian cancer managed medically
confirmed tissue diagnosis needed before chemotherapy (stage 1C onwards)
* 6 cycles of neoadjuvant chemo: carboplatin and paclitaxel
What is endometrial hyperplasia
a precancerous condition involving thickening of the endometrium
What are the 2 types of endometrial hyperplasia
- Hyperplasia without atypia
- Atypical hyperplasia
How is endometrial hyperplasia managed
- Intrauterine system (e.g. Mirena coil)
- Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
- hysterectomy for atypia
Give 5 RFs of endometrial cancer related to unopposed endogenous/exogenous oestrogen
- obesity (endo)
- PCOS - prolonged amenorrhea (endo)
- early menarche (endo)
- nulliparity (endo)
- late menopause (endo)
- tamoxifen therapy (exo)
- HRT (exo)
Give 3 RFs of endometrial cancer that are NOT associated with unopposed oestrogen
- T2DM
- > 55yo
- Lynch 2 syndrome
Give 3 protective factors of endometrial cancer
- combined contraceptive pill
- pregnancy
- smoking
Give 3 symptoms of endometrial cancer
- postmenopausal bleeding (10% risk) - mc presentation
- intermenstrual bleeding
- unusually heavy menstrual bleeding
- haematuria
What is the referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer?
women over the age of 55 with Postmenopausal bleeding (more than 12 months after the last menstrual period) should be investigated within two weeks by ultrasound for endometrial cancer
How is endometrial cancer investigated
- transvaginal ultrasound for endometrial thickness
- Pipelle biopsy - highly sensitive
- Hysteroscopy with endometrial biopsy (GS)
When should women over 55 years be referred for a transvaginal ultrasound
- Unexplained vaginal discharge
- Visible haematuria plus raised platelets, anaemia or elevated glucose levels
What are the stages of endometrial cancer according to the FIGO staging system?
- 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 the bladder, rectum, or beyond the pelvis.
How is endometrial cancer managed surgically
- total laparoscopic hysterectomy with salpingo-oophrectomy
How is endometrial cancer managed medically
- external beam radiotherapy
- adjuvant chemo: paclitaxel and carboplatin
- progesterone hormone Tx
What are the most common types of cervical cancer?
- 80% of cervical cancers are squamous cell carcinoma
- adenocarcinoma - 2nd mc
What is the most common cause of cervical cancer
infection with human papillomavirus (HPV)
Which 2 HPV strains are most associated with cervical cancer and targeted with the HPV vaccine
16 and 18
At what age are children vaccinated against certain strains of HPV to help reduce the risk of cervical cancer?
aged 12 to 13 years
Explain the pathology of cervical intraepithelial neoplasia
- As the columnar epithelium of the cervix undergoes metaplasia to squamous epithelium, exposure to certain HPV results in incorporation of viral DNA into cell DNA
- Viral proteins (E6 and E7) inactivate tumour suppressor genes (P53 and pRb)
- mutations accumulate and can lead to carcinoma
Give 5 RFs of cervical cancer
- HPV infection
- smoking
- non-engagement with screening
- Immunosuppression - HIV/ transplant
- early onset of sexual activity, multiple sexual partners
- high parity
- COCP
What is cervical intraepithelial neoplasia
histological abnormality of the cervix in which abnormal epithelial cells occupy varying degrees of the squamous epithelium
What test is used to diagnose Cervical Intraepithelial Neoplasia (CIN) ?
colposcopy
What are the grades of Cervical Intraepithelial Neoplasia (CIN) and their characteristics?
CIN I: Mild dysplasia affecting 1/3 of the thickness of the epithelial layer, likely to return to normal spontaneously
CIN II: Moderate dysplasia affecting 2/3 of the thickness of the epithelial layer, likely to progress to cancer if untreated.
CIN III: Severe dysplasia affecting full thickness of epithelium, very likely to progress to cancer if untreated. This is carcinoma in situ.
What is the cervical screening schedule for women and transgender men with a cervix?
- Every three years for those aged 25–49.
- Every five years for those aged 50–64.
What are the notable exceptions to the cervical screening program?
- Women with HIV are screened annually.
- Women >65 can request a smear if they haven’t had one since age 50.
- Women with previous CIN may need additional tests (e.g. test of cure after treatment).
- Certain immunocompromised women (e.g., on dialysis, cytotoxic drugs, or organ transplant) may have additional screening.
- Pregnant women due for a smear should wait until 12 weeks post-partum.
What is the aim of cervical cancer screening
aims to detect women that are likely to have cervical intraepithelial neoplasia and therefore at risk of subsequent development of cancer
What is the method used to transport cervical cells for examination in a smear test?
liquid-based cytology
What term is used for cellular abnormalities identified in cervical smears?
dyskaryosis
What are the possible cytology results in cervical screening?
- Inadequate
- Normal
- Borderline changes
- Low-grade dyskaryosis
- High-grade dyskaryosis (moderate/severe)
- invasive squamous cell carcinoma
- cervical glandular intraepithelial neoplasia (any grade)
What happens if a sample tests positive or negative for high-risk HPV in cervical screening?
The samples are first tested for high-risk HPV.
* negative hrHPV - no cytology, woman returns to routine screening
* hrHPV positive -> cytology.
What is the next step if the patient is hrHPV positive and cytology is abnormal
refer for colposcopy
What is the next step if cytology is normal but the patient is hrHPV positive?
Repeat the test in 12 months.
What should be done if the repeat smear test at 12 months is hrHPV negative?
Return to normal recall.
What is the next step if the repeat smear test at 12 months is hrHPV positive but cytology remains normal?
Perform a further repeat test in 12 months.
What is the next step if the repeat smear test at 24 months is hrHPV negative?
Return to normal recall.
What should be done if the repeat smear test at 24 months is still hrHPV positive?
Refer for colposcopy.
When should individuals treated for CIN1, CIN2, or CIN3 be invited for a follow-up test?
should be invited for a test of cure repeat cervical sample 6 months after treatment in the community
What is the next step if a sample comes back as ‘inadequate’
repeat test in 3 months
What is the next step if two consecutive cervical samples are ‘inadequate’?
The patient should be referred for colposcopy.
How are abnormal areas differentiated during colposcopy?
stains such as acetic acid and iodine solution can be used to differentiate abnormal areas
What effect does acetic acid have on abnormal cells during colposcopy
Acetic acid causes abnormal cells to appear white.
What symptoms should prompt consideration of cervical cancer as a differential diagnosis?
- abnormal vaginal bleeding (intermenstrual, postcoital, or post-menopausal bleeding)
- Offensive vaginal discharge
Late features: - Pelvic pain
- Dyspareunia (pain or discomfort during sex)
How is cervical cancer investigated
- vaginal/ speculum - mass/ bleeding
- colposcopy
- cone biopsy or large loop excision of transformation zone (LLETZ)- confirm diagnosis
- MRI - lymph node involvement
How is cervical cancer staged using the FIGO system?
- 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
What are the typical treatments for cervical cancer based on its stage?
- CIN/ stage 1a: LLETZ or cone biopsy (maintain fertility), radical trachelectomy
- Stage 1B-2A: Radical hysterectomy and removal of local lymph nodes with chemo and radiotherapy
- stage 2B-4A/ +ve nodes: pelvic external beam radiotherapy and chemo (cisplatin)
- 4B: chemo (cisplatin + paclitaxel +/- bevacizumab)
What are the complications of cone biopsy
- bleeding
- preterm labour
- pain
What is vulval intraepithelial neoplasia (VIN), and what can it lead to if untreated?
pre-cancerous condition affecting the squamous epithelium of the skin, which can lead to vulval cancer if left untreated
Give 4 RFs for vulval intraepithelial neoplasia
- HPV 16 & 18
- Smoking
- lichen sclerosus
- HSV-2
What are the two types of vulval intraepithelial neoplasia (VIN), and what are their associations?
- Usual: High-grade squamous intraepithelial lesion (HSIL) - associated with HPV
- Differentiated VIN - associated with lichen sclerosis
At what ages do the 2 types of VIN typically occur?
- High-grade squamous intraepithelial lesion - younger women aged 35–50 years.
- Differentiated VIN - older women aged 50–60 years.
Give 3 features of vulval intraepithelial neoplasia
- itching
- burning
- raised, well-defined skin lesion
How is vulval intraepithelial neoplasia investigated
- Punch/ excisional biopsy - histological diagnosis
- HPV testing
How is vulval intraepithelial neoplasia managed
- Topical: imiquimod (immune response modifier)
- Surgical: wide local excision or laser ablation
- follow-up: rpt colposcopy and biopsy if recurrence/ progression is suspected
What type of cancer makes up the majority of vulval cancers?
Around 90% of vulval cancers are squamous cell carcinomas.
Give 5 RFs of vulval cancer
- Advanced age >75
- immunosuppression
- lichen sclerosus
- HPV infection
- Vulval intraepithelial neoplasia
- smoking
Give 4 clinical features of vulval cancer
- lump or ulcer of labia majora
- Inguinal lymphadenopathy
- itching or irritation
- bleeding
How is vulval cancer diagnosed
- biopsy of the lesion
- sentinel node biopsy - demonstrate lymph node spread
How is vulval cancer treated
- wide local excision
- groin lymphadenectomy
- chemo and radiotherapy
