Cancer - done Flashcards
1
Q
Who does cervical cancer typically affect?
A
Younger women, peaking in reproductive years
2
Q
What are the common types of cervical cancer?
A
Squamous cell carcinoma (80%)
Adenocarcinoma
Small cell cancer
3
Q
What virus is cervical cancer typically associated with?
A
Human papillomavirus
4
Q
When are children typically vaccinated against HPV?
A
Aged 12-13
5
Q
What is the purpose of smear tests?
A
To screen for precancerous and cancerous changes to the cells of the cervix
6
Q
What type of cancer is HPV associated with?
A
Cervical
Anal
Vulval
Vaginal
Penis
Mouth
Throat
7
Q
What strains of HPV are responsible for cervical cancers?
A
Types 16 and 18
8
Q
What is the treatment for HPV infection?
A
No treatment (most infections resolve within 2 years)
9
Q
How does HPV cause cancer?
A
HPV produces two proteins E6 and E7 which inhibit tumour supressor genes p53 and pRb respectively
10
Q
What are the types of risks for cervical cancer?
A
- Increased risk of catching HPV
- Later detection of precancerous or cancerous changes (non-engagement with screening)
- Other risk factors
11
Q
What are the risks of catching HPV?
A
- Early sexual activity
- Increased number of sexual partners
- Sexual partners who have had more partners
- Not using condoms
12
Q
What are the other risk factors for cerival cancer?
A
- Smoking
- HIV (patients with HIV are offered yearly smear tests)
- COCP use for more than 5 years
- Increased number of full-term pregnancies
- Family history
- Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)
13
Q
What are the presenting symptoms of cervical cancer?
A
- Abnormal vaginal discharge (intermenstrual, postcoital or post-menopausal bleeding)
- Vaginal discharge
- Pelvic pain
- Dyspareunia (pain or discomfort with sex)
14
Q
After taking a history suspicious of cervical cancer, what is the next step?
A
Examine the cervix with a speculum (during examination swabs can be taken to exclude infection)
15
Q
What appearance on speculum is suggestive of cervical cancer?
A
- Ulceration
- Inflammation
- Bleeding
- Visible tumour
Urgent cancer referral for colposcopy should be made to assess further
16
Q
If a smear test returns normally can that rule out cervical cancer?
A
No
17
Q
What is cervical interaepithelial neoplasia?
A
A grading system for the level of dysplasia (premalignant change) in the cells of the cervix, its diagnosed at colposcopy (not with cervical screening)
18
Q
What are the different grades of cervical intraepithelial neoplasia?
A
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
19
Q
What is CIN III also known as?
A
Cervical carcinoma in situ
20
Q
What is the difference between dysplasia found during colposcopy and dyskaryosis on smear results?
A
21
Q
Who performs a smear test?
A
A practise nurse
22
Q
What are precancerous cells also known as?
A
Dyskaryosis
23
Q
What is the mode of transporting smear cells also known as?
A
Liquid-based cytology
24
Q
What are the smear samples initially tested for?
A
High-risk HPV before the cells are examined, if the HPV test is negative then the person does not have HPV and the cells are not examined and the smear is considered negative
25
How often is the smear test done?
Every 3 years for those ages 25-49
Every 5 years for those aged 50-64
26
What are the exceptions to the smear screening schedule?
- 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 undergoing a routing smear should wait **until 12 weeks post-partum**
27
What are the possible cytology results to the smear test?
Inadequate
Normal
Borderline changes
Low-grade dyskaryosis
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
Possible invasive squamous cell carcinoma
Possible glandular neoplasia
28
What other infections may be reported on the smear result?
- **Bacterial vaginosis**
- **Candidiasis**
- **Trichomoniasis**
29
When are actinomyces-like organisms found on a smear? Do they need treating?
Women with **intrauterine devices** (coil)
Do not require treatment unless they are symptomatic (e.g. pelciv pain or abnormal bleeding) - removal of the device may be considered
30
What are the possible management options of the smear test?
**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
31
What does a colposcopy involve?
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 this stains such as **acetic acid** and **iodine solution** can be used to differentiate abnormal areas
32
What types of cells does acetic acid target and what is the colour change?
Cells with an increased **nuclear to cytoplasmic ratio** (more nuclear material) e.g. cervical intraepithelial neoplasia and cervical cancer cells
Abnormal cells appear white (**acetowhite**)
33
What does Schiller's iodine test involve?
Using an **iodine solution** to stain the cells of the cervix - iodine will stain healthy cells a brown colour, abnormal cells will not stain
34
How can a tissue sample be obtained from a smear test?
**Punch biopsy** or **large loop excision of the transformational zone** can be performed during the colposcopy procedure
35
What is a large loop excision of the transformation zone (**LLETZ**) also known as?
Loop biopsy
36
How is a LLETZ performed?
Under local anaesthetic during a colposcopy with a loop diathermy to remove abnormal epithelial tissue on the cervix **cauterising** the tissue and stopping it from bleeding
37
What is the after care advice after a LLETZ?
**Bleeding and abnormal dischage** can occur for several weeks following a LLETZ procedure
**Intercourse and tampons should be avoided** to reduce the risk of infection
Increased risk of **preterm labour**
38
When is a cone biopsy done?
As a treatment for CIN and very early-stage cervical cancer under general anaesthetic
39
How is a cone biopsy done?
Surgeon removes a cone-shaped piece of the cervix using a scalpel - sent to histology to assess for malignancy
40
What are the main risks of a cone biopsy?
- Pain
- Bleeding
- Infection
- Scar formation with stenonsis of the cervix
- Increased risk of miscarriage and premature labour
41
What is the international federation of Gynaecology and Obstetrics (FIGO) **staging system** for **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
42
What is the usual treatment for cervical intraepithelial neoplasia and early-stage 1A cervical cancer?
LLETZ or cone biopsy
43
What is the treatment for:
Stage 1B – 2A
Stage 2B – 4A
Stage 4B cervical cancer?
**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
44
What is the range of 5 year survival depending on stage of cervical cancer?
98% with stage 1A
15% with stage 4
45
When is pelvic exenteration used?
**Advanced cervical cancer**
46
What is pelvic extenteration?
Operation to remove most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum (vast operation and has significant implcations on the quality of life)
47
What chemotherapy agent is used in the treatment of metastatic or recurrent cervical cancer?
**Bevacizumab** (avastin) a monoclonal antibody
48
What is the MOA of bevacizumab?
Targets **vascular endothelial growth factor A** (VEGF-A) which is responsible for the development of new blood vessels
49
What else is Bevacizumab used for?
Wet age-related macular degeneration - where it is injected directly into the patients eye to stop new blood vessels forming on the retina
50
What is the current NHS vaccine against HPV?
Gardasil (protects against stains 6, 11, 16 and 18)
51
Which strains of HPV cause genital warts?
6 and 11
52
Which strains of HPV cause cervical cancer?
16, 18 and 33
53
What helps when counselling parents for HPV vaccination?
It needs to be given **before** their child is sexually active and it protects them from cervical cancer and genital warts.
HPV is very **common** and infection is the **number one risk factor** for cervical cancer.
54
What is endometrial cancer?
Cancer of the **endometrium,** the lining of the uterus
55
What type of cancer are most endometiral cancers?
**Adenocarcinoma**
56
What stimulates the growth of endometrial cancer?
Oestrogen
57
What is the most likely diagnosis of a woman with postmenopausal bleeding?
**Endometrial cancer**
58
What is endometrial hyperplasia?
Precancerous condition involving thickening of the endometrium
59
What % of endometrial hyperplasias go on to become endometrial cancer?
**5%**
60
What are the two types of endometrial hyperplasias?
- **Hyperplasia without atypia**
- **Atypical hyperplasia**
61
How is endometrial hyperplasia treated?
By a specialist using **progestogens** with:
- **Intrauterine system** (e.g. Mirena coil)
- **Continuous oral progestogens** (e.g. medroxyprogesterone or levonorgestrel)
62
What is unopposed oestrogen?
Oestrogen without progesterone
63
What exposure puts a patient at risk of endometrial cancer?
Exposure to unopposed oestrogen
64
What are some causes of increased unopposed oestrogen?
- Increased age
- Earlier onset of mensturation
- Late menopause
- Oestrogen only HRT
- No or fewer pregnancies
- Obesity
- Polycystic ovarian syndrome
- Tamoxifen
65
How does **polycystic ovarian syndrome** lead to increased exposure to oestrogen?
Lack of ovulation
66
How does PCOS cause the endometrium to have more exposure to unopposed oestrogen?
67
What can be given to women with PCOS for endometrial protection
**Combined contraceptive pill**
**Intrauterine system**
**Cyclical progesterones**
68
Why is **obesity** a risk factor for **endometrial cancer**?
Adipose tissue is a source of oestrogen
69
What is the primary source of oestrogen in **post menopausal women**?
Adipose tissue
70
How does adipose tissue cause increases in oestrogen?
Contains **aromatase** which is an enzyme which converts **androgens** such as **testosterone** into **oestrogen**
71
Where are androgens mainly produced?
72
How does **tamoxifen** increase the amount of unopposed oestrogen?
**Anti-oestrogenic** effect on **breast tissue** but an **oestrogenic** effect on the **endometrium**
73
What are some risk factors for endometrial cancer which are not related to unopposed oestrogen?
**Type 2 diabetes**
**Hereditary nonpolyposis colorectal cancer** or **lynch syndrome**
74
How may type 2 diabetes increase the risk of endometrial cacner?
Increased production of **insulin** which stimulates the endometrial cells, causing hyperplasia and possibly cancer
75
What is the relationship between PCOS and insulin?
**PCOS** is associated with **insulin resistance** and increased **insulin production**
76
What are some protective factors for endometrial cancer?
**COCP**
**Mirena** coil
Increased **pregnancies**
Cigarette smoking
77
How is smoking protective against endometrial cancer?
**Anti-oestrogenic**
78
What oestrogen dependent cancer is smoking not protective against?
Breast cancer
79
How does smoking have an antioestrogenic effect?
- Oestrogen may be metabolised differently in smokers
- Smokers tend to be **leaner** and so have **less adipose tissue** and aromatase enzyme
- Smoking **destroys oocytes** (eggs) resulting in an earlier menopause
80
What is the main presenting symptom for endometrial cancer?
**Post-menopausal bleeding**
81
How else may endometrial cancer present?
**Postcoital bleeding**
**Intermenstrual bleeding**
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
82
When is a 2WW referral needed for suspected endometrial cancer?
**Postmenopausal bleeding** (more than 12 months since last menstrual period)
83
When is a transvaginal ultrasound required for women over 55 years old?
**Unexplained vaginal discharge**
**Visible haematuria** (plus raised platelets, anaemia or elevated glucose levels)
84
What are the three investigations for diagnosing and excluding endometrial cancer?
85
What is a **pipelle biopsy**?
Speculum examination with a thin tube inserted into the uterus through the cervix - tube fills with a sample of endometrial tissue that can be examined for **endometrial hyperplasia or cancer**
86
Why is a **pipelle biopsy** better than a **hysteroscopy** for excluding cancer in lower-risk women?
It's a **quicker** and **less invasive** alternative to hysteroscopy
87
What investigations are sufficient to rule out endometrial cancer and dischage a patient?
- Normal **transvaginal ultrasound** (endometrial thickness \< 4mm)
- Normal **pipelle biopsy**
88
What is the FIGO staging for **endometrial cancer**?
**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
89
What is the usual **treatment** for **stage 1 and 2** endometrial cancer?
**Total abdominal hysterectomy with bilateral salpingo-oophorectomy** (TAH and BSO - removal of cervix, uterus and adnexa)
90
What are the other treatments for endometrial cancer?
**Radical hysterectomy** (also removing the pelvic lymph nodes, surrounding tussue and top of the vagina)
**Radiotherapy**
**Chemotherapy**
**Progesterone** for hormonal treatment to slow the progression of the cancer
91
Why does ovarian cancer often present late?
**Non-specific symptoms** resulting in a worse prognosis (more than 70% of patients with ovarian cancer present after it has spread beyond the pelvis)
92
What are some different types of ovarian cancers?
93
What is the **most common** type of **ovarian cancer**? And some subsets?
Epithelial cell tumours
- Serous tumours (the most common)
- Endometrioid carcinoma
- Clear cell tumour
- Mucinous tumour
- Undifferentiated tumour
94
Are dermoid cysts / germ cell tumours benign or malignant?
Benign
95
What kind of tumours are dermoid cysts and germ cell tumours?
**Teratomas** (they come from germ cells)
96
What do teratomas contain?
Various tissue types such as skin, teeth, hair and bone
97
What are germ cell tumours associated with?
Ovarian torsion
98
What tumour markers may be raised in germ cell tumours?
**Alpha-fetoprotein**
**Human chorionic gonadotrophin**
99
Are sex cord-stromal tumours cancerous?
Can be benign or malignant
100
What are some types of sex cord-stromal tumours?
**Sertoli-leydig cell tumours**
**Granulosa cell tumours**
101
What is a **krukenberg tumour**?
Metastasis in the ovary, usually from a **gastrointestinal tract cancer** particularily the stomach
102
How do **Krukenberg** tumours appear on histology?
"**Signet ring**" cells on histology
103
What are some risk factors for ovarian cancer?
**Age** (peaks at 60)
**BRCA1 and BRCA2 genes** (consider the family history)
**Increased** number of **ovulations**
**Obesity**
**Smoking**
Recurrent use of **clomifene**
104
What are the factors which increase the number of ovulations (and thus the risk of ovarian cancer)?
- Early onset of periods
- Late menopause
- No pregnancies
105
What are some factors which are protective against ovarian cancer?
- Combined contraceptive pill
- Breastfeeding
- Pregnancy
106
How can ovarian cancer present?
Abdominal **bloating**
**Early satiety** (feeling full after eating)
**Loss of appetite**
Pelvic **pain**
**Urinary symptoms** (frequency / urgency)
**Weight loss**
**Abdominal or pelvic mass**
**Ascites**
(have a low threshold for referring older women)
107
Why does hip/groin pain occur in ovarian cancer?
Due to **compression on the obturator nerve** (as it passes along the inside of the pelvis, lateral to the ovaries)
108
When should a 2WW referral be made for suspected ovarian cancer?
- Ascites
- Pelvic mass (unless clearly due to fibroids)
- Abdo mass
109
What **symptoms** should prompt further investigations for ovarian cancer (starting with CA125)?
Women **older than 50** presenting with:
**New symptoms of IBS** / change in bowel habit
Abdominal **bloating**
**Early satiety**
**Pelvic pain**
**Urinary frequency or urgency**
**Weight loss**
110
What are the inital investigations for ovarian cancer in primary or secondary care?
CA125 blood test (\>35 is significant)
Pelvic ultrasound
111
What is the **risk of malignancy index** (RMI) calculating?
Risk of an ovarian mass being malignant
112
What is the RMI based on?
Menopausal status
Ultrasound findings
CA125 level
113
What are some other further investigations in secondary care to include?
**CT scan** to establish the diagnosis and stage cancer
**HIstology** (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
**Paracentesis** (ascitic tap) - assesses ascitic fluid for cancer cells
114
What tumour markers are required for a woman under 40 with a complex ovarian mass?
α-FP
hCG
115
What cancer is CA125 a marker for?
Epithelial cell ovarian cancer
116
What are the non-malignant causes of a raised CA125?
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infection
- Liver disease
- Pregnancy
117
What are the stages of the FIGO system used for 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)
118
How is ovarian cancer managed?
Specialist **gynarcology oncology MDT** usually involving a combination of surgery and chemotherapy
119
Is vulval cancer common?
Rare (compared with other gynarcological cancers)
120
What is the most common type of **vulval cancers**?
90% are **squamous cell carcinoma** (less commonly malignant melanoma)
121
What are some risk factors for vulval cancers?
- Advanced age (**over 75**)
- Immunosuppression
- HPV (human papillomavirus) infection
- **Lichen sclerosus**
122
What percent of women with **lichen sclerosus** get vulval cancer?
5%
123
What is **vulval intraepithelial neoplasia**?
Premalignant condition affecting the **squamous epithelium** of the skin preceding vulval cancer
124
What is a high grade squamous intraepithelial lesion?
Type of VIN associated with HPV infection that typically occurs in younger women aged 35-50 years
125
What is **differentiated VIN**?
**Alternative type** of **VIN associated with lichen sclerosus**, typically occuring in older women (aged 50-60 years old)
126
How is VIN diagnosed?
A biopsy
127
What are the treatment options for VIN?
**Watch and wait** with close follow up
**Wide local excision** (surgery) to remove the lesions
**Imiquimod** cream
**Laser ablation**
128
How may vulval cancer present?
Symptoms of:
Vulval **lump**
**Ulceration**
**Bleeding**
**Pain**
**Itching**
**Lymphadenopathy** in the groin
129
Where does vulval cancer commonly affect?
**Labia majora**
130
How to establish diagnosis of vulval cancer and stage?
**Biopsy** of the lesion
**Sentinel node biopsy** to demonstate lymph node spread
Further imaging for staging (CT abdo and pelvis)
131
What staging system is used for vulval cancer?
**FIGO**
132
What is the management of vulval cancer?
**Wide local excision** to remove the cancer
**Groin lymph node dissection**
**Chemotherapy**
**Radiotherapy**
