Cancers Flashcards
What is Lynch syndrome lifetime risk of EC?
When should we offer TLH BSO
HPNCC
40-60%
Offer TLH BSO age 40
(TVUSS and endometrial biopsy annually from age 35 until hysterectomy)
Amsterdam criteria for Lynch
3 relatives with Lynch associated cancer (colorectal, endometrial, small bowel, ureter, renal pelvis) and:
- One is a first degree relative to the other two
- At least 2 successive generations
- At least one diagnosed at <50y
Pelvic exam for cervical cancer
Size, consistency, mobility of uterus, adnexal masses / parametrial thickening, palpate for ovaries, tumour nodules uterosacrals. PR for rectal involvement.
Colposcopy - BAD signs. concern for cancer
Bizarre vessels (looped, branching) and coarse mosaicism, punctation
Irregular surface + high grade lesion
Yellow, degenerate, friable epithelium + / - contact bleeding
Ulceration +HGL
Large complex lesion occupying 2 or 4 quadrants
HGL extending into canal
Management if concerned re lesion at colposcopy for cancer
BIOPSY
Post biopsy advice: nothing in vagina 1-2 weeks, brown/ grey discharge, come back if heavy bleeding, malodorous discharge
Refer GONC MDM with biopsy
For staging - CLINICAL
- Bloods: GBC, U+Es, LFTs, G+H
- Radiology: MRI or if big disease CXR and renal USS to check for hydronephrosis or CT or MRI
- EUA: (with radiation oncolgist if >stage 1: cystoscopy, sigmoidoscopy (+/- cone if biopsy indeterminate)
Treatment of cervical cancer
- STAGE 1A1 (define on answer too)
Stromal invasion <3mm
<1% LN mets
Either simple hyst or Cone for fertility preserving
Treatment of cervical cancer
- STAGE 1A2, 1B1, 1B2, IIA
<4cm!!!!!
1A2: stromal invasion ≥3 to <5mm
1B1 - macroscopic <2cm
1B2 - macroscopic ≥2 - <4cm
IIA1 - upper 2/3 vagina without parametrium <4cm
Rad hyst + PLND + BSO
(1A2 : small risk LN mets so can consider cone with PLND or radical trachelectomy + PLND)
(1B1: can consider radical tracehlectomy + PLND for fertility sparing - send PLN for frozen section
PLND: external iliac, obturator, common iliac (para - aortic only if concern about them - send for frozen section)
When should you offer adjuvant radiotherapy after surgery for cervical cancer
High risk group: chemo and radiation if positive surgical margins OR LN mets OR parametrial spread
Intermediate risk group should get RTX but no chemo if two of three tumour size >4cm, lymphovascular invasion, deep stromal invasion.
Low risk: none of above - no extra treatment
What is a radical hysterectomy
hyst (+ BSO) + vaginal cuff (2cm) + bilateral parametrium
- uterine arteries divided at source
- paravesical and pararectal spaces must be created
(paravesical bordered by obliterated umbilical artery medially, obturator internus laterally, symphysis pubis anteriorly, cardinal ligament posteriorly)
(pararectal space: rectum medially, internal iliac artery laterally, cardinal ligament anteriorly, sacrum posteriorly)
- medial half of cardinal ligaments and medial half of uterosacral ligaments.
What are the complications of a radical hysterectomy??
All the normal ones
Intrapelvic injury to autonomic nerves e..g hypogastric, sphlanchnic - impairment of urination, defecation, sexual function
ureteric injury
vessel injury
ileus, lymphoedema (20%) (lymphocyst 2-5%), DVT, bladder dysfunction (70%), vesicovaginal fistula (1%), sexual dysfunction
Treatment for tumour >4cm (IIA2 and above) cx ca
CCRT
Pelvic exenteration can be considered if IVA or recurrence
Radiotherapy (brachy and EBRT) PLUS Cisplatin once weekly ( makes tumour more radiotherapy sensitive)
Curative intent: EBRT 5 x / week for 5 weeks, cisplatinum 1x / week for 5 weeks, followed by vaginal brachytherapy
palliative: EBRT only
What is the FU for cervical cancer survivors
Three to four monthly for 2 to 3 years, then 6 monthly until 5 years then annual until death
Surg only: exam, yearly vault cytology, no role for routine imaging
Post RT: exam, no vault cytology, no role for routine imaging
SE Cisplatin
Myelotoxicitiy
ototoxicity
peripheral neuropahty
renal toxicity
SE RTX cx cancer
Short term
- cystitis, proctitis, enteritis
- Uterine perforation and sepsis with brachytherapy
- 1% mortality from PE with LDR brachy
Long term
- Vaginal fibrosis and stenosis (dilator therapy)
- Chronic UTIs 1-5%
- Intestinal and urinary strictures and fistulas 1.5 - 5%
- Radiation fibrosis bladder and bowel 6-8%
- Ovarian destruction and premature menopause
Recurrence cx cancer
- when
- what to do
most within 3 years
RTX if only surgery
Pelvic exenteration if RT treated
Cx cancer in pregnancy
- Concern about microinvasion on a preinvasive specimen - can you do treatment in pregnancy
LLETZ or cone 14-20/40
Cx cancer dx in pregnancy - what to do
MDM
EUA
MRI
CXR fetal shielding
Renal tract USS
Treat immediately if
- LN mets
- Pt choice
- IIA or above
<22/40: IAI cone, <2cm can do simple trachelectomy or large cone, 1B2 NACT - cisplatin and paclitaxel - STOP CTX 3/52 prior to delivery. Rad hyst 34/40
if concer about LN do LND whilst pregnant and if +VE NACT + early delivery, or TOP
> 22/40 - no suspicious LN - <2cm –>
treat 6-8/52 PP, >2cm: deliver and treat or NACT then CS and rad hyst
stage II - IV
- <26/40 TOP
- >26/40: CS and surg staging
Can have NVB if 1A1 or 1A2 - otherwise CS!!
What to do if incidental finding of cx cancer in hysterectomy specimen
≥1a2 - complete rad parametrectomy, upper vaginectomy and PLND OR EBRT
CCRT if positive surgical margins
Pre op ix for endometrial cancer
MRI abdo pelvis
CXR (esp for type 2 cancers)
CT CAP if Grade 3
Which LN does endometrial cancer go to?
utero-ovarian, parametrial, presacral
then to hypogastric, ext iliac, common iliac, presacral, paraaortic
