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
Surgery for endometrial cancer
TAH (vs TLH early), +/- BSO (unless <45y)
Assess diaphragm, liver, bowel, peritoneal surfaces, omentum, pelvic and para-aortic LN. NO WASHINGS anymore
Surgery for endometrial cancer
TAH (vs TLH early), +/- BSO (unless <45y)
Assess diaphragm, liver, bowel, peritoneal surfaces, omentum, pelvic and para-aortic LN. NO WASHINGS anymore
Management of endometrial cancers - low risk
1A, grade 1-2, LVSI neg
TLH +/- BSO unless >45y –> no adjuvant therapy (can sometimes do sentinel LN biopsy)
Management of endometrial cancers - intermediate risk
1b, grade 1-2, LVSI neg
Do TAH +/- BSO + brachytherapy
Management of endometrial cancers - high intermediate risk
1B grade 3, 1a + 1b but LVSI +ve
TAH / BSO + brachy + EBRT
Surgery for endometrial cancer
TAH (vs TLH early), +/- BSO (unless <45y)
Assess diaphragm, liver, bowel, peritoneal surfaces, omentum, pelvic and para-aortic LN. NO WASHINGS anymore
Management of endometrial cancers - high risk
Stage II and above
- II cx
- IIIa - serosa or adnexa
- IIIb - vagina or parametrium
- IIIc - pelvic or para-aortic nodes
- IVA - bladder or bowel mucosa
- IVB - distant mets incl intrabdominal / inguinal LN
Rad hyst + BSO + pelvic LN +/- selective aortic nodes
+ EBRT +/- CRT
IV: combo
What are the advantages and disadvantages of sentinel LN?
Advantage: less morbidity, pick up uncommon LN pathways
Disadvantage: isolated tumour cells elsewhere
What is the FU for endometrial cancers
3-4/12 for 2 y
6/12 for up to 5 y
Inspect vault!!
Ovarian cancer: risk factors
Age (peak = 60)
Nulliparity
Infertility
Perineal talc
Obesity
HRT use
BRCA1 1:2
BRCA 2 1:5
Lynch 1:10
How do you diagnose / investigate ovarian cancer?
USS
Ca125 (epithelial), Ca19-9 (mucinous), CEA (GI)
<40y
AFP (germ cell e.g. yolk sac, immature teratoma, sex cord: sertoli-leydig)
LDH: dysgerminoma (germ cell)
HCG: embryonal, choriocarcinoma (germ cell)
Inhibin B: granulosa cell tumour (sex cord stromal)
Tissue sample - biopsy to guide chemo particularly if poor surgical candidate, advanced stage disease
CTCAP
Ovarian cancer
Stage 1
1A: one ovary
1B: two ovaries
1C1: both ovaries and surgical spill
1C2: capsule rupture pre op or cancer on surface
IC3: in ascites or washings
Ovarian cancer
Stage II
II = pelvic extension
IIA: uterus / tubes
IIB: other pelvic tissues
Ovarian cancer stage III
Spread to peritoneum past pelvis +/- mets to retroperitoneal LN
IIIA: LN or microscopic mets beyond pelvic
IIIB: macroscopic mets ≤2cm +/- LN
IIIC: >2cm - incl liver capsule / spleen
Ovarian cancer stage IV
IVA: positive pleural effusion cytology
IVB: liver / spleen parenchyma / extraabdo organs
Treating epithelial cancer (high grade serous, low grade serous (not v chemosensitive), mucinous, clear cell, endometrioid )
Stage 1-2
Stage 1: TAH, BSO, peritoneal washings, infracolic and infragastric omentectomy, pelvic and para-aortic LND. assess all peritoneal surfaces (diaphragm, liver, GB, spleen, pancreas, bowel), 4 quadrant peritoneal biopsy.
Stage 2: As above but only debulk pelvic / para-aortic LN as having chemo anyway and less morbid
Aim is cytoreduction
- Complete - no macroscopic disease
If incompletely staged 1A / 1B - need CTX, id completely staged - don’t
All others CTX required
Carboplatin and paclitaxel 6 cycles, 3 weeks apart. Start 2-6/52 post op.
Other options for treatment for epithelial cancers as well as surgery and chemo
PARP inhibitors (stops DNA repair in cancers)- give to BRCA patients as huge survival advantage - 20/12 more with olaparib - funded in NZ for BRCA.
Avastin: angiogenesis inhibitor. Can give if BRCA neg. Gives 2/12 extra OS. 2000USD / month
SE of paclitaxel
alopecia, N, V, neurotoxicity, arthralgia, hypersensitivity, nephrotoxicity, neutropenia
MENOPAUSE
How do you treat stage III - IV ovarian epithelial cancer?
Often neoadjuvant CTX, then IDS, then 3 further cycles.
includes diaphragmatic stripping, bowel resection, liver resection, partial gastrectomy, cholecystectomy, splenectomy
MDT!
ICU!
High risk complications!
What is the FU for epithelial ovarian cancers?
3-4/12 2 y
6/12 5 y
Then unclear
Pelvic exam, Ca125 (or other tumour marker if a different one was raised).
How do you treat relapse of ovarian cancer?
> 6/12 from chemo: can treat again with platinum based CTX +/- cytoreduction +/- avastin
<6/12: second regime CTX +/- avastin
When should you do RR surgery for BRCA and Lynch
BRCA 1: 40y, (or 5y prior to sentinel event)
BRCA 2: 45y (or 5y prior to sentinel event)
Lynch: 40y
What are types of Germ cell tumours?
Teratoma
Choriocarcinoma
Embryonal
Mixed germ cell
Yolk sac tumour
What tumour markers should you do to investigate for a germ cell tumour?
AFP: YS, immature teratoma
HCG: embryonal, choriocarcinoma
LDH: dysgerminoma
Who has germ cell tumours?
Adolescents
How do germ cell tumours present?
Ascites, rupture, torsion, mass effect, precocious puberty, abnormal vaginal bleeding.
Grow rapidly and present early stage
How should you investigate a young person with an ovarian mass?
USS
MRI
Tumour markers
How should you treat Germ cell tumours?
1A: USO, omentectomy, washings, peritoneal sample, contralateral ovarian sample, LN assessment
No CTX
1B: try and preserve one ovary
1C: post op CTX
> 1C - BEP - bleomycin, etoposide, cisplatin
Wait 2 y before try and conceive
How do you FU patients with Germ cell tumours after surgery?
Tumour markers 4 weekly for 6/12, then 2/12 for 6/12, then 3/12 for one year then 3-6/12 for 1 year, then 6/12 for 2y, then annually up to 2 y
What are types of sex cord stromal tumours?
sertoli leydig
granulosa
What tumour markers do you do to investigate sex cord stromal tumours?
Inhibin
Estradiol
Testosterone
AFP
What investigations should you do to investigate sex cord stromal tumours?
tumour markers: inhibin, estradiol, testosterone, AFP
USS
Pipelle if AUB or ET >4-5mm in PM pt
