CASE 5 - LEUKAEMIA Flashcards
Human Papillomavirus (HPV) infection is required for cervical cancer to develop. Which types of HPV are responsible for the majority of HPV cases?
HPV 16 / 18
What other types of cancer can HPV 16 / 18 cause?
Anal cancer
Outline the HPV-related pathophysiology of cervical cancer development
- Infection with HPV
- Integration of HPV into host genome
- Cell transforms –> cervical dysplasia (aided by other RFs such as smoking)
- MOST infections are cleared by the immune system
- In some women, the infection progresses into high-grade cervical intraepithelial neoplasia (CIN3) and CERVICAL CANCER
Describe the 2 most common cervical cancer subtypes
- SQUAMOUS CELL CARCINOMA
Originates from cells on the surface (ecto-cervix) - ADENOCARCINOMA
Originates from glands of the cervix (endo-cervix)
List 4 common symptoms of cervical cancer
- Bleeding after intercourse
- Bleeding in between menstrual periods
- Abnormal vaginal discharge
- Post-menopausal bleeding
Over __% of HPV infections clear up after 2 years, whilst up to __% of persistent oncogenic HPV infections progress into cancer
Over 80% of HPV infections clear up after 2 years, whilst up to 30% of persistent oncogenic HPV infections progress into cancer
4 factors that promote the development of cervical cancer
- Smoking
- Early age of first sexual intercourse (more to do with chronic or re-infections)
- Multiple sexual partners
- Immunosuppression
In which area of the cervix do most cervical cancers originate?
Transformation zone / squamocolumnar junction
This is where the squamous and columnar cells meet
How is the transformation zone (TZ) classified? Explain them. (3 types)
TYPE I - TZ fully visible and ecto-cervical
TYPE II - TZ fully visible, but partially in the endocervical canal (most common during reproductive years)
TYPE III - TZ not fully visible and is in the endocervical canal (most common in post-menopausal women)
The number of women diagnosed with cervical cancer has dropped by __% since cervical cancer screening began in 1991 (1991-2005).
The number of women diagnosed with cervical cancer has dropped by 4.5% since cervical cancer screening began in 1991 (1991-2005).
This is an impressive decrease, not seen in any other screening program!
Name the prophylactic vaccine for HPV 16, 18, 6, and 11.
What percentage of cervical cancers does it protect against?
Gardasil
Also v effective!
Protects against 77% of cervical cancers
Name the new vaccine that now protects against 93% of cervical cancers
Gardasil 9
A new cervical screening program was implemented in 2018 (5-yearly HPV testing w/liquid-based cytology). Describe the process involved.
5-yearly screening from women aged 25-69 years.
- Uses a primary HPV test (smear taken and tested for HPV infection).
- It undergoes cytological examination ONLY if HPV infection is found (if not, the woman continues with 5-yearly screening).
- HPV 16/18: refer for colposcopy
- HPV NOT 16/18: repeat screening in 1 year
What is colposcopy and why is it used in women with a positive HPV 16/18 test?
Colposcopy is the examination of the cervix with a magnifying instrument.
It is used to further evaluate abnormal cervical screening tests.
Acetic acid applied –> infected cells stain white and can be visualised
Why do abnormal cells stain white (acetowhite changes)?
Reflects higher protein content due to increased cellular protein and DNA content during HPV infection
How is cervical cancer diagnosed? Describe the 2 approaches/types of investigations.
BIOPSY:
- LOOP EXCISION: thin, electrical wire used to obtain cervical tissue (also called large loop excision of the transformation zone, LLETZ)
- CONE BIOPSY / CONIZATION: cone-shaped sample of the uterine cervix is removed. Allows evaluation of deeper layers.
How does treatment differ for early-stage vs. advanced cervical cancers?
EARLY STAGE: operable
ADVANCED: combined chemo and radiotherapy
What type of surgery is usually performed for cervical cancer?
Extent of surgery depends on stage of disease
Usually, it is a Radical Hysterectomy (removal of uterus & tissue next to the cervix. NOT the ovaries and tubes, as cervical cancer doesn’t spread here)
Pelvis lymph nodes also removed to ensure cancer hasn’t spread
What does cervical cancer chemo and radiotherapy entail?
EBRT + Brachytherapy
Chemotherapy given during radiotherapy as a sensitiser to make the cancer cells more susceptible to X-rays
Do HPV vaccines negate cervical screening?
NO: vaccines do not protect against ALL forms of cervical cancer, therefore screening is still necessary.
What is leukaemia?
Cancers that develop in the bone marrow
Neutrophilia indicates what type of leukaemia?
Myeloid
Lymphocytosis indicates what type of leukaemia?
Lymphoid
List the 4 main types of leukaemia in ascending order according to the age groups they most commonly manifest in
- Acute lymphoblastic leukaemia (ALL): most common in children 2-5 years
- Chronic myeloid leukaemia (CML): most common in adults ~50-60 years old
- Acute myeloid leukaemia (AML): ~65 years old
- Chronic lymphocytic leukaemia (CLL): ~70 years old, but not uncommon in younger populations (30-39). Incidence increases with age.
(memory tip: LATERAL/LYMPHOID at the bookends, MEDIAL/MYELOID in the middle, ACAC order)
https://www.youtube.com/watch?v=Cf15SKTg2Us
What are haematopoietic stem cells, and where do they originate?
HSCs are stem cells that give rise to other blood cells.
They originate in the bone marrow.
Name the 2 lineages that haematopoietic stem cells can differentiate along
Myeloid
Lymphoid
(look up picture)
What is flow cytometry used for?
Detecting physical characteristics and chemical properties of a cell.
Useful when trying to tell blood cells apart, as the appearance is not always indicative.
Name 3 causes of leukocytosis
- Viral infections (e.g. EBV, HIV)
- Drug hypersensitivity
- Medical stress (e.g. MI, trauma, status epilepticus)
- Lymhpoid leukaemias
Name 3 causes of fatigue
- Iron-deficiency anaemia
- Diabetes mellitus
- Hypothyroidism
- Depression
- CHF
- Sleep apnoea
- Multiple sclerosis
- Fibromyalgia (associated w/ muscle pain)
- Drugs (prescription and recreational)
What is the difference in fatigue reporting when it comes to patients with underlying medical conditions vs. psychological conditions?
Patients with underlying medical conditions often associate fatigue with activities they are unable to complete.
By contrast, patients with fatigue that is related to psychological conditions, medication toxicity, or substance use may be tired all the time; their fatigue is not necessarily related to exertion, and it does not improve with rest.
Name 3 causes of splenomegaly
- Leukaemias (infiltration by neoplastic cells)
- Liver disease, e.g. cirrhosis (causes the spleen to become engorged with blood)
- Vascular obstruction (reduced blood flow caused by obstruction –> increased pressure)
What types of cells are affected by acute and chronic leukaemias?
ACUTE LEUKAEMIAS: occur in immature, nonfunctional white blood cells, and proliferate rapidly
CHRONIC LEUKAEMIAS: occur in mature cells, and build up gradually
Acute leukaemias impair normal haematopoiesis and lead to pancytopenia. How does this manifest clinically?
- Anaemia (dec. RBCs)
- Clotting disorders (dec. thrombocytes)
- Increased susceptibility to infection (dec. functional WBCs / leukopenia)
RFs for Acute lymphoid leukaemia
- Prior bone marrow damage (e.g. alkylating chemotherapy, ionizing radiation)
- HTLV
- Genetic disorders, e.g. Downs syndrome
In most cases, there are no identifiable causes or RFs
RFs for Acute myeloid leukaemia
- Pre-existing haematopoietic disorder
- Environmental exposures (e.g. alkylating chemotherapy, ionizing radiation, benzene exposure)
- Genetic disorders, e.g. Downs syndrome
In most cases, there are no identifiable causes or RFs
Describe the clinical features of acute leukaemias in general
- Anaemia: pallor, fatigue, etc.
- Thrombocytopenia: epistaxis, bleeding gums
- Immature leukocytes: Frequent infections
- Leukaemic infiltration: hepatosplenomegaly
- Bone pain & tenderness: marrow expansion due to infiltration of subperiosteum
Abrupt: most patients present within 3 months of onset
Name 5 clinical features of acute LYMPHOID leukaemia (ALL)
- Fever
- Night sweats
- Painless lymphadenopathy
- Airway obstruction due to thymic infiltration
- Meningeal leukaemia (neck stiffness, headache, visual field changes)
2 clinical features that are more characteristic of acute MYELOID leukaemia (AML)
- Leukaemia cutis
- Gingival hyperplasia
Fever and lymphadenopathy are rare in ___, but can be common first signs in ___.
Fever and lymphadenopathy are rare in AML, but can be common first signs in ALL.
ALL = Lymphadenopathy, fever.
Most clinical manifestations of acute leukaemias are caused by what pathophysiological mechanism?
Bone marrow failure due to suppression of the growth of normal haematopoietic stem cells
CNS symptoms (e.g. headache, vomiting, nerve palsies) are more common in which types of acute leukaemia? And what age group?
More common in ALL
More common in children
How are acute leukaemias diagnosed?
Peripheral blood smear (PBS)
Confirmatory diagnosis can be carried out using bone marrow aspiration and biopsy