Chemotherapy and Radiotherapy in Gynaecological Cancers

Question 1

what other cancer can HPV commonly cause and how?

Answer 1

carcinoma of the nasopharynx
HPV infects cells to replicate within them and produce E6 and E7 proteins which inhibit the P53 tumour suppressor protein increasing cancer risk

Question 2

which stage of cervical cancer is suitable for surgery?

Answer 2

stage 1 (A or B)
- where the cancer is limited to the cervix

Question 3

name a recognised feature of cervical cancer in Tayside?

Answer 3

acute renal failure

Question 4

risk factors for cervical cancer?

Answer 4

smoking
earlier age of first intercourse (earlier exposure to HPV and immature transition zones)
high risk males
oral contraceptive
multiple partners

Question 5

symptoms of cervical cancer?

Answer 5

abnormal bleeding (post-coital, intermenstrual, post-menopausal)
acute renal failure

Question 6

surgical management of cervical cancer?

Answer 6

surgery only done when all of it can be excised (well defined etc)
LLETZ (Large loop excision of the transformation zone)
fertility sparing treatment for young women or women who haven’t started families yet (only for cancers confined to cervix)
Wertheim hysterectomy for early/micro-invasive disease
total abdominal hysterectomy, excision of the proximal 1/3 of the vagina and lymphadectomy, (for cancers that have spread)

Question 7

radiotherapy is the main treatment for what in cervical carcinoma?

Answer 7

main treatment for solid metastases to target the tumour cells and the lymph nodes within the pelvis (defined via CT)

Question 8

how is radiotherapy delivered in cervical carcinoma?

Answer 8

a fraction is given each day for 5 days a week

starting with external beam therapy followed by brachytherapy which allows a very high dose of radiation to the cervix

Question 9

what is brachytherapy?

Answer 9

internal radiation treatment

where a pellet/intrauterine tube/ovioid/ring applicator is inserted directly into the site and emits radiation

Question 10

issue with brachytherapy?

Answer 10

everyone involved in treatment is exposed to radiation

Question 11

main use of chemotherapy in cervical carcinoma?

Answer 11

acts as a radiation sensitizer to make the radiotherapy more effective

Question 12

how can chemotherapy be used in cervical carcinoma?

Answer 12

can be used as a neoadjuvant (shrink tumour before other treatment)
concomitant (use of chemotherapy along with radiotherapy)
palliative

Question 13

chemotherapy drugs?

Answer 13

cisplatin 40mg/m2 weekly which inhibits cancer replication

carboplatin + paclitaxel

Question 14

how can you plan for treatment pathway?

Answer 14

do examination under anaesthetic and insert EUA and marker seed insertion to find the most inferior extent of the cancer
view cancer via CT

Question 15

mainstay of treatment for endometrial cancer?

Answer 15

surgical

rarely treated with chemoradiotherapy unless patient is inoperable

Question 16

risk factors for endometrial cancer?

Answer 16

obesity
oestrogen exposure (HRT, tamoxifen)
HNPCC (lynch syndrome)

Question 17

how does endometrial cancer present?

Answer 17

post-menopausal bleeding

incidental finding

Question 18

what surgery is used for endometrial cancer?

Answer 18

TAH (total abdominal hysterectomy) BSO (bilateral salpingooophrectomy) hysterectomy and salipingooophrectomy washings

Question 19

how is radiotherapy used in endometrial cancer?

Answer 19

adjuvant treatment to reduce risk of relapse

- vaginal vault brachytherapy and external beam

Question 20

how is chemotherapy used in endometrial cancer?

Answer 20

adjuvant therapy depending on fitness of patient to reduce relapse risk

Question 21

why are ovarian cancers usually more advanced on presentation?

Answer 21

there is more space for them to grow in the peritoneum so they can grow very big before causing symptoms

Question 22

ovarian cancer increases risk of what other cancer?

Answer 22

peritoneal cancer

Question 23

risk factors for ovarian cancer?

Answer 23

age >50 (or germ cell tumours in young women)
nulliparity (or low parity)
delayed pregnancy
FH of breast/ovarian cancer (BRCA gene)

Question 24

symptoms of ovarian cancer?

Answer 24

ascites
bloating
pelvic mass
bladder dysfunction
acute bowel obstruction
pleural effusion (not always malignant fluid)
SOB
incidental finding

Question 25

investigations in endometrial cancer?

Answer 25

blood tests (CA125 - not always high)
US scan (TV and TA)
cytology (pleural/ascetic fluid sample) need a CT guided biopsy if inconclusive
pathology
RMI (RMI >200 should be referred to gynaecology-oncology MDT)

Question 26

why is US scan useful In endometrial cancer?

Answer 26

shows thickness of endometrium

Question 27

how does endometrial cancer spread?

Answer 27

“cauliflower like metastases”
- varying elements that are cystic and others that are solid
spread to greater omentum = omental cake

Question 28

2 types of spread in endometrial cancer?

Answer 28

peritoneal spread/seeding within the pelvis to abdominal cavity
haematogenous spread to liver and lungs and later to the brain

Question 29

surgical treatment of endometrial cancer?

Answer 29

total abdominal hysterectomy
bilateral salpingooophrectomy
omentectomy and optimal debulking for advanced cancers

Question 30

how is chemotherapy used in endometrial carcinoma?

Answer 30

enhances duration of response to surgery and reduces relapse risk
some people have chemo along with surgery or just chemo alone

Question 31

types of chemo drugs in endometrial cancer?

Answer 31

carboplatin alone (palliative)
carboplatin + paclitaxel (mainstay?)
PARP inhibitors

Question 32

how long are cured stage 1 patients followed up for?

Answer 32

5 years