Gynaecological Cancer Flashcards
what causes 70% of cervical cancer
HPV type 16 and 18
other 30% different strains of HPV
how does HPV cause cancer
Integrate themselves in the DNA of cells (at transformational zone)
Able to produce proteins that inhibit p53 and RB1 which are tumour suppressor genes
produce E6 and E7 oncoproteins
what patients with cervical cancers are suitable for surgery
those with stage 1 cancer only- confined to the cervix- no spread or lymph involvement
why is acute renal failure a common presentation of cervical cancer
as common for it to spread here
where else can HPV cause cancers
oral pharyngeal
what are the different patient groups that get oral cancer
HPV- young
old- smoking and alcohol
what are the risk factors for cervical cancer
smoking
reduce age on onset on intercourse (exposure to HPV, immature transition zone more receptive to HPV damage)
‘high risk’ male
OCP (may just be reduced barrier contraceptive)
multiple partners (exposure to HPV)
how does cervical cancer present
screening
post coital/ intermenstrual/ post menopausal bleeding
acute renal failure (will have bilateral hydronephrosis due to renal mets)
what are the stages of cervical cancer
Stage 1a – microscopic Stage 1b visible lesion (1B1 and 1B2 depending on size of lesion) Stage 2 a – vaginal involvement 2b parametrial involvement Stage 3 lower vagina or pelvic sidewall Stage 4 bladder/rectum or metastases
what stage are the majority of cervical cancers when found
1b (visible lesion, contained within cervix)
what is the 5 year survival rates of cervical cancer 1A and IV
1A >95%
IV 20-30%
what are the treatment options for cervical cancer
surgery (only for grade 1):
- large loop excision of the transition zone (LLETZ)- forvery early cancer found on screening
- fertility sparing- trachelectomy, for small tumours confined to cervix (removal of cervix)
- wertheim (radical hysterectomy =lymphadenohysterocolpectomy = removal of cervix, proximal 1/3rd of vagina, lymph and parametrial excision)
radiotherapy
chemotherapy
what is the role of chemotherapy in cervical cancer
acts as radiotherapy sensitiser
on its own wont cure cancer
what are the forms of radiotherapy to treat cervical cancer
- external beam, targeted at tumour and modes to avoid bladder and rectum
- brachytherapy (implant applied to cervix and uetrus to give high dose of radiation, packing used to push bladder and rectum away- inverse square law = doubling the distance quarters the dose received)
how does radiotherapy affect tumour cells and not normal cells
as tumour cells less able to repair themselves in the interfractional interval
what does planning for radiotherapy involve in cervical cancer
exam under anaesthetic and marker seeds put into tumour to visualise it on imaging
CT planning
pinpoint tattoos to mark site
simulator
what are the forms of chemotherapy used to treat cervical cancer
neoadjuvant (given before radio to try and shrink tumour and reduce symptoms)
concomittant- given at same time as radio
palliative- for disease spread beyond the pelvis
what chemotherapy drugs are used in cervical cancer
cisplatin (platinum based) 40mg/m2 weekly
carboplatin/ paclitaxol
what is brachytherapy
internal radiotherpay Tx
Intrauterine tube through cervix into uterus
Ovoids (colpostats) egg shaped tubes
Ring applicator
what complication can be caused in the sigmoid colon after brachytherapy
can stenose, becomes scarred and narrowed
can develop into fistula
what is the mainstay of endometrial cancer treatment
surgery
chemo and radio therapy only used when patient inoperable (wide spread/ comorbidity)
what are the risk factors for endometrial cancer
obesity
oestrogens- HRT, tamoxifen (given to reduce the risk of breast cancer recurrence, has a slight oestrogenic receptor agonist action)
genetic- HNPCC (lynch syndrome)
what is the most common presentation of endometrial cancer
post menopausal bleeding
what is the treatment for endometrial cancer
Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) and peritoneal washings for cytology
lymphadenopathy- contraversial
Adjuvant Radiotherapy
Vault brachytherapy
External beam
(given to reduce relapse)
Adjuvant Chemotherapy
Depending on grade, more likely to be needed in high grades, reduces risk of relapse by about 5-10%
do more women die from cervical or ovarian cancer
ovarian
does ovarian cancer commonly spread to brain/ liver
no as ovaries and fallopian tubes with within the peritoneum so have big space to grow in
unless BRACA mutation, distant mets more likely
what are the risk factors for ovarian cancers
>50 nulliparity (or low parity) delayed pregnancy FHx of breast/ ovarian Cx BRACA 1 (40%) and BRACA 2 (18%) (most cases are sporadic)
how does ovarian cancer present
often presents late (60% late stage at diagnosis) non-specific presentation ascites/ bloating pelvic mass/ bladder dysfunction pleural effusion/shortness of breath incidental finding early satiety abdominal pain difficulty eating
what tests for: women presenting in general practice with one or more symptoms
of abdominal distension or bloating with or without abdominal pain,
feeling full quickly, difficulty eating, or urinary symptoms, of less than
12 months duration and occurring more than 12 times per month
CA125 blood serum level
urgent pelvic
ultrasound
if symptoms persist but normal Ix then refer to secondary care
what can be done phrophylatically for women predisposed to ovarian cancer
prophylactic salpingo-oophorectomy
who is at high risk of ovarian cancer
carrier of BRCA 1/2 mutation
1st degree relative with mutation
FHx of ovarian, breast, colon, endometrial cancer (lynch)
what shouls all women with non mucinous ovarian or fallopian cancer be offered
BRCA1/2 testing
what are the types of non mucinous ovarian cancers
serous, endometriod, clear cell
how is ovarian cancer diagnosed
blood test Ca125
USS- TA and TV
cytology of pleural fluid/ ascites
pathology
what calculates the likelyhood of a patient having ovarian cancer
risk of malignancy index
considers US features (multilocular cyst, solid areas, bilateral lesions, ascites, intra-abdominal mets), peri/post menopausal, Ca125
RMI >200 referral to a gynaecology-oncology multidisciplinary team
what test should be done in patients with suspected ovarian cancer
CT abdomen
what cancers can spread to the ovaries
pancreatic, gastric and bowel
what are the stages of ovarian cancer
I- confined to 1 or both ovaries
II-spread to other pelvic organs eg uterus, fallopian tubes
III- spread beyond the pelvis within the abdomen
IV- spread into other organs eg liver, lungs
what is the prognosis for a Stage 1 and stage 4 ovarian cancer
stage 1 80-90%
stage 4 up to 15%
(5 year survival)
what are the patterns of spread of ovarian cancer
transcoelomic spread/ peritoneal seeding within pelvis → abdominal cavity
haematogenous spread → liver, lungs, brain- late and rare
incidence of brain metastases in ovarian cancer <2% (unless brca mutation, more common)
what are the types of ovarian cancer
> 90% epithelial:
- serous (most common)
- mucinous
- endometrioid
- clear cell
- undifferentiated
<10% germ cell, granulosa cell
is it common for ovarian cancer to spread to the omentum
yes
what is the treatment for ovarian cancer
Surgery (TAH, BSO, omentectomy, optimal debulking to <2-3cm)
surgery and chemotherapy- (All women with high-grade early stage (Ia-Ib) ovarian cancer should
be considered for adjuvant chemotherapy)
women with stage Ia, grade 1 or grade 2 disease, fertility conserving surgery is an option as long as the contralateral ovary appears normal and there is no evidence of omental or peritoneal disease
optimal surgical staging should be done (nodes, omentum)
Hormonal therapy with tamoxifen or an aromatase inhibitor can be used for women with recurrent, platinum-resistant, ovarian cancer or in those wishing to avoid or delay further chemotherapy
when does ovarian cancer become advanced
when has spread beyond the ovaries (1c-4)
what is the benefit of chemo before surgery in ovarian cancer
de bulks tumour, making it easier to resect
what are the chemo options for ovarian cancer
response rates of 60-70%- carboplatin/ paclitaxel (hope for cure chemos)
relapse rates high
palliative chemotherapy- carboplatin, paclitaxel, etoposide, caelyx, topotecan, gemcitabine, chlorambucil
?intraperitoneal
is ovarian cancer likely to relapse
most with advanced disease recur (70%)
relapsing, chronic illness
some receive many classes of chemotherapeutic agents before their disease becomes truly drug resistant
what is the treatment for endometrial cancer
Hysterectomy bilateral salpingo-oophrectomy = gold standard
Potentially needs vaginal brachytherapy/ extra beam radiotherapy (adjuvant)
Mirena coil if want to spare fertility, need to be very early disease. Biopsy 6 months after insertion and if no cancer at then 1 year to get pregnant. Also for those unfit for surgery
what is the prognosis of grade 1 endometrial Cx
90% 5 year survival
10% will need further treatment
how are endometrial cancer patients followed up
Telephone clinic for low grade and low risk cancer for 2 years
For high risk esp those who need radiotherapy then followed up for 5 years
To detect recurrence= Clinical follow-up should focus on signs and symptoms suggestive of recurrence, such as vaginal bleeding, abdominal or pelvic pain, persistent cough, unexplained weight loss, and new-onset neurological symptoms. The clinician can use the following schedule for follow-up: • Physical examination every 3 to 6 months for 2 years, then annually. • Vaginal cytology, serum CA-125, and annual CXR have no proven role
what is the introitus
opening to the vagina
why does radiotherapy need oxygen to work
produces a hydroxyl radical which causes DNA damage- if hypoxic (anaemia) then radio wont work aswell
when do you do surgery in cervical cancer
only when confident you can get clear margins - only in stage 1A disease
what is the treatment for cervical cancer
Generally chemoradiotherapy (platinum based) is used to treat women with FIGO IB2, IIA, IIB, IIIA, IIIB and IVA disease. Radical hysterectomy with lymphadenopathy for earlier disease
when does treatment for cervical cancer become no longer curative
when it has spread to para-aortic node or distant mets
what is the normal presentation of cervical cancer
inter-menstrual bleeding (IMB) post-coital bleeding (PCB) post-menopausal bleeding (PMB) abnormal appearance of the cervix (suspicion of malignancy) vaginal discharge (blood stained) pelvic pain
why is PET CT better than CT for cervical ca
Bone and brain mets easier to see
More reliable
Shows more in early stages
what is an andenocarcinoma
an epithelial tumour from glandular tissue
what chemotherapy drugs are used in ovarian cancer
carboplatin and paclitaxel.
Carboplatin is main drug (best tolerated) for ovarian cancer, don’t loose hair, get metallic taste in mouth. When add in paclitaxel loose hair.
what type of mutation is BRCA
germline
where are BRCA cancers more like to metastasise to
liver, brain, lung and spleen
what are all serous high grade cancers tested for
BRCA mutation
what does a dark staining serous carcinoma suggesy
its has a p53 mutation
What is the 5 year survival for stage I vs stage III/IV ovarian cancer?
92% stage I v 5% stage IV
what is the treatment for ovarian cancer
given neoadjuvant chemo to shrink tumour then surgery. If older (>70) or not as well would only get carboplatin as better tolerated.
No visible disease after Tx ideal but if can reduce all disease to <1cm in size surgery worthwhile.
what are common side effects of chemotherapy
Infection, diarrhoea, nausea, vomiting, alopecia, anaemia, metallic taste
what might affect chemotherapies effectivity in treating ovarian cancer
Mutation in tumour – how chemo responsive it will be, extent of metastasis, her age and health- co morbidities, histological subtype, brca mutations
what is neo adjuvant and adjuvant therapy
Neo is before surgery, adjuvant is after
can ovarian cancer be cured
early disease yes
Hope to get cancer into remission, hoping to get them well for a significant time but wont cure stage 3 and 4 ovarian cancer
why is ovarian cancer said to relapse rather than recurr
as never went away
chemo and radio will not fully eradicate the disease
how many women who have had platinum based chemo for ovarian cancer will relapse
70% in 2 years
what are the symptoms of an ovarian cancer relapse
persistent abdominal distension /bloating, feeling full (early satiety) and/or loss of appetite pelvic or abdominal pain increased urinary urgency and/or frequency.
can you screen for ovarian cancer
no
Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer
If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis
what is the maintenance therapy for relapsed ovarian cancer
chemo
what does optimal surgical staging of ovarian cancer involve
midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy; biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum; and retroperitoneal lymph node assessment
