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Gynaecological Cancer Flashcards

1
Q

what causes 70% of cervical cancer

A

HPV type 16 and 18

other 30% different strains of HPV

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2
Q

how does HPV cause cancer

A

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

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3
Q

what patients with cervical cancers are suitable for surgery

A

those with stage 1 cancer only- confined to the cervix- no spread or lymph involvement

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4
Q

why is acute renal failure a common presentation of cervical cancer

A

as common for it to spread here

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5
Q

where else can HPV cause cancers

A

oral pharyngeal

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6
Q

what are the different patient groups that get oral cancer

A

HPV- young

old- smoking and alcohol

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7
Q

what are the risk factors for cervical cancer

A

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)

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8
Q

how does cervical cancer present

A

screening
post coital/ intermenstrual/ post menopausal bleeding
acute renal failure (will have bilateral hydronephrosis due to renal mets)

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9
Q

what are the stages of cervical cancer

A 
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
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10
Q

what stage are the majority of cervical cancers when found

A

1b (visible lesion, contained within cervix)

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11
Q

what is the 5 year survival rates of cervical cancer 1A and IV

A

1A >95%

IV 20-30%

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12
Q

what are the treatment options for cervical cancer

A

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

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13
Q

what is the role of chemotherapy in cervical cancer

A

acts as radiotherapy sensitiser

on its own wont cure cancer

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14
Q

what are the forms of radiotherapy to treat cervical cancer

A
  • 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)
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15
Q

how does radiotherapy affect tumour cells and not normal cells

A

as tumour cells less able to repair themselves in the interfractional interval

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16
Q

what does planning for radiotherapy involve in cervical cancer

A

exam under anaesthetic and marker seeds put into tumour to visualise it on imaging
CT planning
pinpoint tattoos to mark site
simulator

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17
Q

what are the forms of chemotherapy used to treat cervical cancer

A

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

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18
Q

what chemotherapy drugs are used in cervical cancer

A

cisplatin (platinum based) 40mg/m2 weekly

carboplatin/ paclitaxol

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19
Q

what is brachytherapy

A

internal radiotherpay Tx
Intrauterine tube through cervix into uterus
Ovoids (colpostats) egg shaped tubes
Ring applicator

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20
Q

what complication can be caused in the sigmoid colon after brachytherapy

A

can stenose, becomes scarred and narrowed

can develop into fistula

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21
Q

what is the mainstay of endometrial cancer treatment

A

surgery

chemo and radio therapy only used when patient inoperable (wide spread/ comorbidity)

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22
Q

what are the risk factors for endometrial cancer

A

obesity
oestrogens- HRT, tamoxifen (given to reduce the risk of breast cancer recurrence, has a slight oestrogenic receptor agonist action)
genetic- HNPCC (lynch syndrome)

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23
Q

what is the most common presentation of endometrial cancer

A

post menopausal bleeding

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24
Q

what is the treatment for endometrial cancer

A

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%

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25
Q

do more women die from cervical or ovarian cancer

A

ovarian

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26
Q

does ovarian cancer commonly spread to brain/ liver

A

no as ovaries and fallopian tubes with within the peritoneum so have big space to grow in
unless BRACA mutation, distant mets more likely

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27
Q

what are the risk factors for ovarian cancers

A 
>50 
nulliparity (or low parity)
delayed pregnancy 
FHx of breast/ ovarian Cx
BRACA 1 (40%) and BRACA 2 (18%)
(most cases are sporadic)
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28
Q

how does ovarian cancer present

A 
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
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29
Q

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

A

CA125 blood serum level
urgent pelvic
ultrasound

if symptoms persist but normal Ix then refer to secondary care

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30
Q

what can be done phrophylatically for women predisposed to ovarian cancer

A

prophylactic salpingo-oophorectomy

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31
Q

who is at high risk of ovarian cancer

A

carrier of BRCA 1/2 mutation
1st degree relative with mutation
FHx of ovarian, breast, colon, endometrial cancer (lynch)

32
Q

what shouls all women with non mucinous ovarian or fallopian cancer be offered

A

BRCA1/2 testing

33
Q

what are the types of non mucinous ovarian cancers

A

serous, endometriod, clear cell

34
Q

how is ovarian cancer diagnosed

A

blood test Ca125
USS- TA and TV
cytology of pleural fluid/ ascites
pathology

35
Q

what calculates the likelyhood of a patient having ovarian cancer

A

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

36
Q

what test should be done in patients with suspected ovarian cancer

A

CT abdomen

37
Q

what cancers can spread to the ovaries

A

pancreatic, gastric and bowel

38
Q

what are the stages of ovarian cancer

A

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

39
Q

what is the prognosis for a Stage 1 and stage 4 ovarian cancer

A

stage 1 80-90%
stage 4 up to 15%
(5 year survival)

40
Q

what are the patterns of spread of ovarian cancer

A

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)

41
Q

what are the types of ovarian cancer

A

> 90% epithelial:

  • serous (most common)
  • mucinous
  • endometrioid
  • clear cell
  • undifferentiated

<10% germ cell, granulosa cell

42
Q

is it common for ovarian cancer to spread to the omentum

A

yes

43
Q

what is the treatment for ovarian cancer

A

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

44
Q

when does ovarian cancer become advanced

A

when has spread beyond the ovaries (1c-4)

45
Q

what is the benefit of chemo before surgery in ovarian cancer

A

de bulks tumour, making it easier to resect

46
Q

what are the chemo options for ovarian cancer

A

response rates of 60-70%- carboplatin/ paclitaxel (hope for cure chemos)

relapse rates high

palliative chemotherapy- carboplatin, paclitaxel, etoposide, caelyx, topotecan, gemcitabine, chlorambucil

?intraperitoneal

47
Q

is ovarian cancer likely to relapse

A

most with advanced disease recur (70%)

relapsing, chronic illness

some receive many classes of chemotherapeutic agents before their disease becomes truly drug resistant

48
Q

what is the treatment for endometrial cancer

A

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

49
Q

what is the prognosis of grade 1 endometrial Cx

A

90% 5 year survival

10% will need further treatment

50
Q

how are endometrial cancer patients followed up

A

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

51
Q

what is the introitus

A

opening to the vagina

52
Q

why does radiotherapy need oxygen to work

A

produces a hydroxyl radical which causes DNA damage- if hypoxic (anaemia) then radio wont work aswell

53
Q

when do you do surgery in cervical cancer

A

only when confident you can get clear margins - only in stage 1A disease

54
Q

what is the treatment for cervical cancer

A

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

55
Q

when does treatment for cervical cancer become no longer curative

A

when it has spread to para-aortic node or distant mets

56
Q

what is the normal presentation of cervical cancer

A

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

57
Q

why is PET CT better than CT for cervical ca

A

Bone and brain mets easier to see
More reliable
Shows more in early stages

58
Q

what is an andenocarcinoma

A

an epithelial tumour from glandular tissue

59
Q

what chemotherapy drugs are used in ovarian cancer

A

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.

60
Q

what type of mutation is BRCA

A

germline

61
Q

where are BRCA cancers more like to metastasise to

A

liver, brain, lung and spleen

62
Q

what are all serous high grade cancers tested for

A

BRCA mutation

63
Q

what does a dark staining serous carcinoma suggesy

A

its has a p53 mutation

64
Q

What is the 5 year survival for stage I vs stage III/IV ovarian cancer?

A

92% stage I v 5% stage IV

65
Q

what is the treatment for ovarian cancer

A

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.

66
Q

what are common side effects of chemotherapy

A

Infection, diarrhoea, nausea, vomiting, alopecia, anaemia, metallic taste

67
Q

what might affect chemotherapies effectivity in treating ovarian cancer

A

Mutation in tumour – how chemo responsive it will be, extent of metastasis, her age and health- co morbidities, histological subtype, brca mutations

68
Q

what is neo adjuvant and adjuvant therapy

A

Neo is before surgery, adjuvant is after

69
Q

can ovarian cancer be cured

A

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

70
Q

why is ovarian cancer said to relapse rather than recurr

A

as never went away

chemo and radio will not fully eradicate the disease

71
Q

how many women who have had platinum based chemo for ovarian cancer will relapse

A

70% in 2 years

72
Q

what are the symptoms of an ovarian cancer relapse

A

persistent abdominal distension /bloating, feeling full (early satiety) and/or loss of appetite pelvic or abdominal pain increased urinary urgency and/or frequency.

73
Q

can you screen for ovarian cancer

A

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

74
Q

what is the maintenance therapy for relapsed ovarian cancer

A

chemo

75
Q

what does optimal surgical staging of ovarian cancer involve

A

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

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