ONCOLOGY MANAGEMENT Flashcards
What are main Epidemiology of Cervical Cancer
- 14th Most common in UK
- More common in White and Black females
- Highest Incidence in 30-34 year olds
What are main Aetiological factors ? 7
- HPV Virus
- increases with more sexual partners
- Early age sexual intercourse
- Smoking
- Oral contraceptives (possibly due to hormonal disruption or increased sexual partners)
- Genetic component for SCC
- more likely if had pregnancy
What is the histology for cervical cancer?
90% Squamous cell carcinoma
Less common is ademocarcinomas
What is the staging used for Cervical Cancers?
FIGO Staging
What does CIN mean?
Cervical Intraepithelial neoplasia = considered “pre-invasive carcinoma” the tumour is confined to the surface epithelium cells
Graded CIN1/2/3 depending on degree of cell differentiation.
what is CIN III sometimes referred as?
Carcinoma in Situ or severe Dysplasia
What is stage 1 of cervical cancer?
Carcinoma strictly confined to cervix
what is stage 2 of cervical cancer
Carcinoma extends beyond the cervix, but does not extend into pelvic call (involved the vagina but not the lower third)
What is stage 3 of cervical cancer?
Carcinoma has extended into the pelvic sidewall. Tumour involves lower third of vagina. *all cases with hydronephrosis/non-functioning kidney are stage 3
What is stage 4 cancer?
Cancer that has extended beyond the true pelvis and involves mucosa of bladder/rectum
What are the 3 main treatment types?
- Surgery
- Radiotherapy (EBRT+/ BRACHYTHERAPY)
-chemotherapy
What are the main symptoms ?
Intermenstrual bleeding
Post-coital bleeding
Post menopausal bleeding
Unusual discharge
Pelvic pain
*advanced disease: lymphoedema // problems voiding bowels and emptying bladder // Haematuria
What are the clinical investigations?
Full blood count
Chest X-ray
Cervical biopsy
CT
PET
MRI
What would you conduct a blood test as an investigation?
To check for anaemia and also look at the liver and kidney functions.
Why would you conduct a chest X-ray?
To check for metastatic spread to the lungs
Why would a biopsy and a swab be taken if there is discharge?
To diagnose the malignancy histology and check for infection
Why is CT/MRI/PET used in diagnosing cervical disease?
To scan the abdomen and pelvis to assess the local extent of tumour and lymphatic involvement.
What are the routes of spread?
Vaginal vault // uterus // bladder//bowel // kidney // liver // lungs
Which lymphatic nodes are involved?
- Internal Illiac Nodes
- External Illiac nodes
- inguinal nodes (sup and deep)
- obrurator nodes
- presacral nodes
- common Illiac nodes
- aortic nodes
What factors does the treatment management depend on?
- Type of cancer
- stage of cancer
- grade of cancer
- general health of patient
- patient preference
What treatment would a women receive if they had CIS?
Treatments aim to remove abnormal cells
- LLETZ (Large loop exercising of the transformation zone.
- laser therapy/ablation
- cone biopsy
- Hysterectomy (if an older women)
*leaves cervix complete - suitable for women who wish to have children in the future.
What is the maximum size a tumour needs to be for LLETZ procedure?
2cm or less - this is due to removing the surface layer of the cervix and keeping the remainder in tact
How is stage 1 cervical cancer treated?
- Hysterectomy or radical vaginal trachelectomy
Radiotherapy - if stage 1b2 - chemo radiation suggested
What is vaginal trachelectomy?
Surgery to remove the cervix, nearby tissue and upper part of vagina
How is stage 2a cancer treated
This is normally treated with surgery or chemo radiation
How is stage 2b cancer treated?
Chemo radiation
How is stage 3 treated?
Chemoradiation
How is stage 4 treated?
Surgery
Radiotherapy
Chemotherapy
OR A COMBINATION OF ALL 3
What is the prognosis for Stage IA1?
100%!!
What is prognosis for stage IB2 - IIB?
50-70%
What is prognosis for stage III ?
30-50%
What is prognosis for stage IV?
5-15%
Why is prognosis worse for patients with cervical adenocarcinoma?
The adenocarcinoma grow inside cervical cancel and may establish a large tumour volume and detected late as doesn’t show up on smear test.
What are the long term complications for cervical cancer? (9)
- Psychological distress
- Guilt (not attending screening)
- Sexual problems
- lymphoedema
- fertility issues
- menopause
- fatigue
- bowel difficulties
- bladder difficulties
Why is hormone therapy not used?
Cervical cancer is not hormone dependant therefore it would not respond to Hormone therapy.
*HRT may be given to younger women following radical treatment.
What is hydronephrosis?
Condition where kidneys become swollen due to build up of urine
What is the GTV?
Primary Tumour
What is the CTV?
2 CTV’S for cervix
CTV T (tumour) - Primary tumour plus spread, include CERVIX, UTERUS, PARAMETRIAL TISSUES, UPPER VAGINA, PROXIMNAL BROAD AND UTERO-SACRAL LIGAMENTS. = 1-1.5cm between GTV and CTV
CTV N (Nodes) - Potential nodal spread, Obturator, internal and external, common illiac, upper pre sacral nodes
Scan with contrast - 7mm margin
What is the PTV?
CTV T = 15-20MM
CTV N = 7-10MM
IMPORTANT TO REMEMBER THIS IS DIFFERENT
On forward planning how many beams?
4:
ANT
POST
LEFT LATERAL
RIGHT LATERAL
Why do you down weight the post field beam?
To minimise the dose to the rectum
What are the prescriptions for EBRT?
45 - 50.5 GY in 25-28
What is the Brachytherapy Boost prescription?
8-11Gy in 2 fractions
What are the border parameters?
Lateral - 1CM outside bony pelvic side walls
Anterior - 3CM of 5th lumbar
Posterior - 2CM anterior to posterior aspect of sacral hollow
What beam modifications are used for Cervix
Wedges - may be used on lateral fields depending on size of patient and curvature.
