Radiotherapy and Chemotherapy; cervix, endometrium and ovary Flashcards
What is the aetiology of cervical cancer?
HPV HPV HPV - 16 and 18
What is the mechanism behind HPV causing cervical cancer?
Integrates into the DNA of cells at the transformation zone
Able to produce E6 and E7 proteins which inhibit p53 and RB1 which are both rumour suppressor genes
Aside from HPV, what are other risk factors for cervical cancer?
Smoking Age of onset of intercourse "High risk" male partner OCP Multiple partners
How will cervical cancer present?
Screening Post coital bleeding Intermenstrual bleeding Post menopausal bleeding Acute renal failure
What is the staging of cervical cancer?
1a; microscopic 1b; visible lesion 2a; vaginal involvement 2b; parametrial involvement 3; lower vaginal or pelvic sidewall 4; bladder and/or rectum or mets
Which stages of cervical cancer are suitable for surgery?
Stage 1
What is the 5 year survival from stage 1A to 4 cervical cancer?
1A; >95%
4; 20-30%
What is the surgical treatment for cervical cancer?
LLETZ; large loop excision of transformation zone
Fertility sparing; removal of cervix
Radical hysterectomy (RH) involves the en-bloc removal of uterus, cervix, parametrial tissues and
upper vagina. It is usually combined with pelvic lymphadenectomy
What operation is offered to women who have cervical cancer who request a fertility sparing procedure?
Radical trachelectomy and pelvic lymph node dissection, providing the tumour diameter is less than 2 cm with no lymphatic-vascular space invasion
In what stages of cervical cancer is chemoradiotherapy offered?
Generally chemoradiotherapy is used to treat women with FIGO IB2, IIA, IIB, IIIA, IIIB and IVA
What type of radiotherapy is offered to women with cervical cancer?
Vaginal brachytherapy; targeted to include tumour +/- nodes
What type of chemotherapy is recommended for cervical cancer?
Platinum based
Cisplatin 40mg/m2 weekly
Carboplatin/ paclitaxol
How is radiotherapy of the cervix planned?
EUA and marker seed insertion
CT planning
Simulator
How is anaemia in cervical cancer managed?
Patients with cervical carcinoma undergoing radiotherapy or chemoradiotherapy should have their haemoglobin level monitored and corrected if it falls below 12 g/dl.
Anaemia should be corrected with either blood transfusion or erythropoietin and iron products
What are the late symptoms of bladder related radiation injuries that occur via radiation treatment for cervical ca?
Urinary frequency Urgency, Dysuria Detrusor instability Haematuria Ulceration Perforation Fistula formation
What rectal symptoms are common whilst undergoing tx for cervical ca?
Acute radiation proctitis is frequently experienced during pelvic radiotherapy with symptoms
including tenesmus, urgency, diarrhoea and occasionally bleeding
What are symptoms associated with incurable advanced cervical cancer?
Pain Renal failure from bilateral ureteric obstruction Thrombosis and haemorrhage Malodorous discharge Lymphoedema Fistulae
What is the mainstay of treatment for endometrial ca?
Surgical
What are aetiological factors for the development of endometrial cancer?
Obesity
Oestrogens; HRT or tamoxifen
Lynch syndrome
How does endometrial cancer tend to present?
PMB
What tends to be the recommended treatment for endometrial ca?
TAH BSO; total abdominal hysterectomy with bilateral salpinoopherectomy and node dissection
Is adjuvant vaginal brachytherapy indicated in endometrial cancer?
Yes;
Patients with stage IA disease with certain
risk factors (i.e., age >60 years, presence of
lymphovascular space invasion [LVI], or grade
3 tumour
In women with symptoms such as abdo distension, bloating, early satiety, difficult eating, urinary symptoms what ix should be performed?
Ca-125
Urgent pelvic USS
In secondary care, what RMI score would indicate the need for CT abdo pelvis?
> 200
In what stages of ovarian cancer should neoadjuvant chemo be utilised?
Stage 3c or 4
In what stages of ovarian cancer should adjuvant chemo be utilised?
All women with high grade early stage 1a or 1b ovarian cancer should be considered for adjuvant chemo
How is RMI calculated?
USS features; multilocular cyst, solid areas, bilateral, ascites, intra-abdominal mets
Pre or post menopausal
Ca125
RMI = USS score x menopausal score x Ca125 in U/ml
What is optimal surgical staging in ovarian cancer?
Midline laparotomy to allow thorough assessment of abdo and pelvis
Removal of ovarian cyst without causing capsular rupture
Total abdominal hysterectomy
Removal or contralateral ovary
Infracolic omentectomy
Biopsies of suspicious looking peritoneal nodules
Iliac and paraaortic lymph node sampling
In what women is fertility conserving surgery appropriate?
Stage 1a, grade 1 or 2 disease with no evidence of contralateral ovarian involvement, omental or peritoneal disease
Involves; biopsies of suspicious looking peritoneal nodules, infracolic omentectomy, iliac and paraaortic lymph node sampling
What is advance ovarian cancer?
Spread beyond ovaries (FIGO stage 1c and above)
What is the goal of surgical management in advanced ovarian cancer?
Remove all macroscopic disease
Remove all deposits measuring over 1cm (optimal cytoreduction)
What is the management of relapse in ovarian cancer?
Chemotherapy/ hormonal agents
In selected patients with relapsed epithelial ovarian ca which is platinum sensitive; secondary cytoreductive surgery may be appropriate
What are the platinum based chemotherapies?
Cisplatin
Carboplatin - more favourable toxicity profile
Often combine carboplatin with paclitaxel
Should biological therapy be offered to women with ovarian cancer?
Women with stage 4 ovarian cancer should be offered bevacizumab (anti VEGF) in combo with carboplatin and paclitaxel
What chemotherapy agents are used for relapsed ovarian cancer?
If platinum sensitive; offered tratement with carboplatin with paclitzel
If platinum resistant; offer paclitazel
Trials of PARP inhibitors have shown benefit in lengthening progression free survival in patients with advanced, recurrent, platinum sensitive ovarian cancer
PARP inhibitors = BRCA mutation
In what cohort of patients is hormonal therapy offered to for relapsing ovarian cancer?
Tamoxifen or aromatase inhibitor offered to women with recurrent platinum resistant ovarian cancer
What is the treatment for colikly pain in malignant bowel obstruction?
Hyoscine butylbromide
What are risk factors for the development of ovarian cancer?
>50 yrs Nulliparity Delayed pregnancy FMHx of breast or ovarian ca BRCA1 (40%), BRCA2 (18%)
How is ovarian cancer diagnosed?
Blood tests; ca-125
USS; TV or abdominal
Cytology; pleural fluid/ ascites
Pathology
Compare ovarian cancer prognosis from stage 1 to stage 4
Stage 1; 80-90%
4; 15%
How will ovarian cancer spread?
Transcoelomic/ peritoneal seeding
Haematogenous; liver, lungs, brain
Brain mets in ovarian cancer <2%
What are the subtypes of ovarian epithelial tumours?
Serous Mucinous Endometrioid Clear cell Undifferentiated
In what cohort of women with ovarian cancer can intraperitoneal chemo be considered?
New diagnosis of epithelial ovarian cancer and residual disease of <1cm after primary surgery provided a regimen of proven benefit in a clinical trial compared to IV is used
How many ovarian cancers respond to tamoxifen?
10%
With around 30% achieving disease stabilisation
What are the treatment goals for ovarian ca?
Cute Prolong survival Achieve a durable objective response Improve cancer related symptoms Optimise quality of life Delay time to symptomatic disease progression
In what subtype of ovarian cancer are PARP inhibitors most helpful?
BRCA
