Reproductive System Oncology

Question 1

Prostate cancer signs and symptoms

Answer 1

Polyuria
Nocturia
Dysuria
Hesitancy
Urgency
Infection
Obstruction
Haematuria

Question 2

Investigations for prostate cancer

Answer 2

Digital Rectal Examination
Blood tests – PSA
Rectal ultrasound.
Biopsy – U/S: 6 samples – 3 from each lobe
CT or MRI – extracapsular spread, enlarged nodes & local invasion of adjacent structures.
Bone scan.
TR Ultrasound Guided Biopsy

Question 3

Grade/Staging of prostate cancer.

Answer 3

> 50% of tumours have more than one type of differentiation.
Assign a Gleason grade to first and second most common patterns.
These are summed to give Gleason Grade.
Correlates well with mortality.

Question 4

indolent meaning

Answer 4

of a disease or condition) causing little or no pain.

Question 5

prostate cancer management

Answer 5

Disease often indolent
Balance toxicity of treatment with benefits to symptoms and life expectancy.
Pt expected life expectancy >10years to be treated radically.
The higher the PSA, Gleason score and T-stage – the higher the chance of tumour progression = radical treatment.

Watchful Waiting
Hormone Therapy – anti-androgens
Radical Radiotherapy
Brachytherapy
Surgery – Radical Prostatectomy (Can lead to bladder problems and erectile dysfunction)

Question 6

Radiotherapy late reactions for prostate cancer

Answer 6

Chronic cystitis
Urethral stricture
Urinary incontinence
Loss of sexual potency
Bowel morbidity include:
- Rectal ulceration or stricture.
- Small bowel obstruction.

Question 7

Testes cancer signs and symptoms

Answer 7

A lump in a testicle.
Enlargement of a testicle.
Testicle feels harder than normal.
A growth external to the testicle (testicular mass).
A dull ache, sense of pressure/heaviness
Pain or discomfort
Gynaecomastia +/or breast tenderness

Question 8

Testes cancer investigations

Answer 8

Scrotal Trans-illumination
Inguinal Orchidectomy & histology
Immunocytochemistry –AFP or HCG elevated in teratoma (can be used for monitoring too)
CT (thorax / abdo)
CXR
Ultrasound

Question 9

testes cancer management

Answer 9

Seminomas are extremely chemo and radiosensitive
Teratomas are less so

Mainstay treatment – surgery – radical orchidectomy
Addition of combination chemo where risk of metastatic disease
RT for prophylactic PA node irradiation in stage 1 = POP
Palliative treatment for chemo-resistant disease

Question 10

Penis cancer signs and symptoms

Answer 10

Usually presents as an exophytic or ulcerating lesion

Most commonly this arises on the glans or the sulcus at the base of the glans

Usually wide surface extension before deeper invasion to the urethra and corpora cavernosa

Question 11

Penis cancer investigations

Answer 11

Physical Examination.
Routine tests.
Phimosis – exposure of glans.
FNA of enlarged inguinal nodes.
US or CT scan of Abdomen & Pelvis, if LN involvement
Possible PET/CT for staging
CXR to rule out lung metastases

Question 12

Penis cancer management

Answer 12

Surgery and radiotherapy are the main treatments:

For localised lesions cryosurgery of laser excision may be sufficient.

More extensive tumours usually require a wider excision and this is normally the treatment of choice.

However, radical amputation of the penis is never a popular choice so radical local radiotherapy is now being increasingly used as an alternative.

With interstitial implantation the patient must be circumcised
Iridium wires (Iridium-192) are used for the interstitial treatments
Implantation is performed under anaesthetic and it obviously depends upon the extent of the tumour as to how many sources are used
They must not pass through the urethra

For MV treatments – 6MV, a customised wax block is normally constructed in the mould room. En bloc with POP of lateral fields
Post-penectomy
patients
CT planned
3 field technique:
ant and/or
two ant obliques

Question 13

Uterus cancer signs and symptoms

Answer 13

Postmenopausal bleeding
Intermenstrual bleeding
Pain and discharge

Question 14

Uterus cancer investigations

Answer 14

Via dilatation and curettage
Peritoneal cytology
CT or MRI
CXR

Question 15

Uterus cancer management

Answer 15

Surgery – primary and treatment of choice:
Total abdominal hysterectomy with bilateral salpingo-oophorectomy.
Little need for RT for well localised tumours.
Used when patient unfit for surgery or inoperable due to local invasion.
Postoperative RT for more advanced tumours.
External beam and/or Brachytherapy

Question 16

Cervix cancer signs and symptoms

Answer 16

Dysplasis or CIN – asymptomatic
Invasive ca: vaginal bleeding – 80%
And/or discharge – often offensive and discoloured
Bleeding often follows intercourse
Abdominal pain
Dyspareunia
Low back pain
Urinary and rectal symptoms

Question 17

Cervix cancer investigations

Answer 17

Tumour usually visible with simple speculum techniques
Colposcopy
Inspection
Palpation
Curettage and biopsy
CXR
CT
MRI

Question 18

Cervix cancer management

Answer 18

CIN3 / CiS
Cone biopsy = complete excision and cure
Laser & cryotherapy – cure 70% without cone biopsy
Hysterectomy

Invasive disease:
Surgery
Radiotherapy
Stage 1B & 2A – equivalent local control & survival rates
RT primary treatment for bulky or node+ disease - Stage 2B-4A

Question 19

Ovary cancer signs and symptoms

Answer 19

Lower abdominal pain
Bloating
Anorexia
Difficultly eating / early satiety
Common but often insufficient to raise suspicion
Ascites
Palpable pelvic mass
Often indicate advanced disease

Question 20

Ovary cancer investigations

Answer 20

Usually late presenting
Emergency presentation is the most common route (31%)
25% diagnosed following routine or urgent GP referral
Blood test (CA-125 tumour marker)
Abdominal x-ray
CT / MRI
Ultrasound (TV)
Surgery – detailed EUA

Question 21

Ovary cancer management

Answer 21

Surgery mainstay treatment
Initial operation greater bearing on outcome
Careful inspection of entire abdominal cavity essential before resection
For stage 1: total abdominal hysterectomy and bilateral salpingo-oophorectomy
Advanced disease – stages 2-4: excision of as much tumour as possible at initial operation
Pelvic exenteration – now performed more frequently

Question 22

Vulva cancer signs and symptoms

Answer 22

Lump/growth on the vulva
Puritus/itching (that does not go away)
Spotting or bleeding
Discharge
Tenderness/pain
Difficultly urinating or defecating or with intercourse
Oedema of lower extremities
Inguinal/pelvic node involvement

Question 23

Vulva cancer investigations

Answer 23

Physical examination
CT
PET-CT
MRI

Question 24

Vulva cancer management

Answer 24

Early stage:
Surgery – vulvectomy/wide local excision
+/- Sentinel node biopsy

Advanced:
Radiotherapy plus chemotherapy
Possibly followed by limited surgery

Question 25

Vagina cancer management

Answer 25

Radiotherapy preferable to surgery
Total vaginectomy
Organ preservation
Small tumours treated with brachytherapy alone
Advanced tumours will require external beam radiotherapy to include regional lymph nodes

Question 26

Pelvic Radiotherapy info

Answer 26

CT-simulator
Large bore
Indexed couch
Match the treatment unit couches
Allow for accurate and reproducible positioning of patient and immobilisation devices

Once treatment has begun:
Daily verification images required
Check patient position and PTV position
Electronic portal image (BEV)
CBCT – Cone-beam CT
Ultrasound
Check soft tissue/OAR location
Rectal emptying/bladder filling protocols