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Gynae-Oncology > Cervical Cancer > Flashcards

Cervical Cancer Flashcards

1
Q

HPV 16 and HPV 18 account for ____ % cervical cancer cases

A

71%

FIGO, 2018

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2
Q

What are the two major approaches for prevention of cervical cancer?

A

1) Prevention of invasive cancer by HPV vaccination

2) Screening for precancerous lesions

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3
Q

What percentage of sexually active women will acquire HPV infection at some stage in their life?

A

80%

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4
Q

What is the HPV vaccine?

A

Recombinant vaccine
Composed of virus-like particles (VLPs)
Not infectious since they do not contain viral DNA
VLPs induce an antibody response; when exposed to live HPV, the antibody response protects that individual from infection.
Not a therapeutic vaccine; it does not treat existing lesions.

WHO has reviewed safety data and concluded that there is no safety concern regarding HPV vaccine

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5
Q

How does cervical cancer spread

A

Direct extension: parametrium, vagina, uterus and adjacent organs i.e. bladder and rectum

Lymphatic channels: regional lymph nodes namely obturator, external iliac and internal iliac, and then to the common iliac and para-aortic nodes

Haematogenous spread: lungs, liver, skeleton by haematogenous route is a late phenomenon

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6
Q

What is the best method of radiological assessment of primary cervical tumours greater than 10mm?

What is the advantage of imaging?

A

MRI Pelvis

Imaging has the advantage of the ability to identify additional prognostic factors, which can guide the choice of treatment modality.
The goal is to identify the most appropriate method and to avoid dual therapy with surgery and radiation as this has the potential to greatly augment morbidity

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7
Q

What is the standard treatment for locally advanced cervical cancer (Stage IIB - IVA)

A

Concurrent chemoradiation

IV administration of weekly cisplatin for 5-6 cycles during the course of EBRT

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8
Q

Describe the distribution of peak incidence age of cervical cancer:

A

Bimodal distribution peaking 35-39 and 60-64 years of age.

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9
Q

What is the incidence of cervical cancer in NZ?

What is the mortality rate of cervical cancer in NZ?

A
  • Incidence of cervical cancer is 7 per 100,000 and was reduced by 40% due to screening.
  • Mortality rate of cervical cancer is 2 per 100,00 and was reduced by 60% due to screening
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10
Q

List the two most common high risk HPV subtypes.

What percentage of cervical cancers are they responsible for?

A

HPV subtypes 16 and 18.

Implicated in 70% of cervical cancers.

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11
Q

List the risk factors for cervical cancer:

A
  • Young age of first sexual intercourse
  • Smoking
  • Multiple sexual partners
  • Ethnicity
  • Low SES
  • Chronic immunosuppression
  • Un-vaccinated (HPV vaccine)
  • COCP and depo use
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12
Q

What is the efficacy rate of the HPV vaccine?

A

95-100%

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13
Q

What HPV subtypes are covered by the 9-valent HPV vaccine (Gardasil 9)?

A

HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58

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14
Q

What are HPV subtypes 6 and 11 responsible for?

A

90% of genital warts

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15
Q

Who should receive the HPV vaccine?

A
  • Females age 9 - 45
  • Males age 9 - 26
  • Vaccination program - aged 12-13 2 vaccines; if > 15yo need 3 vaccines
  • Women with previous HPV (protects against other subtypes they have not been infected with)
  • Women with previous CIN (not therapeutic; protects against other subtypes they have not been infected)
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16
Q

Describe the NZ HPV vaccination programme including the vaccination schedule:

A
  • Gardasil 9 vaccine used.
  • Funded for females and males age 9 to 26 years old.
  • Currently offered to Year 8 students at school.
  • Two doses at 0 and 5-13 months
  • If immunocompromised or older than 15 years, 3 doses recommended at 0, 2 and 6 months.
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17
Q

List the side-effects of the HPV vaccine:

A
  • Localised discomfort
  • Redness and swelling at injection site
  • Heavy arm.
  • Mild fever
  • Nausea
  • Dizziness
  • Anaphylaxis (rare; 1-3 in 1 million)
  • Guillain-Barré syndrome and acute disseminated encephalomyelitis (1 in 100,000).
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18
Q

Describe the pathophysiology of CIN and cervical cancer development:

A
  • 15 oncogenic HrHPV exist - HPV 16 & 18 account for 70% cancers
  • HPV infect the basal cells of squamous epithelia of the transformation zone
  • Persistence or failure of the immune response to clear HrHPV causes progressive dysplasia through LSIL, HSIL to invasive cancer - this takes 10-15 years
  • HrHPV produces oncogenic proteins E6 nad E7
  • Interaction of viral E6 and E7 proteins with tumour suppression genes p53 and Rb.
  • Inhibition of p53: prevents cell cycle arrest and cellular apoptosis which normally occurs if damaged DNA present.
  • Inhibition of Rb: disrupts transcription factor E2F resulting in unregulated cellular proliferation.
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19
Q

What is the squamo-columnar junction of the cervix?

A

The area in which the squamous epithelium of the ectocervix meets the columnar epithelium of the endocervical canal.

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20
Q

Describe the natural history of LSIL and HSIL

A
  • 60-90% of LSIL/CIN1 revert to normal within 10-23 months

- 30% of HSIL progress to cervical cancer over 10 years if left untreated.

21
Q

Describe the grades of CIN:

A

CIN is characterised by dysplasia - lack of differentiation, disordered cellular maturation of squamous epithelium - without invasion of the basement membrane

  • CIN-1: mild dysplasia; lower one-third of epithelium affected.
  • CIN-2: moderate dysplasia; lower two-thirds of epithelium affected.
  • CIN-3: severe dysplasia; full thickness of epithelium affected - includes CIS
22
Q

Regarding atypical glandular cells:

  • What is the incidence ?
  • Describe the treatment :
A
  • Incidence 0.15% (rare)

Treatment:

  • Cone knife biopsy depth 25 mm to avoid missing skip lesions +/- D&C
  • Consider hysterectomy if not desiring fertility or margins not clear due to inaccuracy of follow-up smears and colposcopy.
23
Q

What are the two most common types of invasive cervical cancer and their relative frequency?

A
  • Cervical squamous cell carcinoma 80%

- Cervical adenocarcinoma 20%. Develops from ‘atypical glandular cells’.

24
Q

Describe the presentation of advanced cervical cancer:

A
  • Abnormal, malodorous PV bleeding
  • Unintentional weight loss
  • Obstructive uropathy
  • Severe pain
  • Lymphoedema
  • Haematuria
  • Rectal bleeding
25
Q

Describe the colposcopic findings suggestive of cervical cancer:

A
  • Abnormal blood vessels: looped, branched or reticular. Punctate vessels.
  • Irregular surface contour with loss of surface epithelium and ulceration.
  • Yellow-orange colour instead of pink.
26
Q

In the work up for cervical cancer, what is the role of CT CAP or PET-CT scan?

A

Indicated in locally advanced disease - Stage IB2 to IVa. (i.e. from ≥5mm depth and ≥2cm size.)

Role is to assess pelvic and para-aortic lymph nodes for involvement.

PET-CT more sensitive and lower false negative rate than CT or MRI.

27
Q

What are the complications of LLETZ and cone knife biopsy?

A
  • Bleeding
  • Infection
  • Preterm labour (depends of depth >10mm/amount of tissue removed, and if repeat treatments needed)
  • Cervical stenosis.
  • Incomplete margins and persistence of disease.
28
Q

List the complications of a radical hysterectomy

A
  • Bleeding
  • Infection
  • Urinary dysfunction (partial denervation of detrusor muscle)
  • Vaginal shortening
  • Fistulas: ureterovaginal, vesicovaginal, rectovaginal
  • Bowel obstruction
  • Stricture or fibrosis of intestine and rectosigmoid colon
29
Q

Define cervical cancer stage IA1.

How should cervical cancer stage IA1 be managed?

A

-Stage IA1: Micro-invasive disease. Confined to cervix, deepest invasion ≤3 mm.

Definitive treatment:
- Cone biopsy

If family complete, OR LVSI or incomplete margin on cone:
- class I hysterectomy (extra-fascial/simple)
30
Q

Define cervical cancer stage IA2.

How should cervical cancer stage IA2 be managed?

A
  • Stage IA2: micro invasive. Confined to cervix, deepest invasion ≥3mm and <5 mm.

Definitive treatment:

  • class II modified radical hysterectomy PLUS pelvic node dissection
  • OR class I hysterectomy (extra-fascial/simple) PLUS pelvic node dissection (risk of pelvic node spread 5%).
  • Fertility sparing treatment:
  • Radical trachelectomy OR repeat knife cone biopsy with laparoscopic pelvic node dissection and close follow-up
31
Q

Define cervical cancer stage IB1.

How should cervical cancer stage IB1 be managed?

A
  • Stage IB1: limited to cervix and uterus with ≥5 mm depth and <2 cm in greatest dimension

Definitive treatment: class II modified radical hysterectomy and pelvic lymphadenectomy.

Fertility sparing treatment: radical trachelectomy (removal of cervix, parametrium and vaginal cuff) and laparoscopic pelvic node dissection for frozen section. Or 2 step procedure with LN sampling 1 week prior to radical trachelectomy.
- only if tumour <2 cm.

32
Q

Who is suitable for fertility sparing surgery?

A

○ Desire to preserve fertility
○ Reproductive age <40 years old
○ Early stage disease stage IA1 to small stage IB1 (<2 cm)
○ Absence of recurrence risk factors (LVSI)
○ SCC or adenocarcinoma histology
- No evidence of lymph node metastasis.

33
Q

What are the acute complications / side effects of radiotherapy for cervical cancer?

A
  • Bowel: proctitis, diarrhoea, abdo cramping, rectal discomfort, bleeding
  • Cystourethritis: dysuria, urinary frequency and nocturia
  • Perineal skin inflammation and desquamation
  • Vaginal stenosis
  • Dyspareunia
34
Q

What are the late complications (1-4 years later) / side effects of radiotherapy for cervical cancer?

A
  • Vaginal or rectal stenosis
  • Small bowel obstruction
  • Malabsorption
  • Radiation enteritis
  • Chronic cystitis
35
Q

What is the recommended management for locally advanced disease i.e. stages II to stage IVA?

A

Stage IIA1 (i.e. invaded upper vagina but <4cm lesion): type III radical hysterectomy, pelvic and para-aortic lymphadenectomy.

From stage IIA2 (invaded upper vagina and ≥4cm): concurrent chemoradiotherapy
(as high risk of nodal involvement and localised recurrence requiring adjuvant radiotherapy with increased morbidity if dual therapy used.)

Stage IIB-IVA: primary chemoradiation
Stage IVA: primary exenteration (pelvic clearance) can be considered if centralised mass, but high rates of morbidity.

Chemotherapy: weekly cisplatin for 5-6 cycles.

Radiotherapy: EBRT or cervical brachytherapy.

36
Q

What is the recommended management for cervical cancer stage IVB?

A

Chemoradiotherapy
OR Palliative chemotherapy
+/- bevicazumab an anti- VEGF MAB

37
Q

Why is adjuvant radiotherapy recommended in the presence of intermediate risk factors?

A

Because risk of recurrence and death is up to 30% following surgery only.

Radiotherapy improves progression-free survival and overall survival.

38
Q

What are intermediate risk factors (Sedlis’ criteria)?

Who gets adjuvant radiotherapy?

A

Sedlis criteria:

  • Dimension
  • Depth
  • LVSI

Radiotherapy If have 2 of 3:

  • ≥4cm
  • LVSI
  • deep stromal invasion
39
Q

Why is adjuvant chemo-radiotherapy recommended in the presence of high risk factors?

A
  • High risk: parametrial spread, node positive, incomplete margins
  • Risk of recurrence up to 40% and death up to 50% following surgery alone in presence of high risk factors.
  • Chemo-radiation therapy improves progression-free survival and overall survival
40
Q

What are high risk factors (Peter’s criteria)?

A
  • Involved lymph nodes
  • Microscopic parametrial invasion
  • Positive surgical margins.
41
Q

When is primary radiotherapy for the treatment of cervical cancer indicated?

A
  • Early stage disease and Poor functional status or medical comorbidites that make pt poor surgical candidate
  • Palliation of symptoms associated with advanced stage IV cancer
42
Q

Describe pelvic lymph node dissection as part of cervical cancer treatment:

A

Removal of nodal tissue from:

  • Distal one-half of each common iliac artery
  • Anterior and medial aspect of the proximal half of the external iliac artery
  • Distal half of the obturator fat pad anterior to the obturator nerve.
43
Q

Describe para-aortic lymph node dissection as part of cervical cancer treatment:

A

Removal of nodal tissue from:

  • Distal vena cava from the level of the inferior mesenteric artery to the mid right common iliac artery
  • Between the aorta and left ureter from the inferior mesenteric artery to the left mid common iliac artery.
44
Q

List the complications associated with pelvic and para-aortic lymph node dissections:

A
  • Vascular damage
  • Ureteral injury
  • Infection
  • Fistula formation
  • Lymphocyst/lymphedema
  • Bowel obstruction
  • Thrombophlebitis.
45
Q

What is recommend follow-up after fertility sparing treatment of cervical cancer?

A

There is a lack of formal guidance on ideal follow-up.

FIGO recommends:

  • 3 monthly smear and colposcopy for first 3 years.
  • Then 6 montly smear and colposcopy for next 2 years
  • Yearly smear and colposcopy thereafter.
  • HPV vaccination if not had already.

What is NOT recommended:
- Routine hysterectomy after child-bearing completed.

46
Q

What is recommended follow-up after surgical management of stage IA1 cervical SCC?

A

TAH and cone biopsy treated the same.
3 monthly for first 2 years, then 6monthly for 3 years.

If normal follow-up till 5 years, return to routine screening.

47
Q

What is recommended follow-up after surgical management of cervical SCC stage IA2, IB1 and all IA adenocarcinoma?

A

Routine follow-up visits are recommended every 3–4 months for the first 2–3 years, then 6-monthly until 5 years, and then annually for life.

At each visit, history taking and clinical examination are carried out to detect treatment complications and psychosexual morbidity, as well as assess for recurrent disease.

If normal follow-up to 5 years return to normal screening program.

48
Q

Can the HPV vaccination be given in pregnancy?

A

Vaccination not recommended, category B2

But monitoring of women who have inadvertently been vaccinated during pregnancy has NOT identified any risk for infant or mother

If a woman has started the vaccination programme and then becomes pregnancy, she can resume the vaccination programme after (the increased time between vaccinations doesn’t matter)

49
Q

How can HPV evade the immune system?

A
  • Infects basal cell of squamous epithelium - short life span
  • Does not infect blood causing viremia
  • Hence is able to evade detection
  • E6 and E7 oncoproteins down regulate gene expression for interleukins - pro-inflammatory cytokines involved in mounting immune response

Gynae-Oncology (14 decks)

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