Cervical Cancer

Question 1

Define Cervical intraepithelial neoplasia (CIN)

Answer 1

Pre-cancerous dysplastic lesion of the transformation zone
Usually atypical cells within the squamous epithelium - dyskaryotic with larger nuclei and frequent mitoses

Question 2

What are the risk factors for CIN and cervical cancer

Answer 2

HPV infection
Early pregnancy
Smoking
Immunocompromise e.g. HIV, steroid use
Long-term and combined contraceptive use
Not attending smear screening
Young age at first intercourse
Age 45-59

Question 3

What are the types of CIN

Answer 3

CIN 1: Lower 1/3rd of the epithelium
CIN 2: 2/3rd of the epithelium
CIN 3: Affects the full thickness of the epithelium (Risk of stage Ia1 FIGO) - carcinoma in situ
(malignancy = cells invade the basement membrane)

Question 4

What investigations are done for CIN

Answer 4

Cervical smear for histology:
- Increased nuclear to cytoplasmic ratio
- Abnormal nuclear shape - poikilocytosis
- Increased nuclear size
- Increased nuclear density - koilocytosis
- Reduced cytoplasm

Question 5

What is the management for CIN 1

Answer 5

Conservative (watch and wait)
Annual cervical smears

Question 6

What is the management for CIN 2/3

Answer 6

Cryosurgery (using nitrous oxide to freeze and kill abnormal cells)
- Conization (removal of the affected cells)
- Cold-knife conization (scalpel)
- Laser
- Heated electrical loop (LLETZ or Loop electrosurgical excision procedure/LEEP)
- Needle excision of the transition zone/NETZ
Cone biopsy
Hysterectomy

+ follow up 6 months later for smear and HPV test

Question 7

What should be done at follow up after treatment for CIN

Answer 7

Smear and HPV test
Smear -ve, HPV absent: discharge
Abnormal smear OR HPV present: re-colposcopy

Question 8

What are the benefits and risks of treating CIN

Answer 8

Removes abnormal cervical cells
Reduces risk of future cervical cancer

Early
- Infection, bleeding, pain, treatment failure
Late
- Premature birth in future pregnancy
- Repeat treatment

Question 9

What is the prognosis for CIN

Answer 9

Untreated, 1/3 of women with CIN/II/III will develop cervical cancer over the next 10 years
CIN I commonly regresses spontaneously

Question 10

Which strains of HPV are most associated with cervical cancer

Answer 10

HPV 16, 18 (+33)

Question 11

What is the histology of cervical cancer

Answer 11

Most commonly squamous cell cancer (90%) (can be adenocarcinoma) at the transformation zone (where columnar cells and squamous cells meat and transition)

Question 12

Describe how cervical cancer spreads

Answer 12

1. Parametrium and vagina
2. Pelvic side wall
3. Lymphatic spread to pelvic nodes
4. blood borne spread

Question 13

What are the symptoms of cervical cancer

Answer 13

Often asymptomatic

Abnormal vaginal bleeding
Post-coital bleeding
Pelvic or back pain
Dyspareunia
PV bleeding
Mucoid or purulent vaginal discharge
Metastases may cause bladder, renal, or bowel obstruction or bone pain

Question 14

What are the differentials for cervical cancer

Answer 14

CIN
HPV infection
Pelvic infection
Nabothian cyst
Glandular hyperplasia
Endometriosis
Cervical polyp
Fibroid

Question 15

What are the signs of cervical cancer on examination

Answer 15

Bimanual
- Cervical mass felt on palpation
- Blood
Speculum
- Cervical mass visualised
- Cervical bleeding

Question 16

What investigations should be done for cervical cancer

Answer 16

Bedside: Cervical smear + HPV testing
Bloods: FBC, renal function, LFTs, U&Es (most fitness for surgery)
Other:
- Colposcopy (abnormal vascularity, white change with acetic acid, exophytic lesions)
- Biopsy
- MRI pelvis
- CXR (fitness for surgery)

Question 17

What is FIGO stage 1A and 1B for cervical cancer

Answer 17

1A = Confined to cervix, only visible by microscopy and less than 7 mm wide:
A1 = < 3 mm deep
A2 = 3-5 mm deep

1B = Confined to cervix, clinically visible or larger than 7 mm wide:
B1 = < 4 cm diameter
B2 = > 4 cm diameter

Question 18

What is FIGO stage 2 for cervical cancer

Answer 18

Extension of tumour beyond cervix but not to the pelvic wall
A = upper two thirds of vagina
B = parametrial involvement

Question 19

What is FIGO stage 3 for cervical cancer

Answer 19

Extension of tumour beyond the cervix and to the pelvic wall
A = lower third of vagina
B = pelvic side wall

NB: Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III

Question 20

What is FIGO stage 4 for cervical cancer

Answer 20

Extension of tumour beyond the pelvis or involvement of bladder or rectum
A = involvement of bladder or rectum
B = involvement of distant sites outside the pelvis

Question 21

What is the management for cervical cancer stage 1A

Answer 21

Fertility desired: cone biopsy (cold knife, LLETZ, laser)

Fertility not desired: simple hysterectomy ± lymphadenectomy

Question 22

What is the management for cervical cancer stage 1B

Answer 22

Fertility desired: Radical trachelectomy + lymphadenectomy (tumour size <2cm)

Fertility not desired: simple hysterectomy ± lymphadenectomy ± chemoradiation

Question 23

What is the management for cervical cancer stage 2

Answer 23

Radical hysterectomy + lymphadenectomy
± post-operative chemoradiation
± nephrostomy for hydronephrosis

Question 24

What is the management for cervical cancer stage 3

Answer 24

Combination chemotherapy + bevacizumab (+ paclitaxel)
± local treatment to metastases
± nephrostomy for hydronephrosis

Question 25

What is the management for cervical cancer stage 4

Answer 25

Chemoradiation
Palliative chemotherapy for stage IVB

Question 26

What does a radical hysterectomy and radical trachelectomy involve

Answer 26

Radical hysterectomy (wertheim’s) = pelvic node clearance, hysterectomy, and removal of the parametrium and upper 1/3 of the vagina

Radical trachelectomy = Removal of 80% of the cervix and upper vagina

Question 27

What is the prognosis for cervical cancer

Answer 27

Death is usually from uraemia due to ureteric obstruction
Overall 5-year survival = 65%