Cervical Cancer Flashcards
Definition
Is a human papillomavirus (HPV)-assosicated malignancy.
Types of cervical cancer
= Squamous cell carcinoma (MC subtype)
= Adenocarcinoma
= Adenosquamous carcinoma
Types of HPV which are responsible for cervical cancer
HPV 16
HPV 18
Which HPV strains are responsible for genital warts
HPV 6
HPV 11
How is HPV infection typically spread
Sexual contact
What is the premalignant cervical cancer
Cervical intraepithelial neoplasia (CIN), which is assessed for with national screening
Epidemiology
- Young females: 25-29
- HIV: reduction in CD4+T causes an impaired immune response to HPV
- Immunosuppression or medications such as steroids
- Smoking
- Early age of first intercourse
- Multiple sexual partners
- COCP: increases the risk of cervical cancer but decreases the risk of endometrial and ovarian cancer
- Low socioeconomic status
Pathophysiology
HPV produces the oncogenes E6 and E7 which encourage cell proliferation:
- E6 inactivates tumour suppressor p53 , thus preventing apoptosis
- E7 binds retinoblastoma (Rb), causing the release of E2F which drives cell proliferation
Signs
Abnormal cervical appearance
- White or red patches on the cervic
- Erosion and ulcerations
- Mass
- Bleeding
Vaginal discharge
Dyskaryosis on screening
Symptoms
Can be ASx in early stages
Abnormal vaginal bleeding:
- post-coital bleeding
- intermenstrual bleeding
Vaginal discomfort
Pelvic pain, urinary, or bowel symptoms in advanced disease
Diagnosis
- Bloods: tests renal function. liver function and bone profile to assess for disease spread
- Colposcopy and biopsy: DYSKARYOSIS or CIN and malignant changes
- HPV testing
- Staging imaging: CXR, renal USS, PET/CT and MRI
Staging
The International Federation of Gynecology and Obstetrics ( FIGO )
Stage 1A
Confined to the cervix
- A1 : ≤ 3 mm deep
- A2 : 3-5 mm deep
Stage 1B
Clinically visible lesion confined to the cervix or larger than 7 mm wide
- B1 : ≤ 4 cm in size
- B2 : > 4 cm in size
Stage 2
Invasion beyond the cervix, but not to the lower third of vagina or pelvic wall
- A : upper 2/3 of vagina without parametrial invasion
- B : with parametrial invasion
Stage 3
Involves lower third of vagina , or extends to pelvic wall
- A: lower third of vagina
- B : extends to pelvic wall, OR causes hydronephrosis or non-functioning kidney
Stage 4
Invades the bladder or rectum , or extends beyond the pelvis
- A : involvement of bladder or rectum
- B : spread to distant organs
Pre-malignant CIN Tx
Following colposcopy and biopsy , excision or ablation may be appropriate
Early stage disease: 1A - 2A
- Microinvasive disease (stage IA) : consider ablation or excision:
< 2cm and wishing to preserve fertility : radical trachelectomy with lymphadenectomy
≤ 4cm : radical hysterectomy with lymphadenectomy, +/- adjuvant chemoradiotherapy
> 4cm : chemoradiotherapy
Locally advanced disease: stage 2B - 4A
Chemoradiotherapy : FIRST LINE = Platinum-based chemotherapy (e.g. cisplatin) is the most commonly used form of chemotherapy
Radiotherapy may be either external beam radiotherapy or brachytherapy
Metastatic disease: Stage 4B
- Chemotherapy and bevacizumab: bevacizumab prevents tumour angiogenesis by blocking VEGF
- Palliative chemotherapy : may be required in some patients
If cancer recurs:
- Surgery : pelvic exenteration if relapse is confined to pelvis and chemoradiotherapy has failed
- Chemotherapy : palliative
Complications
Invasion-related:
Hydropnephrosis
Rectal involvement
Surgical complications:
Pre-term birth
Utereral fistual
Short-term radiotherapy complications:
- Radiation proctitis
- Radiation cystitis
- Radiation burns
- Vaginal bleeds
Long-term radiotherapy complications:
- Lymphoedema
- Ovarian failure
- Tissue fibrosis
