Cervical Cancer

Question 1

What causes cervical cancer ?

Answer 1

HPV (16 AND18)

Question 2

How many HPV viruses are oncogenic ?

Answer 2

15

Question 3

Why is it that although 80% of women have a HPV infection, not at a lot have cervical cancer?

Answer 3

Because in majority of the cases the HPV gets cleared by the host immune system.

Question 4

What kind of epithelium lines the ectocervix and endo-cervix?

Answer 4

1.Endocervix is lined by glandular/columnar epithelium
2.Ectocervix is lined by Stratified squamous epithelium.

Question 5

How does the TZ come to be during puberty?

Answer 5

-During puberty, under the influence of estrogen, the glandular/columnar epithelium of endocervix is pushed out onto the ectocervix.
Due to low PH in the vagina, it undergoes physiological squamous metaplasia and it is this area referred to as the transformation zone.

Question 6

What is the squamocolumnar junction?

Answer 6

Where the ectocervix and endocervix meet.

Question 7

What is the transformation zone?

Answer 7

The are between the new and old SCJs

Question 8

Why is the TZ vulnerable to HPV?

Answer 8

Because it is an area of high mitotic activity.

Question 9

What is the pathophysiology of cervical cancer?

Answer 9

HPV produces proteins(E6 and E7) that inhibit the function of tumor suppressor genes p53 and pRB.
These TSG are responsible for regulating the cell cycle by making sure cells divide when they are supposed to, trigger cell death and repair DNA damage

Question 10

What are the HPV related risk factors HPV- related for cervical cancer ?(7)

Answer 10

HPV- related
Persistent high HPV infection
Multiple sexual partners
Immunosuppression
Early onset of sexual activity
History of STI’s
Multiparity
Uncircumcised partner

Question 11

What are HPV-non related factors for cervical cancer(3)

Answer 11

-Smoking
-Low social economic status( detection and treatment is delayed)
-Use of COCs

Question 12

What are the clinical features of Cervical cancer?

Answer 12

-Abnormal vaginal bleeding
-Post coital bleeding
-Dyspareunia
-Abnormal Vaginal Discharge- malodorous, watery, blood tinged
-Vaginal discomfort and pain
-Pelvic pain and back pain
-Hematuria, dysuria, constipation, urinary obstruction symptoms
- Signs of anemia
-weight loss, fevers, night sweats

Question 13

What exams are performed in a patient with cervical cancer?

Answer 13

Bimanual examination
Digital rectal exam
Speculum examination

Question 14

What investigations are done in cervical cancer?

Answer 14

Imaging: Bone scan,Chest x-ray
Investigations : VIA, Pap smear , colposcopy ,cervical biopsy and HPV DNA testing

Question 15

Describe the FIGO stating of cervical cancer .

Answer 15

REFER TO HANDOUT.

Question 16

What is the treatment for stage 1A1?

Answer 16

Cervical conization

Question 17

Treatment for stage 1A2?

Answer 17

Radical hysterectomy with pelvic lymphadenectomy
Simple hysterectomy and Trachelectomy with pelvic lymphadenectomy
Cervical conization with laparoscopic lymphadenectomy in patients who desire fertility
Follow up with 3 monthly Pap smears for 2 years then 6 monthly for 3 years

Question 18

Treatment for 1b1,1b2,2a1

Answer 18

Radical hysterectomy with pelvic lymphadenectomy
Trachelectomy in those who desire fertility
Radiotherapy may used for stage IB2 and IIA1

Question 19

Treatment for stage 2a2 and 3

Answer 19

-Surgery
-Radiotherapy
-Chemotherapy

Question 20

Treatment for stage 4A?

Answer 20

Pelvic exenteration
Radiotherapy
Concurrent chemo-radiotherapy

Question 21

Treatment for Stage 4B?

Answer 21

Concurrent chemo-radiotherapy

Question 22

Treatment for a recurrence?

Answer 22

Pelvic exenteration
Radiotherapy
Concurrent chemo-radiotherapy

Question 23

How do we treat cervical cancer in Pregnant women?

Answer 23

1.Before 16-20 weeks (Surgery and chemoradiation
2.After 20 weeks- Cancer to be left alone until delivery at 34weeks where a c/s is done together with a radical hysterectomy

Question 24

How is cervical cancer prevented?

Answer 24

Through primary, secondary and tertiary prevention

Question 25

What is primary prevention of Cervical cancer?

Answer 25

Aims at preventing infection with HPV
HPV vaccine give between 9-14years plus advise on behavior.

Question 26

What is Secondary prevention?

Answer 26

Prevention to those who already have the HPV infection.
Advise to get screening depeding on their age and sero status

Question 27

What is tertiary prevention?

Answer 27

This is treatment given to those who already have cervical cancer.

Question 28

At what range is the HPV vaccine targeted for?

Answer 28

9-14
It is assumed that at this age they have not started engaging.

Question 29

How does the HPV vaccination work?

Answer 29

HPV vaccine produces specific type humoral antibodies that prevents new HPV infection by blocking its entry into the host cells.
They do not help in resolving pre-existing HPV infections

Question 30

At which body sites does he HPV vaccine work at?

Answer 30

oropharynx, cervix, vagina, vulva ,anal canal,penis

Question 31

What are the types of HPV vaccinations given?

Answer 31

Cervarix (HPV2)-16 and 18
Gardasil(HPV 4)-6,11,16,18.
Gardasil (HPV9)-Has replaced Gardasil4 as it gives protection to all HPV serotypes in HPV4. it protects against all HPV types in HPV4 plus types 31, 33, 45, 52 and 58.

Question 32

How often is cervical screening done?

Answer 32

-If HIV neg-from 25 to50yrs once every 3years
-If HIV pos- from the time of diagnosis and once every year after that till 65years
-If born with HIV and endulging then starting from 21years.