Cervical Cancer Flashcards
Three Gynae Cancers
Cervical
Ovarian
Uterine
Non-malignant lesions of the cervix
Cervicitis
Endocervical polyp
Epidemiology of Cervical Cancer
5% of all Ca deaths worldwide - biggest cause of deaths in Africa (60/100,000 to 16/100,000 in UK)
Incidence of CIN and invasive Ca
Peak for CIN 3 is 25-35 years, takes about 10-20yrs to progress so peak for Ca is 50-60
This gives two peaks (25-30 and 50-60)
Mortality from Cervical Ca in UK
2800pa diagnosed, 2/3 have never been screened
1200 deaths/yr – 2nd worst survival rate to ovarian
Effects of Screening
Cervical Ca incidence and mortality has fallen 40% since the introduction of screening in 1988
Cause of cervical Ca
HPV (>95%) – 16,18 are worst with 31 and 33 in african populations
Produce proteins E6 and E7 which inactive tumour suppressor genes
Risk factors for Cervical Ca
Increased exposure to HPV –> age of first intercourse, number of sexual partners, poverty, smoking , COC, immunosuppression and HIV
Also not attending for a cervical smear
CIN
Cervical intra-epithelial neoplasia
CIN I - bottom third of the epithelium is dysplastic
CIN II - bottom two thirds are dysplastic
CIN III - Full thickness is dysplastic
Presentation of Cervical Ca
Detected by screening (usually CIN rather than invasive Ca) Abnormal bleeding (often post-coital), vaginal discharge, If there is backache or pelvic pain this indicates later nodal disease and local spread
Histopathology of cervical Ca
90% squamous, 10% adenocarcinoma (from the endocervix) - the squamo-columnar junction (between the ecto- and endocervix
Starts as dysplasia>CIN I>CIN II>CIN III>invasive
BUT a fraction of all CIN regresses
Progression of cervical Ca
Tumor may be Fungating, ulcerating or infiltrative
Local invasion into the bladder, rectum or vagina
Can spread to lymph nodes –> metastases to liver, lung and bone
Causes of Death in Cervical Ca
Metastatic disease - particularly to the bladder and kidneys –> leads to sepsis and renal failure
Staging of Cervical Ca
T0 - CIN
T1a - microscopic lesion with stromal invasion
T1b - visible lesion in cervix
T2 - invades beyond the cervix, A/B=with/without parametrial invasion
T3 - extends to pelvic wall and lower 1/3 of vagina
T4A - Local spread beyond the pelvis
M1/T4B - distant metastatic spread
Five year survival of Cervical Ca
90% at T1
40-60% at T2
30-40% at T3
10% at T4
Treatments for Cervical Ca
CIN and T1 can be managed by LLETZ sometimes
Radical hysterectomy is first line up to T2a
T2 and above will also be given radiotherapy, and chemotherapy as well - if the pt can tolerate it
T4 can be operated on if there is no distant spread
Chemotherapy for Cervical Cancer
Cisplatin or Carboplatin mainly used so that patients do not lose the hair on their heads
Regional Lymph nodes for Cervical Ca
Paracervical and parametrial
Obdurator around the internal iliac, common and external iliac nodes
Presacral and lateral sacral nodes
Side effects of Radiotherapy for Cervical Ca
Ovarian function is always lost - can harvest eggs beforehand - done as an OP
Can use Braca therapy to tightly direct radiation
Braca Therapy
A technique to introduce radioactive sources directly into the body near to the site of cancer
Vulval and Vaginal Cancers
Rare – 80% squamous, 10% melanomas
Staged by T1:2cm. T3:vagina, urethra,anus or unilateral LN, T4:rectum, bladder, distant mets
Summary of Vulval Ca
Primarily HPV and VIN related, 95% squamous, causes bleeding, pruritus, discharge, mass,
Treatment is biopsy, vulvectomy+LN dissection
Stage 1 90% 5yr survival, Stage III 40% 5yr survival
Radical Trachelectomy
AKA Dargent Operation
Performed for locally extensive cervical cancers where the women would like to preserve fertility. The uterine cervix, parametria and end of the vagina are removed. It can be combined with a lymph node ectomy.
Cervical Cancer recall length
From 25 to 50yrs the recall is every 3yrs. After 50 it is every 5yrs and stop by 65 unless they have had abnormal results or haven’t had one since 50.
Cervical Cancer in the young
There has been a recent rise in Cervical Ca in younger women and these women have a worse prognosis
Cervical Smears in immunosuppressed people
Should have yearly smears because of the risk of false negatives and increased risk of Ca
