Cervical Cancer

Question 1

Three Gynae Cancers

Answer 1

Cervical
Ovarian
Uterine

Question 2

Non-malignant lesions of the cervix

Answer 2

Cervicitis

Endocervical polyp

Question 3

Epidemiology of Cervical Cancer

Answer 3

5% of all Ca deaths worldwide - biggest cause of deaths in Africa (60/100,000 to 16/100,000 in UK)

Question 4

Incidence of CIN and invasive Ca

Answer 4

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)

Question 5

Mortality from Cervical Ca in UK

Answer 5

2800pa diagnosed, 2/3 have never been screened

1200 deaths/yr – 2nd worst survival rate to ovarian

Question 6

Effects of Screening

Answer 6

Cervical Ca incidence and mortality has fallen 40% since the introduction of screening in 1988

Question 7

Cause of cervical Ca

Answer 7

HPV (>95%) – 16,18 are worst with 31 and 33 in african populations
Produce proteins E6 and E7 which inactive tumour suppressor genes

Question 8

Risk factors for Cervical Ca

Answer 8

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

Question 9

CIN

Answer 9

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

Question 10

Presentation of Cervical Ca

Answer 10

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

Question 11

Histopathology of cervical Ca

Answer 11

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

Question 12

Progression of cervical Ca

Answer 12

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

Question 13

Causes of Death in Cervical Ca

Answer 13

Metastatic disease - particularly to the bladder and kidneys –> leads to sepsis and renal failure

Question 14

Staging of Cervical Ca

Answer 14

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

Question 15

Five year survival of Cervical Ca

Answer 15

90% at T1
40-60% at T2
30-40% at T3
10% at T4

Question 16

Treatments for Cervical Ca

Answer 16

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

Question 17

Chemotherapy for Cervical Cancer

Answer 17

Cisplatin or Carboplatin mainly used so that patients do not lose the hair on their heads

Question 18

Regional Lymph nodes for Cervical Ca

Answer 18

Paracervical and parametrial
Obdurator around the internal iliac, common and external iliac nodes
Presacral and lateral sacral nodes

Question 19

Side effects of Radiotherapy for Cervical Ca

Answer 19

Ovarian function is always lost - can harvest eggs beforehand - done as an OP
Can use Braca therapy to tightly direct radiation

Question 20

Braca Therapy

Answer 20

A technique to introduce radioactive sources directly into the body near to the site of cancer

Question 21

Vulval and Vaginal Cancers

Answer 21

Rare – 80% squamous, 10% melanomas

Staged by T1:2cm. T3:vagina, urethra,anus or unilateral LN, T4:rectum, bladder, distant mets

Question 22

Summary of Vulval Ca

Answer 22

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

Question 23

Radical Trachelectomy

Answer 23

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.

Question 24

Cervical Cancer recall length

Answer 24

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.

Question 25

Cervical Cancer in the young

Answer 25

There has been a recent rise in Cervical Ca in younger women and these women have a worse prognosis

Question 26

Cervical Smears in immunosuppressed people

Answer 26

Should have yearly smears because of the risk of false negatives and increased risk of Ca