Cervical Cancer Flashcards
What’s the mc cause of death from female pregnancy worldwide?
Cervical Cancer
What’s the major RF a/w cervical cancer?
HPV 16 and 18
What are the lateral structures of cervix?
Parametria lie within the broad ligaments and contain ureters (1-2 cm) from the cervix and uterine arteries
Which viral proteins are responsible for malignant transformation?
E6 and E7
which virus may act as co factor ?
HSV type 2
What are the RFs which increases chances of exposure to HPV?
- early onset of sexual activity
- early age at 1st pregnancy
- multiparity
- multiple sexual partners
- smoking and low social class
- smoking and immunocompromised states
- DES: exposure in utero: clear cell carcinoma as in vagina
what’s the standard screening technique in England and wales
Liquid Based Cytology
replaced Papanicolau smear
How does screening guide further managment?
Normal: repeat in 3 to 5 years
Inadequate: repeat
Borderline : refer for colposcopy within 4 weeks
CIN1 to CIN 3: Colposcopy
Possible invasion and Glandular invasion: Colposcopy within 2 weeks
who can avoid colposcopy following Cervical Screening?
HPV test negative
HPV +: immediate colposcopy
How can Cervical Cancer be prevented?
Quadrivalent Vaccine (HPV 6, 11, 16 and 18)
Does vaccination obviate the need for screening? and WHy?
No
other viruses can cause
How long does it take from CIN to Invasive cancer?
10 to 12 years
About what % of pts with CIN 3 develop Invasive carcinoma?
30%
On IHC, how are sq cell carcinoma and Adenocarcinoma differentiated?
Reactivity to anti cytokeratin: epithelial origin
ab against mucin: Adenocarcinoma
How to distinguish between endocervical and endometrial adenocarcinoma?
Endocervical: CEA +, P16 +, HPV +
Endometrial tumors: vimentin +, ER +, PgR +
What are s/s of cervical cancer?
- Abnormal VAgina bleeding
- Vaginal discharge
- Dyspareunia
What does abnormal vaginal bleeding mean?
Post coital
intermenstrual
post menopausal
heavy menstrual bleeding with pain/pressure symptoms
what are the clinical features of local spread of cervical cancer?
- Renal failure due to ureteric obstn
- frequency and dysuria
- pelvic pain
- bladder outflow obstruction
- change in bowel habbit
- rectal bleeding
- hematuria
- urine incontinence (vvf)
- faecal incontinence
- deep pelvic pain and lymphedema of legs
How is parametrial invasion best examined?
PR
What are staging Investigations for cervical cancer?
- Cervical Biopsy
- MRI for primary tumor assessment
- CT Chest
- PET CT for locally advanced cervical caner amenable to CRT
What test should not be missed in premenopausal women ?
Pregnancy test
What’s the Rx of St IA1 cervical cancer?
Simple Hysterectomy is adequate
Post menopausal : Hysterectomy + BSO
Fertility sparing: Knife cone biopsy
What’s the Rx of St IA2 cervical cancer?
LN risk: 7.4 %
Mod Rad Hysterectomy and LND
Fertility sparing: RAdical tracheloectomy
Medically unfit or pt who decline: RT RAdical
What’s the Rx of St IB1 and small volume st IIA cervical cancer?
Surgery or RT
Which structures are removed in radical Wertheim hysterectomy?
Uterus, upper third vagina and entire parametrium and B/L Lymphadenectomy
Preserve ovary if premenopausal
Fertility sparing: Radical Vaginal Trachelectomy and laparoscopic Lymphadenectomy
What’s the Rx of St IB2 to IVA cervical cancer?
CRT followed by Brachy
No conc chemo for unfit pts
What’s the Rx of St IVB cervical cancer?
Palliative Rx (chemo, RT, and surgery)
What’s the Rx for recurrent cervical cancer?
Central Pelvic Recurrence:
following CRT: Surgery
isolated mets as regional LN: SBRT
What are the four level defined by RCR for IGBT?
- verification of applicator position
- accurate definition of OAR doses
- Conformation of dose distribution
- Dose escalation
What should be the minimum equivalent (2 Gy/#) to HRCTV?
75 to 80 Gy
What should be included in HRCTV?
All residual macroscopic tumor, whole cervix and presumed extracervical tumor (grey zones on MRI)
what tolerances are taken for rectum, sigmoid/bowel and Bladder?
alpha/beta: 3,
rectum 70 to 75 Gy
Sigmoid/bowel 70 to 75 Gy
Bladder 90 - 95 Gy
what are advantages of HDR BT over LDR BT?
- patient convenience
- reduced treatment time
- radiation protection and machine availability
what’s current recommended dose for EBRT in UK for cervical cancer?
45 Gy/ 25#
50.4 Gy/ 28#
what’s the BT dose?
21 Gy/ 3 sessions
others; 14 Gy/ 2 sessions
what are conventional field borders for Cervical CAncer RT ?
As in Endometrial cancer
How is image verification done for RT ?
1st 3 days CBCT or portal beam and then weekly
What chemo, at what dose and when should be given with RT
Cisplatin 40 mg/m2 weekly , 1 hour prior to RT
when should cisplatin not be given?
poor renal function or poor PS
what is definition of pt A ?
Manchester system
2 cm above the lateral vaginal fornixes and 2 cm lateral to central uterine tube
what is pt B?
5 cm lateral to midline
what is ICRU 38 bladder point?
posterior surface of bladder balloon
What is rectal point?
5 mm behind the postr vaginal wall at the level of lower end of the intrauterine source
What are the indications of adjuvant CRT in cervical cancer?
- positive LN
- Positive margin
- positive parametria
what are the systemic treatment options for Cervical Cancer? (NCCN 2025)
- PD-L1–positive tumors
Pembrolizumab + cisplatin/paclitaxel
± bevacizumab (category 1)e,f,i,7
Pembrolizumab + carboplatin/paclitaxel
± bevacizumab (category 1)e,f,i,7 - Cisplatin/paclitaxel/bevacizumabe,8
(category 1) - Carboplatin/paclitaxel/bevacizumabe
- Atezolizumab + cisplatin/paclitaxel +
bevacizumab (category 1) - Atezolizumab + carboplatin/paclitaxel +
bevacizumab (category 1)e,
what are Concurrent Chemo recommendation as per NCCN (2025)?
Cisplatin + pembrolizumab
category 1: FIGO 2014 Stage IIIA, IIIB, and IVA
category 2B: select FIGO 2018 stage III–IVA
* Carboplatin + pembrolizumab
if cisplatin intolerant
category 1: FIGO 2014 Stage IIIA, IIIB, and IVA
category 2B: select FIGO 2018 stage III–IVA
* Cisplatin
* Carboplatin if cisplatin intolerant
How to manage Cervical cancer during pregnancy?
1st and 2nd trimester: termination of pregnancy followed by Rx
3rd : Wait for Birth: CS and Hysterectomy
How is SCLC cervix treated?
Chemo as in SCLC followed by RT
Surgery for few pts with small volume
what are the prognostic factors for cervical cancer?
Tumor Related
Patient Related
Treatment related
what are the tumor related prognostic factors for cervical cancer?
- increased tumor bulk
- LN +
- LVSI +
- higher stages
- Adenocarcinoma
what are the Patient related prognostic factors for cervical cancer?
- anemia
- smoking
- PS poor
what are the treatment prognostic factors for cervical cancer?
- margin
- long duration of RT treatment
- no ICBT
What are approx 5 yrs survival for Cervical cancer pts, stage wise?
IA: 100 %
IB: 80 to 95 %
II: 60 to 90 %
III: 30 to 50 %
IV: 5 to 20 %
