Cervical cancer Flashcards
Most common histological type
Squamous cell carcinoma
Risk factors
STDs Multiple sexual partners High parity Smoking OCP Early first coitus Immunosuppression HIV HPV infection
Presentation
abnormal vaginal bleeding (common) postcoital bleeding (common) pelvic pain, dyspareunia (uncommon) cervical mass (uncommon) cervical bleeding (uncommon) mucoid discharge
Pathogenesis
HPV acts via E6 and E7 genes,
which differ in high vs. low risk HPV types;
HPV is integrated in premalignant lesions with tumor DNA vs.
present in episomes (not integrated) in condylomas;
in HPV 16 and 18, E6 binds to p53,
causing its proteolytic degradation;
E7 binds to retinoblastoma gene (Rb) and
displaces transcription factors normally bound by Rb
Other co-factors are important, because (a) most with HPV don’t get cervical cancer,
(b) 10-15% of cervical cancer is NOT associated with HPV
Age group
Ten year premalignant stage
Age: 40-50
Clearance rates of HPV
Eight months: 50% cleared
2 years: 90% cleared
Regression rates
CIN 1 >95%
CIN 3
Depth of prominent nuclei and CIN classification
Endocervical polyp: % women, epidemiology, presentation
2-5% of adult women
Usually multigravida age 30-59 years
Produces bleeding or mucoid discharge
Probably secondary to chronic inflammation and not neoplastic
Gross features
Exophytic
Infiltrative
Ulcerative
Where does it metastasise to
Lung
Liver
Bone
Clinical assessment
Pap smear->asymptomatic
Colposcopy->symptomatic/abnormal smear
Biopsy
Prognosis
Stage IA1 - 100%
Stage IB2-IIB - 50% to 70%
Stage III - 30% to 50%
Stage IV - 5% to 15%.
Causes of death
Uremia
Hemorrhage
Sepsis
Investigations
1st tests to order
vaginal or speculum examination
colposcopy, biopsy, HPV testing
Tests to consider FBC, renal function testing liver function tests (LFTs) CXR, IVP, barium enema? proctoscopy, cystoscopy MRI pelvis, PET whole body PET/CT whole body CT of chest/abdomen/pelvis with IV/oral contrast
Management
non-pregnant stage IA1: pre-invasive disease
1st line: local excision
adjunct: hysterectomy or chemoradiation
non-pregnant stage IA2-IB1: early stage disease
>2 cm or not desiring fertility: surgical candidate
1st line: radical hysterectomy + lymphadenectomy
adjunct: postoperative chemoradiation
>2 cm or not desiring fertility: non-surgical candidate
1st line: chemoradiation
Chemotherapy agents
Cisplatin
Paclitaxel
anti-VEGF agent
Bevacizumab
Follow up
3- to 6-monthly clinical review, physical exam, and cervical/vaginal cytology in the first 2 years, then every 6 to 12 months for 3 to 5 years. An annual CXR is recommended for 5 years.
report significant symptoms (pain, bleeding, swelling) early
Staging
Stage 1: cervix only
Stage 2: beyond cervix, not affixed to pelvic wall, not involving lower 1/3 vagina
Stage 3: Extends to pelvic wall, lower 1.3 vagina
Stage 4: Extends to mucosa of bladder and rectum
