Cervical cancer

Question 1

CIN - risk factors

Answer 1

1. Persistent high risk HPV infection
2. Multiple partners (increase risk of exposure to HPV infection)
3. Smoking
4. Immunocompromise (e.g. HIV, immunosuppressive agents
5. Associated with COCP use (probably due to non-barrier method and exposure to HPV)

Question 2

Physiology of transformation zone

Answer 2

1. Endocervix = secretory glandular epithelium
2. Ectocervix = stratified squamous epithelium
3. The two are in continuity and meet at the squamocolumnar junction
4. Under the influence of estrogen, the glandular epithelium is pushed out onto the ectocervix and in response to low pH undergoes physiological squamous metaplasia -> transformation zone
5. As an area of high mitotic activity, the TZ is vulnerable to HPV-driven neoplastic change (8-10y from acquisition to development of cancer)

Question 3

CIN - histology

Answer 3

1. CIN = histological dx
2. Characterised by loss of differentiation and maturation from the basal layer of the squamous epithelium upwards
3. Bottom 1/3 = CIN 1
4. Bottom 2/3 = CIN 2
5. Full-thickness = CIN 3

Question 4

Cervical cancer - presentation

Answer 4

1. Pap smear -> colposcopy + biopsy
2. Post-coital bleeding
3. Post-menopausal bleeding
4. Ureteric obstruction, bowel disturbance or vesicovaginal fistula (advanced disease)
5. Weight loss (advanced disease)

Question 5

Cervical cancer - histology

Answer 5

1. SCC 90%
2. Adenocarcinoma 10%
3. Neuroendocrine tumour (?)
4. Clear cell carcinoma
5. Glassy cell (?) carcinoma (?)

Question 6

Cervical cancer - examination + colposcopy

Answer 6

Vaginal/bimanual examination

1. Roughened hard cervix
2. +/- loss of fornices and fixed cervix, if there is extension of disease

Colposcopy

3. Irregular cervical surface
4. Abnormal vessels
5. Dense aceto-white changes

Question 7

Cervical cancer - ix/dx

Answer 7

1. Dx = punch biopsy at colposcopy

Further ix if ca confirmed on biopsy

2. UEC, LFTs, FBE
3. CT abdomen and pelvis (staging and pre-operative assessment)
4. MRI pelvis
5. Examination under anaesthesia (important in Ib1 tumours when considering surgery - ?)

Question 8

Cervical ca - mx

Answer 8

1. Confirm dx
2. Assign FIGO stage (clinical)
3. Determine spread (abdominal-pelvic U/S, CT, MRI, PET)
4. Assign treatment
   - Typically hysterectomy + removal of fascia of cervix, +/- resection of vagina +/- resection of bladder - dependent on stage/spread