Cervical Cancer

Question 1

What is the aetiology of cervical cancer?

Answer 1

HPV (99.7%)

- 16

- 18

= 70% of cancers.

Genital warts = 6+11

Question 2

What are the risk factors for cervical cancer?

Answer 2

1. High HPV exposure
   - multiple sexual partners
   - early onset of sexual activity.
   - OCP use.

2. Immunosuppression/ inflammatory state

• Immunosuppression: HIV, diabetes.
• cigarette smoking.
• low socioeconomic background.

3. Age: 45-49 years

Question 3

What are the clinical features of cervical cancer?

What is the most common presenting complaint?

Answer 3

HISTORY

Most common complaint - abnormal vaginal bleeding (age 45-49)

• intermenstrual
• post coital
• post menopausal

Others

• discharge (purulent/mucoid)
• abdominal pain/ dysparaunia
• urinary change (usually increased frequency)
• symptoms due to mets (liver, lungs, bones)
• weight loss (late sign)

Exam

• Often normal

Late signs:

General:

• enlarged inguinal/supraclavicular lymph nodes.
• hepatomegaly.
• edema (legs).
• PV exam:

. cervix (ulcerative/exophytic)

. bleeding on palpation

. discharge: serous, purulent, bloody.

• Rectovaginal exam (essential)

> diameter of primary cancer

> spread to parametria

> extension to uterosacral ligaments.

Question 4

What is the course of lymphatic spread of cervical cancer? Indicates stage of disease if lymphadenopathy found….

Answer 4

1. pelvic (external iliac, hypogastric, obturator, and common iliac lymph nodes)
2. para aortic
3. thoracic (curling over clavicle - supraclavicular)
4. venous drainage.

Question 5

What are the CIN classifications and what do they mean?

Answer 5

CIN = histological classification.

normal - endocervical cells are present.

CIN1 - Dysplastic cells confined to basal 1/3.

CIN2 - Dysplastic cells involve lower 2/3 of epithelium

CIN3 - Dysplastic cells involve the superficial 1/3 of epithelium.

Question 6

What is the process of screening and investigation for cervical cancer in Australia?

Answer 6

1. Papsmears within 2 years of starting sexual intercourse OR from 18-20 (whichever is later). Regularly: every 2 years.

If LSIL found

Pt < 30 years: repeat in 6months (most will resolve). If 2 consecutive LSIL -> Colpsocopy.

Pt > 30 years: Colposcopy.

If HSIL found:

Colposcopy.

COLPOSCOPY

If high level of acetyl acetate: LLETZ.

Repeat Colposcopy again at 6months.

Question 7

What is the staging of cervical cancer? What is the general management for each stage?

Answer 7

Stage 0: carcinoma in situ.

Mx:

• Conization (cold knife).
• Loop electrosurgical excision procedure (LEEP)
• Laser surgery
• Hysterectomy (if reproduction does not need preservation).

Stage I: Carcinoma confined to the cervix, invasion into the stroma is no more than 5mm in depth. 1A - no greater than 5mm wide, 7mm deep. 1B: greater than 1A.

Mx:

1A -

. radical hysterectomy.

OR to preserve repro:

. large cone biopsy

. radical trachelectomy

. pelvic lymph node dissection.

1B

. Radical hysterectomy (ovaries spared).

. Bilateral lymphadenectomy

Stage II: Carcinoma extends beyond cervix (does not reach pelvic wall/lower third of vagina) - A = no parametrial involvement. B= obvious parametrial involvement.

Mx

• Radical hysterectomy
• Chemoradiation.

Stage III: Carcinoma extends beyond the cervix to the pelvic side wall/ lower third of the vagina.

Mx - chemoradiation + palliative treatment.

Stage IV: Carcinoma extending beyond the true pelvis (includes bladder/rectal mucosa/distal mets).

Mx - chemoradiation + ​palliative treatment.

Question 8

What are the different types of cervical cancer?

Answer 8

1. SCC (80%)
2. Adenocarcinoma (15%)
3. Adenosquamous (3.5%)
4. Others
   - small cell
   - neuroendocrine
   - transitional cell.

Question 9

What are first line tests done if a papsmear result comes back as LSIL (2 times) or HSIL?

Answer 9

1. Colposcopy:

Visualisation of the cervix under a high powered microscope

Acetic acid used to stain abnormal lesions: this is used to know where to do the biopsy.

• Abnormal vascularity, acetic white changes, obvious exophytic lesions.
  2. Biopsy:

A - LLETZ (large loop excision transitional zone) - if numerous areas of patches.

B - Cold knife cone biopsy.

Question 10

What is a cervical ectropian?

Answer 10

Distal growth of the columnar epithelium that extends beyond the external cervical os - NORMAL due to hormonal changes.

Question 11

What is the transformation zone?

Answer 11

The interface between the squamous and columnar epithelium: continuous remodelling. Therefore susceptible to metaplasia and dysplasia due to this.

Question 12

What is the hallmark of HPV infection seen under a microscope?

Answer 12

Koilocytes: squamous cells with abnormal nucleus, perinuclear clearing, peripheral dyskeratosis.