Cervical Cancer

Question 1

EPIDEMIOLOGY:

Answer 1

• Incidence 8 per 100 000 women
• Peak incidence in 30s and 80s
• Majority of cases 25-49y
• 80% are squamous carcinomas. 30% are adenocarcinomas.

Question 2

CLINICAL FEATURES:

Answer 2

1. Post-coital bleeding
2. Intermenstrual bleeding
3. Postmenopausal bleeding
4. Offensive, blood-stained vaginal discharge
5. Involvement of ureters(renal failure), bladder, recutm and nerves.
   - uraemia, haematuria, PR bleed and pain
6. Visible ulcer/mass
7. Lower limb oedema
   - due lymph node metastasis

Question 3

FIGO STAGING FOR CERVICAL CARCINOMA:

1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4

Answer 3

1. Stage 1:
   a(i) Diagnosed by microscope, invasion <3mm in depth, lateral spread <7mm.

a(ii) Diagnosed by microscope, invasion between 3-5 mm with lateral spread <7mm.

b(i) Clinically visible lesion/greater than 1a(ii). <4cm in greatest dimension

b(ii) Clinically visible lesion, >4cm in greatest dimension.

2. Invasion into vagina but not pelvic side wall:
   a(i) Involves upper 2/3 vagina, without parametrial invasion, <4cm in greatest dimension.

a(ii) >4cm in greatest dimension

b) invasion of parametrium
3. Invasion of lower vagina/pelvic wall/causing ureteric obstruction.
4. Invasion of bladder/rectal mucosa/beyond true pelvis

Question 4

INVESTIGATIONS:

1. Confirming diagnosis
2. Staging
3. Assessing fitness for surgery

Answer 4

1. Biopsy
2. a) PV and PR examination
   - size of lesion, parametrial or rectal invasion.
   b) MRI: tumour size, spread and lymph node involvement
   c) Cystoscopy: bladder inolvement
3. CXR, FBC, U&E, cross-match

Question 5

TREATMENT:

1. Stage 1a(i)
2. Stage 1a(ii)-b(i)
3. Stage 1a(ii)-2a
4. Stage 2b and above or positive lymph nodes

Answer 5

1. Cone biopsy/simple hysterectomy
   - Post-op complications: haemorrhage, preterm labour
   - Simple hysterectomy preferred in older women
2. Laparoscopic lymphadenectomy and radical trachelectomy
   - if lymph nodes positive, chemo-radiotherapy preferred.
   - if lymph nodes negative, radical trachelectomy involving removal of 80% of cervix and upper vagina.
   - cervical suture to help prevent preterm delivery.
   - if inadequate excision margins, chemoradiotherapy
3. Wertheim’s hysterectomy(if lymph nodes negative) or chemo-radiotherapy
4. Chemo-radiotherapy alone. Pelvic exenteration can be considered in selected few

Question 6

WERTHEIM’S HYSTERECTOMY:

1. Procedure
2. Complications

Answer 6

1. Involves pelvic node clearence, hysterectomy, removal of parametrium and upper 1/3 of vagina. Ovaries spared only in young women with squamous carcinoma.
2. haemorrhage, ureteric and bladder damage and fistula, voiding problems, lymphocyst

Question 7

CHEMO-RADIOTHERAPY INDICATIONS:

Answer 7

1. Positive lymph nodes on MRI/after lymphadenectomy
2. Alternative to hysterectomy
3. Surgical resection margins not clear
4. Palliation for bone pain and haemorrhage(radiotherapy)

Question 8

RISK FACTORS:

Answer 8

1. Young age at 1st intercourse
2. High no. of sexual partners
3. Smoking
4. Poor uptake of screening
5. Immunosuppression
6. HPV 16, 18, 31, 33.
7. Lower socioeconomic status
8. High parity

*Condoms are protective