Cervical Cancer

Question 1

Aetiology of cervical cancer.

Answer 1

HPV 16 & 18 
- other types can cause genital warts 
Smoking 
Early first episode of sexual intercourse 
Combined oral contraceptive use 
Multiple sexual partners

Question 2

How does HPV affect cervical cells?

Answer 2

HPV enters the cervical cells and release proteins E6 & E7. These proteins then bind to tumour suppressor gene p53 to keep the virus inside the cells
The HPV then interferes with the physiological metaplasia in the transformation zone, leading to dysplasia (CIN) and squamous cell carcinoma

Question 3

What is the HPV vaccine and who is it for?

Answer 3

All girls 11-13 in secondary school to protect against HPV 6, 11, 16 and 18
- this covers cervical, vulval, vaginal and anal cancer, as well as genital warts

Question 4

Describe cervical screening advice

Answer 4

25-65 year old women
- every three years up until the age of 50
- then once every five years after that
Prevents 80% of cancers developing

Question 5

Histology of the cervix

Answer 5

Inner surface of the internal os and uterus lined by columnar epithelium
Outer surface of external os and vagina lined by squamous epithelium
The junction between the two forms of epithelium is called the transformation zone

Question 6

When would a smear not be appropriate and why?

Answer 6

If the cervix is visually abnormal after insertion of the speculum
- this is because the patient will have to be referred to colposcopy and biopsy no matter the result of the smear

Question 7

When are patients referred to colposcopy?

Answer 7

Abnormal screening result

Visually abnormal cervix on inspection

Question 8

Describe the process of colposcopy

Answer 8

Microscope and light used to visualise the cervix
Acetic acid applied and cervix observed for changes
Biopsy obtained
CIN treated if required
- excision (LLETZ) or destruction techniques (cold coagulation)

Question 9

Describe CIN1.

Answer 9

Mild dysplasia limited to the basal third of the epithelium

Question 10

Describe CIN2

Answer 10

Moderate dysplasia confined to the basal two thirds of the epithelium

Question 11

Describe CIN3

Answer 11

Severe dysplasia that may involve the full thickness of the epithelium

Question 12

List the histopathological subtypes of cervical cancer

Answer 12

Squamous cell carcinoma (most common) 
Adenocarcinoma 
Adenosquamous carcinoma 
Endometriod 
Clear cell
Squamous 
Neuroendocrine (poor prognosis)

Question 13

Presentation of cervical cancer

Answer 13

Unscheduled vaginal bleeding 
Offensive vaginal discharge 
Obstructive renal failure 
Supraclavicular node 
Asymptomatic - found on cytology or histology

Question 14

Diagnosis of cervical cancer

Answer 14

Speculum examination 
Biopsy - LLETZ or punch 
Imaging 
- MRI
- CT
- PET-CT

Question 15

FIGO stage one of cervical cancer

Answer 15

Limited to the cervix

• 1A1 = DOI <3mm and lateral spread of <7mm
• 1A2 = DOI 3-5mm and lateral spread of <7mm
• 1B1 = visible lesion <4cm
• 1B2 = visible lesion <4cm

Question 16

FIGO stage two of cervical cancer

Answer 16

Extension to the uterus/vagina/parametria

• 2A = involves the upper third of the vagina
• 2B = involves the upper third of the vagina and also involves the parametria

Question 17

FIGO stage three of cervical cancer.

Answer 17

Extension to the pelvic side wall/lower third of the vagina

• 3A = involvement of the lower third of the vagina
• 3B = extension to the pelvic side wall and/or hydronephrosis

Question 18

FIGO stage four of cervical cancer

Answer 18

Extension to adjacent organs or beyond the true pelvis

• 4A = tumour spread to the adjacent pelvic organs
• 4B = distant metastases

Question 19

Fertility sparing surgery in cervical cancer - what is it and when would it be appropriate

Answer 19

Appropriate in early onset disease ( up to 1B2)
Treatment includes LLETZ, trachelectomy and radical trachelectomy
- Pelvic lymphadenectomy needed in 1A1 and 1B2

Question 20

Management options for treatment of cervical cancer

Answer 20

Fertility sparing
Surgery
Chemotherapy
Radiotherapy

Question 21

What surgical options are there for cervical cancer?

Answer 21

Simple hysterectomy - 1A1 and 1A2 if family complete
+ 1A2
Radical hysterectomy and pelvic node clearance - 1B1, 1B2 and 2A

Question 22

Treatment for advanced cervical cancer (stage 2B and above)

Answer 22

Chemotherapy and radiotherapy based on MDT discussion
- neoadjuvant therapy can be used in some cases
Palliative input
Nephrostomy/ureteric stents if hydronephrosis present
Symptomatic radiotherapy for heavy bleeding