Cervical Cancer

Question 1

Cervical Cancer: prognosis

Answer 1

• GOOD CURE RATE IF DETECTED EARLY
  
  • CERVICAL SCREENING REDUCES RISK of CERVICAL CANCER
  • HPV INFECTION V. COMMON + RARELY LEADS to CANCER

Question 2

Cervical Cancer: presentation

Answer 2

• ABNORMAL VAGINAL BLEEDING (young pt. DDx = CHYLAMYDIA, HORMONAL CONTRACEPTIVE)
  
  • POST-COITAL BLEEDING - RED FLAG (also red flag for CHLAMYDIA CERVICITIS)
  • INTERMENSTRUAL BLEEDING/PMB
  • DISCHARGE - CONSTANT, BLOOD-STAINED, OFFENSIVE
  • PAIN - ADVANCED CANCER i.e. EXTENDED to PELVIC SIDE WALLS (unlikely to have pain unless it reaches somatic nn.)

Question 3

Cervical Cancer: risk factors

Answer 3

• MULTIPLE PARTNERS - more likely to come into contact w/ someone w/ a HPV infection
  
  • EARLY AGE at 1ST INTERCOURSE
  • OLDER AGE of PARTNER - older partner may have HPV
  • CIGARETTE SMOKING - affects cell-mediates immunity, makes pt. more susceptible to HPV infection

Question 4

Cervical Cancer: pathophysiology

Answer 4

• TRANSFORMATION ZONE IN TEENAGERS MORE SUSCEPTIBLE to HPV INFECTION
  
  • TUMOUR CELLS from EPITHELIUM INVADE INTO UNDERLYING STROMA - pre-cancerous changes present before (CIN)

80% squamous cell carcinoma : 20% adenocarcinoma (endocervical)

Question 5

Cervical Cancer: investigations/diagnosis

Answer 5

Diagnosis:
• CLINICAL DIAGNOSIS
• SCREEN DETECTED - sometimes unknown if pt. had symptoms prior to screen or if screen was done as pt. had symptoms; screening for detecting precancerous pt.
• BIOPSY + URGENT REFERRAL to GYNAECOLOGY if symptomatic

Staging:
• PET-CT - ANY HOT SPOTS
• MRI - PELVIS, TUMOUR SIZE, LYMPH NODE INVOLVEMENT

Question 6

Cervical Cancer: management

Answer 6

STAGE 1a1 = type 3 excision of cervical transformation zone/hysterectomy

STAGE 1b - 11a (2a) = radical hysterectomy/chemo-radiotherapy

STAGE 11b - 1V (4) = chemo-radiotherapy

• RADICAL HYSTERECTOMY = EXPLORATION of PELVIC & PARA-AORTIC SPACE; REMOVAL of UTERUS, CERVIX, UPPER VAGINA, PARAMETRIA (loose connective tissue ~ uterus), PELVIC NODES, OVARIES CONSERVED

	○ NORMAL HYSTERECTOMY = UTERUS + CERVIX REMOVED; NEED TO REMOVE MARGIN of HEALTHY TISSUE in radical hysterectomy

* RT = EXTERNAL BEAM x 20 FRACTIONS
* CHEMOTHERAPY = 5 CYCLES CISPLATIN
* CAESIUM INSERTION (24HRS)

Question 7

Cervical Cancer: risk factors

Answer 7

• MULTIPLE PARTNERS - more likely to come into contact w/ someone w/ a HPV infection
  
  • EARLY AGE at 1ST INTERCOURSE
  • OLDER AGE of PARTNER - older partner may have HPV
  • CIGARETTE SMOKING - affects cell-mediates immunity, makes pt. more susceptible to HPV infection

Question 8

Cervical Cancer: staging

Answer 8

stage 1a: INVASIVE CANCER IDENTIFIED ONLY MICROSCOPICALLY

* IA1 = ≤ 3 mm DEPTH & ≤ 7 mm DIAMETER (MICROINVASIVE
* IA2 = ≤ 5 mm x 7 mm

stage 1b: CLINICAL TUMOURS CONFINED to CERVIX

stage 2: spread to VAGINA (UPPER 2/3)

stage 3: spread to LOWER VAGINA, PELVIS

stage 4: spread to BLADDER, RECTUM

METASTASES: LYMPHATIC (pelvic nodes), BLOOD (liver, lungs, bone)

Question 9

Cervical Cancer: epidemiology

Answer 9

• PEAK AGE = 45 - 55YRS

* Mainly LOWER SOCIO-ECONOMIC COUNTRIES + PT.

Question 10

UK HPV immunisation programme

Answer 10

2 DOSE QUADRIVALENT VACCINE (16/18/6/11) for those 12 - 13 YRS (BOYS + GIRLS)

	○ ≥ 15YRS = 3 DOSES given as immune system rapidly ages

Question 11

Cervical Screening:

Answer 11

• WOMEN aged 25 - 64yrs (identified through CHI number - identifies age + person w/ cervix)

5-YEARLY SMEARS = LIQUID BASED CYTOLOGY (LBC) + TEST for HIGH-RISK HPV

hrHPV test = all women checked for presence of high risk HPV DNA; if -ve - routine recall in 5yrs, if +ve - triage w/ cytology

CYTOLOGY = microscopic assessment of cervical cells for dyskaryosis; if normal - repeat test in 1yr, if abnormal - colposcopy

COLPOSCOPY = magnification, light, dyes

Question 12

Cervical Screening: colposcopy management

Answer 12

OBVIOUS ABNORMALITY - referral to fast track cancer clinic

PUNCH BIOPSY to MAKE DIAGNOSIS
RETURN for TREATMENT if CIN2/3
SEE + TREAT at 1ST VISIT = LLETZ, THERMAL COAGULATION, LASER ABLATION

	○ LLETZ = LARGE LOOP EXCISION of TRANSFORMATION ZONE

Question 13

Cervical Screening: follow-up after rx

Answer 13

• CONFIRM Rx was EFFECTIVE = RESIDUAL DISEASE w/I 2YRS
  
  • PREVENT INVASIVE CANCER = RECURRENT DISEASE 5% AFTER 3 - 5YRS, DETECT OCCASIONAL CANCER
  • REASSURE WOMAN
  • INCREASED RISK of CERVICAL CANCER compared w/ NORMAL POPULATION

6 months after rx = follow-up liquid based cytology + hrHPV - if both -ve then return to recall; if either +ve then return to colposcopy

Question 14

HPV infection:

Answer 14

• EARLY HPV INFECTIONS can cause MILD EPITHELIAL CHANGES - e.g. through a MICROABRASION, VIRUS can then REPLICATE using CERVICAL BASAL CELL MACHINERY, if viral DNA is incorporated w/ the cervical basal cell DNA it causes DYSREGULATED REPLICATION

	○ STIs (which are common in the age group that HPV infection also occurs in) can cause CERVICAL INFLAMMATION - further trauma & microabrasions

	○ CERVIX UNDERGOES LOTS of PHYSIOLOGICAL CHANGES DURING PUBERTY - MORE SUSCEPTIBLE to DAMAGE

	○ HPV EVADES IMMUNE SYSTEM by REMAINING W/I CELLS - as cells DESQUAMATE, VIRAL PARTICLES SLOUGH OFF

90% CLEAR HPV INFECTION; those w/ PERSISTENT INFECTION (not cleared after a few years) - can be picked up on CERVICAL SCREENING