Cervical cancer Flashcards
What percentage of women will be infected with HPV in their lifetime?
% of cervical ca due to HPV?
70%
- 99.7%
Which strains of HPV cause:
- Cervical cancer and high grade abnormalities
- Genital warts and low grade abnormalities
- HPV 16 & 18 (70% cervical ca and 50% high grade change)
2. HPV 6 & 11 (>90% warts, 10% low grade change)
Other cancers associated with HPV
Vulval, vaginal
Oropharyngeal
Penile cancer
Anal cancer
HPV virology
Double stranded DNA
Genome enclosed in protein capsule
Major capsid protein from L1 gene is on the outer surface- vaccine creates immune response to this
- early (E) genes and late (L) genes
- E genes conduct its replication and life cycle
- L genes used later in the piece to complete new virus particles
- E genes are in the lower layers and L genes in more superficial layers
- Low risk serotypes 6 and 11 cause genital warts
- Serotypes 16 and 18 cause neoplasia (+ 45 and 31)
Transmission
- penetrative intercourse
- oral and digital also possible
- congenital possible
LLETZ
Indication: excision of CIN
Need to orientate specimen
Cone biopsy
Indication: Glandular lesions, can’t see all of CIN, discrepancy between smear and colp findings, unreliable pt, incomplete LLETZ
Investigations for cervical ca
Colposcopy and biopsy
Cone biopsy
EUA +/- cystoscopy + PR +/- sigmoidoscopy
CXR- for distant spread to lungs
CT/MRI/PET scan - not part of formal FIGO staging but can help with surgical planning (FIGO now changed slightly so this is now integrated into staging for HIC)
Minimal resources but advanced disease: CXR and USS to look for hydronephrosis
Investigations for cervical ca
Colposcopy and biopsy Cone biopsy EUA +/- cystoscopy + PR +/- sigmoidoscopy CXR- for distant spread to lungs Intravenous pyelogram
CT/MRI/PET scan - not part of formal FIGO staging but can help with surgical planning.
FIGO staging cervical ca - Stage 2
The carcinoma invades beyond the uterus, but has not extended onto the lower third of the vagina or to the pelvic wall
IIA Involvement limited to the upper two‐thirds of the vagina without parametrial involvement
○IIA1 Invasive carcinoma <4 cm in greatest dimension
○IIA2 Invasive carcinoma ≥4 cm in greatest dimension
IIB With parametrial involvement but not up to the pelvic wall
FIGO staging cervical ca - Stage 3
The carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or non‐functioning kidney and/or involves pelvic and/or paraaortic lymph nodesc
IIIA Carcinoma involves the lower third of the vagina, with no extension to the pelvic wall
IIIB Extension to the pelvic wall and/or hydronephrosis or non‐functioning kidney (unless known to be due to another cause)
IIIC Involvement of pelvic and/or paraaortic lymph nodes, irrespective of tumor size and extent (with r and p notations)c
○IIIC1 Pelvic lymph node metastasis only
○IIIC2 Paraaortic lymph node metastasis
FIGO staging cervical ca - Stage 4
The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to stage IV
IVA Spread of the growth to adjacent organs
IVB Spread to distant organs
Summary of treatment for cervical ca:
1A1 and 1A2= microinvasive disease. Either hysterectomy or cone/trachelectomy for fertility sparing. 1A2= lymphadenectomy or SNL
1B1, 1B2, 2A1: Invasive cervical carcinoma. Radical hysterectomy and lymphadenectomy
1B3 and >2A2: Bigger tumours or more invasive therefore risk higher. Chemoradiation instead of surgery as otherwise 80% need radiation after surgery - which has higher morbidity than going straight to chemoradiation. Addition of chemotherapy has a survival benefit at 5 years.
- 4: individualised
CIN1
Low grade abnormality - conservative follow up with repeat smear in 12 months
High grade abnormality- CIN2 or 3
High-grade pre-invasive changes (CIN2 to 3) are treated via diathermy (wire loop excision), laser or cryotherapy. Single treatment is usually extremely effective. A cone biopsy involves a larger excision of cervical tissue and is generally reserved for adenocarcinoma in situ (the glandular ‘equivalent’ of CIN3), disease going up the cervical canal that cannot be fully visualised at colposcopy, or if invasive disease is suspected.
Patients treated for adenocarcinoma in situ, despite clear margins on cone biopsy, are at ongoing risk for developing further pre-invasive or invasive disease long term, and are therefore advised to have a completion hysterectomy (with ovarian conservation) once childbearing is completed.
Risk factors for cervical cancer
smoking, early coitus, multiple partners, multiple pregnancies, poor general health, poor nutrition a genetic predisposition to cervical cancer. ?COC makes HPV more virulent
Lifestyle factors include: prolonged stress, eating disorders, poor diet, excessive exercise and inadequate rest.
Illnesses that increase a woman’s risk include diabetes and immune disorders. Immunosuppressent agents also increase a woman’s risk.
Presenting symptoms
Abnormal bleeding e.g. persistant post coital bleeding
Advanced disease: Pain (particularly sciatic type pain), pressure symptoms and sometimes vaginal passage of urine or faeces
Radical hysterectomy
compared to a simple hysterectomy to achieve adequate clearance from the tumour, a vaginal and paracervical cuff of tissue is excised in continuity with the cervix.
Much of the morbidity of this procedure comes from the additional dissection required to attain lateral clearance (bladder and bowel dysfunction) but this is usually temporary.
Radical trachelectomy
in patients with no lymph vascular invasion (LVSI) and tumours <2cm who want ongoing fertility, this procedure involves radical excision of the cervix with a vaginal and paracervical cuff, with reanastamosis of the vagina to the isthmus of the uterus with or without cerclage.
This procedure enables the patient to undergo future childbearing, can be performed vaginally, laparoscopically or abdominally, and is combined with a pelvic lymphadenectomy.
Chemoradiation
definitive radiation with concomitant chemotherapy (weekly cisplatin 40mg/m2). Chemoradiation compared to radiation alone for the treatment of cervical cancer has been shown to provide a 30–50 per cent reduction in the risk of death, and is now the preferred option for the treatment of cervical cancer
