Cervical cancer and intraepithelial neoplasia

Question 1

What is the definition of cervical cancer?

Answer 1

Malignancy of uterine cervix.

Question 2

What is the aetiology of cervical cancer?

Answer 2

HPV implicated in 95% (16/18). Asociated with multiple partners, low age of first sex, low SES, HIV.

Question 3

What is the epidemiology of cervical cancer?

Answer 3

6% of female malignancies, 500k/yr globally.

Question 4

What is in the history of cervical cancer?

Answer 4

1. Random bleeding
2. Signs of mets

Early: PV discharge (offensive, blood). PCB/IMB/PMB. May be asymptomatic.

Late symptoms from metastasis: lower limb odema, haematuria, rectal bleeding, signs of fistulae, pressure symptoms.

Question 5

What would you find on examination in cervical cancer?

Answer 5

Unremarkable if early stage or in endocervical canal.

Chest signs of mets, Abdominal masses if pelvic spread, hepatosplenomegaly.

Speculum: discoloration, ulceration, erosion, macroscopic tumor

Vaginal masses if pelvic spread.

Question 6

What pathologies exist in cervical cancer?

Answer 6

Histology: 85% squamous or adnosquamous, 15% adenocarcinoma.

Spread: direct or lymphatic.

Question 7

What is the staging system in cervical cancer?

Answer 7

Staging: FIGO 2009.

· Ia invasive diagnosed by microscopy

· Ib clinically visible lesions in cervix

· II invades beyond uterus, but not to pelvic wall or lwer 1/3 of vagina

· III extends to lower 1/3 of vagina

· IV spread beyond pelvis/ bladder / rectal mucosa.

Question 8

What investigations do you do in cervical cancer?

Answer 8

Tissue diagnosis: coloposcopy and biopsy

Blood: FBc, UE, LFT, clotting if LFT abnormal, G&S for surgery.

Imaging: CXR, CT, MRI for mets.

Cystoscopy for mets.

Question 9

What is the surgical management of cervical cancer?

Answer 9

· I: core biopsy or simple abdominal hysterectomy, +/- pelvic lymphadenectomy.

· II: radical hysterectomy and pelvic lymphadenectomy.

· Ib may be eligible for trachelectomy to preserve fertility.

Question 10

How do you use chemoradiation in cervical cancer?

Answer 10

· Stage Iib and above. External bea radiation and brachytherapy with cisplatin.

Recurrence - Consider radiaiton if not previously given.

Question 11

What are the complications/ prognosis of cervical cancer?

Answer 11

Metastases: LL odema, GU obstruction, fistulae

Surgery: bleeding, infection, stenosis, infecrtility, urinary dysfunction.

Radiotherapy: cystitis, rectal’vaginal stenosis, fistulae, bowel obstruction.

5y survival 95% stage I, 65% stageII, 35% stage III.

Question 12

What is cervical intraepithelial neoplasia?

Answer 12

Premalignant cellular atypia within squamous epithelium of cervix

Question 13

What is the aetiology of cervical intraepithelial neoplasia?

Answer 13

HPV implicated in 95%, 16/18. RF as per CC.

Question 14

What is the epidemiology of cervical intraepithelial neoplasia?

Answer 14

Peak 25/29yr.

Question 15

What is the history/ exam of cervical intraepithelial neoplasia?

Answer 15

Asymptomatic, on screening.

Speculum: unremarkable.

Question 16

What investigations do you do for cervical intraepithelial neoplasia?

Answer 16

Coloposcopy and biopsy.

Question 17

What is the management of cervical intraepithelial neoplasia?

Answer 17

CIN I: conservative may resolce, but if persistent excise or cryotherapy.

CIN II or III: LLETZ, conisation, laser, if family is completed or olfer age, consider TAH.

F/U: Cin I: 6/18m, CINII/III: 1, 12, 18mo. Annual smears for 10y after.

Question 18

What are the complications/ prognosis of cervical intraepithelial neoplasia?

Answer 18

Progression to CC. Tx cmx: bleeding, infection, future cervical incompetence with excision procedures.

CINI 20% progress to CC, CIN II 33% progress 33% regres, CIN III 30% 10yprogression.

Question 19

What is the pathology of CIN?

Answer 19

Histoogy: dysplastic changes, high nucelar to cytoplasm ratio, high nuclear size, abnormal nuclear shape (poikliocytosis), high nuclear density.

CIN grades:

· CIN I: mild dysplasia in lower 1/3 of epithelium

· CIN II: moderate dysplasia affecting 2/3 of epithelium

· CIN III: severe dysplasia in upper 1/3 of epithelium (Carcinoma in situ)