Cervical cancer diagnosis and management

Question 1

What are the risk factors for cervical cancer ?

Answer 1

• Smoking
• Age of onset of intercourse – the earlier the higher risk
• OCP – once used for more than 5 yrs
• Multiple sexual partners
• HPV 16&18 cause 70% of cervical cancer

Question 2

How does cervical cancer usually present/is found?

Answer 2

Usually on screening - but not all

Question 3

What are the signs/symptoms suggestive of cervical cancer?

Answer 3

• Inter-menstrual bleeding (IMB)
• Post-coital bleeding (PCB)
• Post-menopausal bleeding (PMB)
• Abnormal appearance of the cervix (suspicion of malignancy)
• Vaginal discharge (blood stained)
• Pelvic pain/dysparenuria

Question 4

What is one of the ways in which advanced stage cervical cancer can present ?

Answer 4

Acute renal failure due to advanced disease pushing on the urethra resulting in build up of back pressure and hydronephrosis

Question 5

What are some of the other potential different diagnosis which may present with similar symptoms to cervical cancer ?

Answer 5

• STIs
• Endometrial cancer
• Endometriosis
• Ectropion or cervical polyps
• Hormonal contraception

Question 6

How is cervical cancer staged ?

Answer 6

Using FIGO staging:

• Stage 1a – microscopic
• Stage 1b visible lesion
• Stage 2 a – vaginal involvement
• 2b parametrial involvement
• Stage 3 lower vagina or pelvic sidewall
• Stage 4 bladder/rectum or metastases

The parametrium is the fibrous tissue that separates the supravaginal portion of the cervix from the bladder. The parametrium (called cervical stroma in some texts) lies in front of the cervix

Question 7

When do you refer someone following cervical smear for colposcopy ?

Answer 7

If any of these abnormalities seen:

• Moderate dyskaryosis
• Severe dyskaryosis
• Glandular abnormalities
• Query ?Invasive

Question 8

When would a women be sent for investigation to diagnose cervical cancer ?

Answer 8

If had abnormal results on cervical smear or presented with symptoms suggestive of cervical cancer

Question 9

How is cervical cancer diagnosed

Answer 9

Cervical cancer is diagnosed with colpscopy + biopsies for histopathological study

Question 10

What imaging modality is used to stage cervical cancer ?

Answer 10

MRI

Question 11

In women with CIN (cervical intraepithelial neoplasia) treat with:

1. Colposcopy
2. Biopsy and histopathological analysis
3. If moderate to severe abnormalities (CIN II and III) found treat with excision or alblation

What procedures would normally be used for excision ?

Answer 11

Cone biopsy or LLETZ (large loop excision of the transformation zone)

Question 12

What FIGO stage may be treated with conservative management of cervical cancer and what does conservative management entail ?

Answer 12

FIGO stage IA1 (microscopic disease depth up to 3mm, width up to 7mm)

Conservative managment is cone excision (biopsy) or LEETZ lymphadectomy is not required also

Question 13

What is the standard management of stage IA1 cervical cancer in women who have completed their families (fertility not a problem) ?

Answer 13

Radical hysterectomy without lymphadectomy

Question 14

What is the standard management of stage IA1 cervical cancer in women who havent completed their families (want to remain fertile) and coservative management not possible ?

Answer 14

Radical trachelectomy

Question 15

What is the standard management of early stage cervical cancer (IA2 to IIA) in women whom have completed their families ?

Answer 15

Radical hysterectomy with lymphadenectomy for tumours <4cm

For tumours >4cm then chemoradiation

Question 16

What is management can be considered for early stage cervical cancer (IA2 to IIA) in women whom havent completed their families ?

Answer 16

Radical trachelectomy and lymphadenectomy, providing the tumour diameter is less than 2 cm and no lymphatic-vascular space invasion is present

Question 17

What is the management of locally advanced? (IIB to IVA) i.e. parametrial involvement to adjacent organs e.g. bladder and bowel

Answer 17

1st ine = Chemoradiation

Question 18

For chemoradiation what is the chemotherapy drug of choice ?

Radiotherapy meaning high energy x-rays targeted to include the tumour and nodes, what are the 2 ways in which the radiotherapy component of chemoradiation can be given ?

Answer 18

1. For the chemo component give cisplatin (agent of choice in cervical cancer)
2. For radio component - give external beam radiotherapy or internal beam radiotherapy (brachytherapy)

Note - any tumour greater than 4cm or stage IIB to IVA give chemoradiation

Question 19

What is the 1st line treatment for Stage IVB (metastatic disease) in cervical cancer ?

Answer 19

Combo chemotherapy - Carboplatin/paclitaxel

Question 20

What is the treatment of cervical cancer in pregnancy ?

Answer 20

MDT management and delivery after 35wks gestation

Question 21

What is the follow-up required after cervical cancer treatment ?

Answer 21

Test of Cure = post treatment follow up:

• Combined smear and HPV test after 6 months

If both negative – 3 yearly repeat smear

If positive need further colposcopic assessment