Cervical Cancer Tutorial Flashcards
What is the commonest cancer in O&G?
- Endometrial cancer
- Ovary & peritoneum
- Cervix (due to screening programme) = 600 a year
Most common female cancer: 1. Breast CA, 2. Lung, 3. Colorectal, 4. CA Corpus
Look on cancer registry
Trend in cervical cancer
Rate started dropping before screening programme
However, over half of the elligible woman is still not getting screened
Median age is 50 something
The stage distribution of cervical CA is quite even
How to detect HPV?
Swab HPV
Urine HPV? (clinical validation is still limited)
What are the presenting symptoms of cervical cancer?
- Intermenstrual & post-coital bleeding (classical sign)
- Abnormal vaginal discharge
- Post-menopausal bleeding
- Urinary or bowel symptoms
- Metastatic Sx: pelvic fullness, back pain, DVT, SOB if lung mets, pain if bone mets
- Constitutional symptoms
- Abnormal smear - asymptomatic
What is WHO Initiative of eliminating Cervical CA?
WHO Initiative of eliminating Cervical CA
1. Vaccination (1º prevention): 90% of girls fully vaccinated with the HPV vaccine by the age of 15 [90% of young girls in HK uptake];
2. Screening (2º prevention): 70% of women screened using a high-performance test by the age of 35, and again by the age of 45;
3. Treatment: 90% of women with pre-cancer treated and 90% of women with invasive cancer managed.
Very long pre-malignant stage, very clear
Hx taking for cervical cancer
- PC
- Menstrual Hx
- Cervical smear Hx
- Gyn Hx - Previous cervical pathology
- Obs Hx
- FHx
- Sexual Hx, contraception
- Social Hx - Smoking
- HPV vaccination
Is HPV vaccination after sexual intercourse effective?
If you get the HPV vaccination after exposure, the efficacy drops dramatically
What causes cervical cancer
Risk factors of cervical cancer
Mechanism= persistent infection (exposure/inability to remove virus)
- HPV (the cause)
- Early sex
- Multiple partners
- Smoking (immunocompromise)
- Immunosuppression
- Lower social-economic class
- OC pills (not using condoms)
Why you get it (more exposure)?
- Multiple sexual partner
- Early age of sexual intercourse
- No use of condom (no use of condom)
What can’t you get rid of it?
- AIDs
Persistent infection:
- Early exposure
- HPV is usually cleared by own immunity,
P/E for patient with suspected cervical CA
- General (pallor, cachexia, lymph nodes [supraclavicular], pleural effusion, legs [DVT = pelvic LN can press on venous return])
- Constitutional signs
- LN - inguinal groin, SCF
- Abdo (ascites, masses)
- PV - speculum (cervical erosion, mass, ulcer, contact bleeding), bimanual (assess size, fornices)
- PR (may be able to feel for masses, Rectovaginal septum [feel for parametrium, put two fingers in] Pouch of Douglas [ovarian CA])
Why would cervical CA patient have distended uterus?
If cervical CA is big and obstructs the outflow
Hydrometra = distended uterus filled with clear, non-infected fluid
If cervical CA spreads to uterus
- Take a biopsy
- If there is bleeding, Ferric subsulfate (Monsel’s solution) or pack her with gauze
- Referral to gynaeoncology
Ix
- Blood test (CBC, L/RFT [parametrial involvement may block ureters or liver mets]
** SCC anitgen
** CA123 (adenocarcinoma) - Imaging (MRI abdomen and pelvis, local extent, [operable or non-operable, i.e. if parametria is involved], LN mets), (CXR -> CT thorax for lungs), PET-CT, PET-MR
- EUA
- Cystoscopy - bladder invasion
- Sigmoidoscopy - rectosigmoid invasion
Colposcopy is for microscopic lesions that we cannot see with naked eye
Clinical staging of cervical CA
Advanced stages are not operable, so surgical staging is not used
Route of LN spread in cervical cancer
- Cervix
- Paracervial
- Obturator
- External iliac
- Common iliac
- Para-aortic
CA Cervix FIGO (2018)
IA: invisible to naked eye
IB: visible tumour on cervix
II: Involving vagina
IIA1, IIA2: size
IIB: Parametrium
III: adding notation of r(imaging) and p(pathology) to indicate the findings that are used to allocate the stage to IIIC
What is early stage cervical CA?
Stage I is early stage
Management plan
Surgery
* For early disease (eg stage 1)
Chemoradiation
* For early disease if surgery not suitable
* For late disease ( stage 2 or above )
* Giving both: lower dose cisplatin weekly during course of RT = radiosensitisation, making RT more effective [10%])
Chemotherapy
* For metastatic disease / recurrence
Targeted therapy - Bevacizumab
* Use in combination with chemotherapy
Immunotherapy - Pembrolizumab
* Use in combination with chemotherapy
Decide with S/E profile
- ChemoRT S/E
What are the surgeries which can be performed for cervical CA?
- Very very early (microscopic <3mm deep, stage IA1) - cone / simple hysterectomy
- Wertheim’s hysterecetomy (radical hysterectomy and pelvic lymphadenectomy)
– Remove uterus, upper vagina, parametria, pelvic lymph nodes
– Route: abdominal
Advantages:
- Preserve ovarian function
- Avoids long term morbidities of radiotherapy
Can remove ovary if no fertility wish = the ovary itself will reach menopause
Remove ovary as there may be met to ovary + risk of ocarian cancer
What are the risks of pelvic lymphadenectomy?
- Pain
- Lymphoedema
- Lymphocyst (abscess)
What approach is used for Wertheim’s hysterectomy?
Robotic radical hysterectomy
(Wertheim’s hysterectomy = Cervical CA operation)
- Radical = take more of parametrium and vagina
LACC trial showed survival is poorer with minimal invasive surgery (stopped using robotic radical hysterectomy nowadays)
LACE trial looked at minimally invasive technique for endometrial cancer = outcome is save with minimally invasive = laparascopically
Cervix poorer prognosis, endometrium same prognosis
Proposed reasons
1. Laparoscopic surgery = manipulate frank tumour / tumour got exposed to peritoneal cavity + high pressure CO2 = tumour got blown up to other parts of the abdomen and metastasises
Can take hormonal medication
Irradiation for the treatment of cervical cancer
Short-term side effects: Fatigue, skin irritation, diarrhea, nausea, bladder or bowel irritation.
Long-term side effects: Vaginal dryness, narrowing of the vagina, bowel problems, bladder problems, sexual dysfunction.
Radiation toxicity: Damage to healthy tissues surrounding the cervix, leading to skin changes, fibrosis (scarring), or damage to organs like the bladder or rectum.
Risk of secondary cancers: A small chance of developing secondary cancers in the long term, particularly in patients who receive high radiation doses or have a history of radiation therapy.
A 55-year-old woman, G3P3, presented to the Gynaecology clinic with postmenopausal bleeding. Her past health was unremarkable. Pelvic examination showed 2cm cervical mass with no parametrial involvement.
Cervical biopsy showed squamous cell carcinoma. MRI of the abdomen and pelvis showed no lymphadenopathy or distant metastasis.
* What is the MOST appropriate treatment?
A. Chemoradiation
B. Chemotherapy
C. Radical hysterectomy and pelvic lymphadenectomy
D. Radiotherapy
C. Radical hysterectomy and pelvic lymphadenectomy
If involves the parametrium, patient is not suitable for surgery
A 55-year-old woman, G3P3, presented to the Gynaecology clinic with postmenopausal bleeding. Her past health was unremarkable. Pelvic examination showed 4cm cervical mass just involving the left parametrium.
Cervical biopsy showed squamous cell carcinoma. MRI of the abdomen and pelvis showed no lymphadenopathy or distant metastasis.
* What is the MOST appropriate treatment?
A. Chemoradiation
B. Chemotherapy
C. Radical hysterectomy and pelvic lymphadenectomy
D. Radiotherapy
A. Chemoradiation
Cistplatin ototoxic (may do audiogram before starting treatment)
Irradiation is pointless if the mets are too extensive, allover the body (i.e. extensive LN met, lung met). Chemo induced radiosensitization (makes RT more effective).
Paclitaxel and carboplatin (PC, CarboTaxol)
SBA
* A 55-year-old woman, G2P2, presented to the Colposcopy clinic with abnormal cervical smear showing HSIL. Her past health was unremarkable. Colposcopy and cervical biopsy showed HSIL. LLETZ was performed and histopathology showed a focus of SCC with depth of invasion of 2mm, LVSI negative, margins clear by 1mm.
* What is the MOST appropriate treatment?
A. Cone biopsy
B. Radical hysterectomy
C. Simple hysterectomy
D. Trachelectomy
C. Simple hysterectomy
Cone biopsy not indicated as she does not need to preserve fertility
- Very very early (microscopic <3mm deep, stage IA1) - cone / simple hysterectomy
- A 30-year-old woman, G0P0, presented to the Colposcopy clinic with abnormal cervical smear showing HSIL. Her past health was unremarkable. Colposcopy and cervical biopsy showed HSIL. LLETZ was performed and histopathology showed a focus of SCC with depth of invasion of 2mm, LVSI negative, margins clear by 1mm.
- What is the MOST appropriate treatment?
A. Cone biopsy
B. Radical hysterectomy
C. Simple hysterectomy
D. Trachelectomy
A. Cone biopsy
