Cervical carcinoma

Question 1

At what age is cervical cancer classically seen?

Answer 1

Two peaks:
30-39yrs
70+yrs

Question 2

What is associated with cervical cancer?

Answer 2

High risk assoc with HPV 16 and 18
Risk factors as for CIN 
Immunosuppression (e.g. HIV or steroids) accelerates invasion from CIN
FHx cervical cancer not relevant
Smoking
COCP

Question 3

How does cervical cancer present?

Answer 3

Cervical smear abnormal i.e. showing invasion (unreliable)
Incidental finding on LLETZ treatment of CIN (occult carcinoma)
PCB and/or PMB
Watery vaginal discharge
Features of advanced disease
-heavy PV bleed
-ureteric obstruction
-weight loss
-bowel disturbance
-vesicovaginal fistula
-pain, haematuria, renal failure (bladder invasion)

Question 4

How common is cervical cancer?

Answer 4

3000 new cases diagnosed annually
1000 deaths/year
Incidence decreased by 50% between 1980’s-2000’s (screening), but rates on rise again in young women

Question 5

What is the pathology of cervical cancer?

Answer 5

90% squamous cell carcinoma

10% adenocarcinoma (from columnar epithelium - worse prognosis)

Question 6

Why is HPV vaccination important?

Answer 6

99.7% cervical cancer found to contain HPV DNA

Given to all young girls as prophylaxis

Question 7

What may be seen on examination of a patient with cervical cancer?

Answer 7

Ulcer/mass visible or palpable on cervix, cervix may also be normal in early disease
Look for uptake of 0.5% acetic acid
Hardened cervix on bimanual (may be fixed in advance disease)
On speculum, cervix may bleed on contact

Question 8

What Ix would be performed in suspected cervical cancer?

Answer 8

Bloods (FBC, U&E, LFT)
Punch biopsy for histology (LLETZ contraindicated as bleeds heavily and not definitive treatment)
CT abdo pelvis/MRI for staging (also examination under anaesthetic

Question 9

What staging classification is used for cervical cancer?

Answer 9

FIGO
Stage 1 - confined to cervix (1a= microscopic, 1b= macroscopic)
Stage 2 - extended locally to upper two-thirds of vagina (2b= if to parametria)
Stage 3 - spread to lower third of vagina (3a) or pelvic wall (3b)
Stage 4 - spread to bladder/bowel (4b= spread to distant organs)

Question 10

How is cervical cancer managed?

Answer 10

Stage 1a1 (<3mm depth): local excision e.g. cone biopsy(fertility sparing) or hysterectomy
Stage 1a2 (<5mm depth) and 1b1 (<4cm diameter): lymphadenectomy and, if node negative, Wertheim’s hysterectomy
Stage 1b2 (>4cm diameter) and early 2a: chemotherapy (if -ve LN biopsy, consider Wertheim’s)
>Stage 2b: combination chemotherapy
Stage 4b: chemoradiotherapy, palliative radiotherapy for bleeding control

Question 11

What is the main chemotherapeutic agent used in cervical cancer management?

Answer 11

Cisplatin

Question 12

What complications are associated with Wertheim’s (radical) hysterectomy and lymphadenectomy?

Answer 12

Big four
Ureteric fistula
Bladder dysfunction
Lymphoedema

Question 13

What complications are associated with radiotherapy?

Answer 13

Acute bladder and bowel dysfunction

• Tenesmus
• Mucositis
• Bleeding
• Ulceration
• Strictures and fistula formation
• Vaginal stenosis, shortening, dryness

Question 14

What is the prognosis of cervical carcinoma?

Answer 14

5yr survival rates:

Stage 1a = 95%
Stage 1b = 80%
Stage 2 = 60%
Stage 3-4 = 10-30%
LN involved = 40%
LN clear = 80%

Overall - 65%

Question 15

How is cervical cancer managed?

Answer 15

Conservative 
-Cone biopsy
-Radical trachelectomy
-Simple hysterectomy
Radical
-Radical hysterectomy (open/laparoscopic)
-Radical radiotherapy +/- chemotherapy
-Exenterative surgery