Cervix

Question 1

incidence

Answer 1

common in younger women (25+)
screening from 25

Question 2

presentation

Answer 2

discharge: dark in colour and odour

Question 3

diagnosis

Answer 3

colposcopy and biopsy

Question 4

what staging system is used

Answer 4

FIGO

Question 5

what is CIN

Answer 5

cervical intraepithelial neoplasia

Question 6

what is CIN I-III

Answer 6

pre-malignant change
follow up at 6 and 24 months

Question 7

what is the common pathology

Answer 7

SCC (80-90%)

Question 8

what is cervical cancer linked with

Answer 8

HPV and damage to the transitional zone
theses a vaccine for HPV

Question 9

what are the other pathology types

Answer 9

adenocarcinoma (columnar of the endocervix)
rare: small cell carcinoma

Question 10

what can early stage result in

Answer 10

surgical removal

Question 11

stage 0

Answer 11

pre malignant, screening as asymptomatic

Question 12

stage I

Answer 12

very localised growth

Question 13

IA

Answer 13

asymptomatic, only picked up through screening

Question 14

IB

Answer 14

invasive disease

Question 15

II

Answer 15

direct local spread, not extending within the parametric

Question 16

management for IA/IB

Answer 16

IA = cone biopsy
IA/IB = simple hysterectomy of the Cervi, uterus, FT, parametria, ovaries left to prevent early menopause

IB = surgery
TAH+BSO
trachelectomy removes the cervix and involved nodes and preserves the uterus and ovaries so can potentially have a baby, not invasive

Question 17

management for II-IVA

Answer 17

chemoradiation: cisplatin + EBRT + ICBT

Question 18

management for IVB

Answer 18

rare
palliative chemo: carbo + pacilitaxel
EBRT for symptom control

Question 19

what is stage I

Answer 19

small, may spread to LN not to other body parts

Question 20

what is stage II

Answer 20

larger have have spread outside uterus and cervix to/ or LN

Question 21

what is stage III

Answer 21

spread to lower vagina or to pelvis

Question 22

what is stage IV

Answer 22

outside the pelvis to organs like lung, bone and liver

Question 23

CIN

Answer 23

glandular epithelium of endocervix

Question 24

CIN I

Answer 24

watch and wait

Question 25

CIN II-III

Answer 25

conisation

Question 26

CKC

Answer 26

no difference in outcomes

Question 27

where is direct spread

Answer 27

uterus (sup), further into the cervix

Question 28

where is lymphatic spread

Answer 28

paramterium later on common iliac and para-aortic

Question 29

what investigations take place

Answer 29

EUA = examine the uterine cavity, paramteria cystoscopy + sigmoidscopy CT/MRI = visualise nodes, thorax/lung - local node invasion and spread FBC+LFT

Question 30

describe stage I

Answer 30

I = confined to cervix IA = micro invasive diagnosed by microscopy <3 IB = clinically invasive

Question 31

describe stage II

Answer 31

II = spread beyond the uterus to the upper vagina not pelvis side wall or lower vagina IIA = no paramteria involved IIB = into paramteria leaving origin

Question 32

describe stage III

Answer 32

spread to pelvic side wall and/or lower vagina and/or causes hydronephrosis or non functioning kidney and/or involves pelvis an/or para-aortic nodes IIIA = spread to lower vagina NOT pelvic side wall IIIB = spread to pelvic side wall +/- hydronephrosis or non functioning kidney IIIC = involvement of pelvic +/- para-aortic nodes

Question 33

describe stage IV

Answer 33

spread beyond the true pelvis into bladder or rectum distant mets IVA= adjacent organs IVB= distant site

Question 34

what is the management for stage IIA

Answer 34

radical hysterectomy: cervix, uterus, ovaries, FT paramterium and vaginal cuff removed

Question 35

what may be introduced for young women

Answer 35

an artificial menopause, with the ovaries going into situ

Question 36

what does recurrence result in

Answer 36

a pelvic exenteration cervix, uterus, ovaries, partial or total vagina removed + LN and other pelvic organs like bladder or part bowel

Question 37

describe chemo

Answer 37

cis-platin is commonly used appropriate for FIGO IB+ chemorad once a week for 4 cycles

Question 38

SE

Answer 38

nausea vomiting temporary hair loss nephrotoxicity (dose limiting) - kidney tests are important tinnitus or hearing loss neurotoxicity - loss of pro perception

Question 39

describe EBRT

Answer 39

primary + primary nodes + wide field followed by BT (HDR) high doses externally and internally can be 3 or 4 field box, low weight post field 45-50Gy, 1.8-2.2Gy per fraction for 4.5/5 weeks cisplatin - concurrent 5 weeks weekly followed by BT

Question 40

describe RT

Answer 40

45Gy in 25 2 cups in 30 daily CBCT daily US glycerin suppository

Question 41

when is RT given

Answer 41

IA+

Question 42

describe RT for IA+

Answer 42

locally advanced no distant spread non lymphatic daring, spread is common: medial external, internal iliac, obturator [less common in common and para-aortic] wide field, if no nodes then a narrow field can be used primary radical = bulky IB, II, III, IV + BT

Question 43

what is the high risk residual disease

Answer 43

close or involved surgical margins lymphovascular invasion nodal involvement

Question 44

IMRT

Answer 44

reduces dose to normal tissues minimise rectum size via an enema inter fractional movement of 30mm in S-I direction and 15mm in A-P direction 1,2,3 weekly imaging

Question 45

describe the dosimetry for BT

Answer 45

point A & B are reference points dose is prescribed at point A measured from the lowest part of uterus (external os), position of radioactive substances

Question 46

what is point A

Answer 46

approx anatomical position of ureter [2cm sup and 2cm lat], dose prescribed here

Question 47

what is point B

Answer 47

falls on the lat side of pelvis wall [2cm sup, 3cm lat from point A] at roughly the pelvic all

Question 48

radiation dose prescription for BT

Answer 48

encompasses a 2cm radium around the cervix when tumour extends this EBRT is involved rectal dose - max 2/3 of dose prescription HDR - max fraction size is 7Gy 14Gy in 2 fractions (following 45Gy in 25 of EBRT)