Cancer

Question 1

What are the common presenting symptoms for CA cervix?

Answer 1

• Asymptomatic
• PV bleeding (IMB, PMB, PCB)
• Mass
• Vaginal discharge due to infected tumor

Question 2

What is the radiological investigations for CA cervix?

Answer 2

1. MRI pelvis
2. CXR for metastasis
3. USG abdomen and pelvis

Question 3

Treatment for CA cervix?

Answer 3

Depends on staging:

Stage1A1 (microscopic <3mm depth): cone biopsy OR simple hysterectomy

Stage 1A2-2A: Radical hysterectomy and bilateral pelvic lymphadenectomy or RT

Stage 2B-4: Chemotherapy and radiotherapy

Question 4

2 Preventive measures of CA cervix besides lifestyle measurement?

Answer 4

1. Regular pap smear

2. HPV vaccination

Question 5

How will you explain results of HSIL in pap smear to patient?

Answer 5

1. Neoplastic changes at cells of squamocolumnar junction

2. HSIL is microinvasive condition but not cancer, but can progress to SCC

Question 6

Colposcopy shows extensive acetowhite lesions on cervix and vagina is not involved. Multiple biopsies show early
stromal invasion. How would you advise this patient?

Answer 6

Already a carcinoma, stage 1A (with microscopic invasion) <3mm= 1A1

• Requires microscopy to see for depth of invasion; if >3mm = stage1A2, which then requires radical hysterectomy + bilateral pelvic lymphadectomy or chemo RT (rather than cone biopsy OR simple hysterectomy)

Question 7

If a patient has cone biopsy done, showing frank invasive and carcinoma of stage IBI. What would you do before deciding on the
definite treatment? (4)

Answer 7

1. MRI pelvis to confirm operability of Ca, any soft tissue involvement or parametrium (stage 2b),
   - non-operative if gross hydronephrosis, not intact pelvic wall, obturator lymphadenopathy
2. CXR for any metastasis
3. Patient factor: whether patient is fit for surgery or not

Question 8

If a patient has cone biopsy done, showing frank invasive and carcinoma of stage IBI. How to counsel the patient?

Answer 8

1. If the patient has no fertility wish, advise radical hysterectomy + BSO + lymphadenectomy

Question 9

Discuss the pros and cons of surgery and radiotherapy in Ca cervix. Which treatment would you recommend?

Answer 9

Surgery 
Pros
- specimen for histology, 
- check for margin involvement, 
- lowers risk of recurrence 
- lowers risk of ovarian cancer 

Cons

• Infection, bleeding,
• injury to other organs,
• lymphedema,
• fistula,
• surgical menopause,
• infertility,
• GA risk

Radiotherapy
Pros
- more tolerable, non-invasive, no GA risk

Cons
- Loss of ovarian function, vaginal stenosis, cystitis, proctitis,
lead to secondary malignancy, will not be eligible for 2nd RT, no specimen for histology

Prefer surgery for younger patient, RT for older patient (same survival)

Question 10

What is radical trachelectomy?

When it can be done?

Answer 10

• Resection of cervix +/- some vagina, then connects uterine body to remaining vagina + lymphadectomuy
• When tumor <2cm, SCC only (not adenocarcinoma because requires resection of some uterine body)

Question 11

What are the pros and cons of radical trachelectomy?

Answer 11

Pros: fertility sparing as functional uterine body is retained

Cons:

1. Higher chance of abortion
2. Higher chance of needing ART
3. Requires cerclage in the next pregnancy

Question 12

Indications for colposcopy?

Answer 12

Abnormal pap smear findings
e.g. LSIL, HSIL, cancer

• Refer to colposcopy if:
  1. ASCUS or above x2 at 6 months/12 months of PS
  2. ASC-H
  3. LSIL > triage with HPV testing if haven’t done, then colposcopy + biopsy if HPV +ve ; 1 year after if HPV -ve
  4. HSIL in 6 weeks + biopsy
  5. Carcinoma in 1 week + biopsy

Question 13

Name the solution used in colposcopy.

Answer 13

Acetic acid +/- Lugol’s iodine

• then use Monsel’s solution for hemostasis if needed

Question 14

Describe possible abnormalities found in colposcopy (4). (esp found in high grade CIN)

Answer 14

1. Patches of acetowhite
2. Punctations
3. Mosaic vascular pattern
4. Ulcerations

Question 15

Best treatment for a 29/F lady with 2 children for HSIL findings in colposcopy.

Answer 15

LEEP

- Loop electrosurgical excision procedure

Question 16

What are the complications for LEEP? (5)

Answer 16

1. Bleeding, hemorrhage
2. Infection
3. Cervical impotence, risk of preterm delivery or infertility
4. Damage adjacent tissues or organs
5. Recurrence or failure

Question 17

Indications of LEEP?

Answer 17

1. CIN2,3
2. CIN2 if lesions occupies >3/4 of cercix, patient’s personal choice
3. Unsatisfactory colposcopy (cannot see SCJ, but HSIL, still need to confirm by LEEP)

Question 18

What is the Reid’s colposcopic index?

Answer 18

SEVI

1. Sharpness of margin
2. Epithelial color
3. Vascular pattern
4. Iodine staining

0-2 points - HPV or CIN1

3-4 points - CIN1 or CIN2

5-8 points - CIN2 or CIN3

Question 19

4 advantages of liquid based pap smear over traditional pap smear?

Answer 19

1. Does not miss a population of cells
2. Avoid obscuring the view by inflammatory cells
3. Can do multiple test with one sample, including HPV, gonorrhea, chlamydia etc.
4. More efficient and quicker analysis

Question 20

Management of LSIL findings in pap smear?

Answer 20

1. Colposcopy in 12 weeks and biopsy
2. Triage with HPV testing
   if +ve > colposcopy
   if -ve > repeat-co-testing at 12 months, refer if either test is abnormal

If colposcopy shows LSIL : repeat PS Q6m x3

If colposcopy shows HSIL: proceed to LEEP

Question 21

Management of HSIL findings in pap smear?

Answer 21

1. Colposcopy in 6 weeks and biopsy
2. Perform PS Q6M

if confirmed HSIL in colposcopy > LEEP