cervical cancer

Question 1

common sites of distant spread

Answer 1

para- aortic nodes
supraclav or mediastinal nodes
bone
lungs
liver

Question 2

epidemiology

Answer 2

-85% found in developing countries
-Mortality high there too due to little assess of screening and treatment
-incidence of cancer is higher in some ethic groups-hispanic, black and asian women

Question 3

Aetiology
cervical cancer can be caused by
pt1

Answer 3

-persisant infection with HPV virus
it can be passed by skin to skin contact from oral,vaginal. or anal sex.

Question 4

cervical cancer can be caused by pt 2

Answer 4

-immunosupression such as HIV which can 5x the risk
-history of sexual transmitted disease

Question 5

cervical cancer can be caused by pt 3

Answer 5

-high parity (3 or more babies)
-early age for first born (doubles the risk)
-early age of onset of coitus
-multiple sexual partners
-oral contraceptive(combined oestrogen-progestogen-5years)
-tobacco smoking

Question 6

Grading Systems- pre cancerous

Answer 6

-Cervical Intraepithelial Neoplasia (CIN)
-Bethesda System

Question 7

-Cervical Intraepithelial Neoplasia (CIN)

Answer 7

different degrees of dysplasia

Question 8

Bethesda Grading System:

Answer 8

low grade squamos intraepithelial cells=low risk HPV subtypes with a low risk of progessiing into a invasive cancer

high grade squamos intraepithelial cells=high risk PHV with a high risk of progressing into a invasive cancer

Question 9

Grading System- CIN
what does the CIN refer to
categorised by
stages

Answer 9

-a lesion that could progress into a invasive cancer
-depth of involvement
-CIN1-CIN3

Question 9

CIN1-
caused by
treatment

Answer 9

-caused by low risk HPV
-no tx unless persisent
-regular monitoring / smears

Question 10

CIN 2&3
caused by
treatment

Answer 10

-considered pre true cancer
-tx required
-excision
-follow up

Question 11

Signs and Symptoms
pt1

Answer 11

post coital spotting
intermenstrual bleeding
prominent menstrual bleeding
post menopausal bleeding- result in anemia and fatigue
Vaginal discharge with offensive smell

Question 12

Signs and Symptoms
pt2

Answer 12

-pelvic pain or dragging sensation
-pain during sex
-blood in urine
-rectal bleeding

Question 13

DIAGNOSTIC WORK-UP AND STAGING:
staging system

Answer 13

International Federation of Gynecology and Obstetrics (FIGO)

Question 14

Staging- Investigative procedures pt1

Answer 14

-pelvic examination
-biopsy
a)punch biopsy
b)small loop biopsy or cone biopsy
c)Endo cervical curettage
-Colposcopy
-FBC
-liver and renal function test

Question 15

Endo cervical curettage

Answer 15

scrapping of cells from endocervical canal to test for any abnormal cells

Question 16

Staging- Investigative procedures (imaging modalities)
pt1

Answer 16

MRI Pelvis (pelvic and abdominal)
-best method of radiological assessment of primary tumours greater thab 10mm

ultrasound
-good diagnostic accuracy

Question 17

Staging- Investigative procedures (imaging modalities)
pt2

Answer 17

-CT (abdo/pelvis)
◦ Thoracic-metastasis assessment

-PET/CT
◦accurate
◦can detect nodal mestastese less than 10mm

-Chest xray

Question 18

Clinical Staging- Investigative procedures:

Answer 18

-Hysteroscopy
-cystoscopy
-proctoscopy
-intravenous urography/pyelography

Question 19

Hysteroscopy

Answer 19

visual examination of the cervix canal and the interior part of the uterus using a thin and flexible tube

Question 20

cystoscopy

Answer 20

examines urinary bladder and urethra

Question 21

proctoscopy

Answer 21

investigates anal cavity, rectum and sigmoid colon

Question 22

Intravenous urography/pyelography

Answer 22

examine kidneys , bladder , urethra and ureter

Question 23

Histological Types

Answer 23

-70- 80% Squamous cell (epidermoid) carcinoma
-20-25% adenocarcinoma including adenosquamous

Question 24

adenocarcinoma including adenosquamous

Answer 24

-increasing particular in young women -exposure to oestrogen, obesity and conttraceptives -not always detected on screening

Question 25

Grading

Answer 25

Does not modify stage groups GX: Grade cannot be assessed G1: Well differentiated G2: Moderatley differentiated G3:Poorly or undifferentiated.

Question 26

Treatment Options Available

Answer 26

surgery chemo radiation brachy

Question 27

Surgery

Answer 27

-primary tx of early stage cancer( stage - 1A,1B1,1B2 ) -allows lymph nodes to be assessed accurately -ovarian function remains = no early menopause

Question 28

Sentinel Lymph Node Mapping -what is it -when is it used - Recommended for -benefits

Answer 28

-dyes and radioactive substances to identify lymph nodes that may contain tumor cells. -stage 1cervical -T1b1/T2a1 -decreases the need in pelvic lymphadectonomy

Question 29

Strategic Plan for T1b1/T2a1

Answer 29

aim to avoid combining treatments- surgery and RT = highest morbidity after. tx

Question 30

Fertility Sparing procedures

Answer 30

-only offered to highly selected patients -Not recommended for patients with neuroendocrine tumours or adenoma malignum(lack of data)

Question 31

Criteria for Adjuvant treatments

Answer 31

-if pathological risk factors are discovered after radical hysterectomy (removal of womb) -observation is needed if patient has sedlis criteria

Question 32

sedlis criteria

Answer 32

risk factors for recurrence warranting post-hysterectomy radiation for early-stage cervical cancer

Question 33

Criteria for Adjuvant treatments: -Post-op RT is recommended for

Answer 33

high risk disease (positive pelvic nodes & positive surgical margin).

Question 34

Neo- adjuvant chemotherapy

Answer 34

no recommended outside a clinical trial Awaiting result of new key trial ◦ INTERLACE

Question 35

aim of interlace

Answer 35

investigate whether a short course of chemo given out weekly immediately before the standard chemoradiation improves OS for locally advanced cervical cancer

Question 36

Chemoradiation

Answer 36

-Primary treatment of Stage IIB-IVA -suitable for early stages if patient not suitable for surgery -results in ovarian failure for pre-menopausal women -ovarian transportation may be considered in women less 45

Question 37

Concurrent Chemotherapy

Answer 37

-Patients with FIGO IB2- proven effectiveness of chemoradiation to radiation alone -Standard treatment:cisplatin 40mg/m2 IV weekly

Question 38

Criteria for Adjuvant treatments: Pelvic EBRT is recommended

Answer 38

w or w/o concurrent platinum based chemotherapy for patients with all -stage IA2, IB, or IIA1 disease -negative lymph nodes after sx -large primary tumors, deep stromal invasion