Cervical Cancer

Question 1

Definition

Answer 1

Is a human papillomavirus (HPV)-assosicated malignancy.

Question 2

Types of cervical cancer

Answer 2

= Squamous cell carcinoma (MC subtype)
= Adenocarcinoma
= Adenosquamous carcinoma

Question 3

Types of HPV which are responsible for cervical cancer

Answer 3

HPV 16
HPV 18

Question 4

Which HPV strains are responsible for genital warts

Answer 4

HPV 6
HPV 11

Question 5

How is HPV infection typically spread

Answer 5

Sexual contact

Question 6

What is the premalignant cervical cancer

Answer 6

Cervical intraepithelial neoplasia (CIN), which is assessed for with national screening

Question 7

Epidemiology

Answer 7

• Young females: 25-29
• HIV: reduction in CD4+T causes an impaired immune response to HPV
• Immunosuppression or medications such as steroids
• Smoking
• Early age of first intercourse
• Multiple sexual partners
• COCP: increases the risk of cervical cancer but decreases the risk of endometrial and ovarian cancer
• Low socioeconomic status

Question 8

Pathophysiology

Answer 8

HPV produces the oncogenes E6 and E7 which encourage cell proliferation:
- E6 inactivates tumour suppressor p53 , thus preventing apoptosis
- E7 binds retinoblastoma (Rb), causing the release of E2F which drives cell proliferation

Question 9

Signs

Answer 9

Abnormal cervical appearance
- White or red patches on the cervic
- Erosion and ulcerations
- Mass
- Bleeding
Vaginal discharge
Dyskaryosis on screening

Question 10

Symptoms

Answer 10

Can be ASx in early stages
Abnormal vaginal bleeding:
- post-coital bleeding
- intermenstrual bleeding
Vaginal discomfort
Pelvic pain, urinary, or bowel symptoms in advanced disease

Question 11

Diagnosis

Answer 11

• Bloods: tests renal function. liver function and bone profile to assess for disease spread
• Colposcopy and biopsy: DYSKARYOSIS or CIN and malignant changes
• HPV testing
• Staging imaging: CXR, renal USS, PET/CT and MRI

Question 12

Staging

Answer 12

The International Federation of Gynecology and Obstetrics ( FIGO )

Question 13

Stage 1A

Answer 13

Confined to the cervix
- A1 : ≤ 3 mm deep
- A2 : 3-5 mm deep

Question 14

Stage 1B

Answer 14

Clinically visible lesion confined to the cervix or > 7 mm wide
- B1 : ≤ 4 cm in size
- B2 : > 4 cm in size

Question 15

Stage 2

Answer 15

Invasion beyond the uterus, but not to the lower third of vagina or pelvic wall
- A : without parametrial invasion
- B : with parametrial invasion

Question 16

Stage 3

Answer 16

Involves lower third of vagina , or extends to pelvic wall
- A: lower third of vagina
- B : extends to pelvic wall, OR causes hydronephrosis or non-functioning kidney

Question 18

Stage 4

Answer 18

Invades the bladder or rectum , or extends beyond the pelvis
- A : involvement of bladder or rectum
- B : spread to distant organs

Question 19

Pre-malignant CIN Tx

Answer 19

Following colposcopy and biopsy , excision or ablation may be appropriate

Question 20

Early stage disease: 1A - 2A

Answer 20

• Microinvasive disease (stage IA) : consider ablation or excision:

< 2cm and wishing to preserve fertility : radical trachelectomy with lymphadenectomy

≤ 4cm : radical hysterectomy with lymphadenectomy, +/- adjuvant chemoradiotherapy

> 4cm : chemoradiotherapy

Question 21

Locally advanced disease: stage 2B - 4A

Answer 21

Chemoradiotherapy : FIRST LINE = Platinum-based chemotherapy (e.g. cisplatin) is the most commonly used form of chemotherapy
Radiotherapy may be either external beam radiotherapy or brachytherapy

Question 22

Metastatic disease: Stage 4B

Answer 22

• Chemotherapy and bevacizumab: bevacizumab prevents tumour angiogenesis by blocking VEGF
• Palliative chemotherapy : may be required in some patients

Question 23

If cancer recurs:

Answer 23

• Surgery : pelvic exenteration if relapse is confined to pelvis and chemoradiotherapy has failed
• Chemotherapy : palliative

Question 24

Complications

Answer 24

Invasion-related:
Hydropnephrosis
Rectal involvement
Surgical complications:
Pre-term birth
Utereral fistual
Short-term radiotherapy complications:
- Radiation proctitis
- Radiation cystitis
- Radiation burns
- Vaginal bleeds
Long-term radiotherapy complications:
- Lymphoedema
- Ovarian failure
- Tissue fibrosis