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Gynae Oncology > Cervical cancer > Flashcards

Cervical cancer Flashcards

(47 cards)

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1
Q

Stage I cervical cancer

A

Tumour confined to cervix
(80%)

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2
Q

Stage IA
- IA1
- IA2

A
  • ‘microinvasive’: <5mm invasion
    1 - < 3mm invasion
    2 - 3-5mm invasion
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3
Q

Treatment of IA1 cervical cancer

A

Cone or LLETZ with adequate margin or simple hysterectomy

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4
Q

Treatment of IA2 cervical cancer
- Fertility sparing vs not

A
  • Fertility desired: cone or trachelectomy + pelvic lymphadenectomy
  • fertility not desired: modified radical hysterectomy + pelvic lymphadenectomy (or SNLB if low risk)
    Brachytherapy +/- EBRT if surgery contra-indicated due to medical problems
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5
Q

Cervical cancer Stage IB
- 1
- 2
- 3

A

> 5mm invasion
1: <2cm
2: 2-4cm
3: >4cm

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6
Q

Treatment for stage IB cervical cancer

A

IB1: radical hysterectomy + pelvic lymphadenectomy (consider trachelectomy + pelvic lymphadenectomy if desiring fertility) *
IB2 and IIA1: radical hysterectomy + pelvic lymphadenectomy OR radiation as primary treatment (surgery preferred). SNLB experimental. *
IB3 and IIA2: usually chemoradiation as larger tumour with higher chance of recurrence and positive margins. **
* If there are contraindications to surgery, radiation has equally good results in terms of control and survival. Benefits of surgery are re staging, treating radiotherapy resistant tumours, and preserving ovarian function.
** Surgery feasible but is not encouraged as 80% require adjuvant chemoradiation and the combination is associated with significant increase in morbidity

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7
Q

Cervical cancer stage II

A

Tumour extends beyond cervix but not to lower 1/3 of vagina or to pelvic side wall
(65%)

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8
Q

Cervical cancer stage IIA
IIA1
IIA2

A

IIA - involves upper 2/3 of vagina but not parametrium
IIA1 - <4cm
IIA2 - >4cm

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9
Q

Cervical cancer stage IIB

A

involves parametrium

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10
Q

Treatment of cervical cancer stage IIA1 and IIA2

A

IIA1 same as IB2:
radical hysterectomy + pelvic lymphadenectomy. Consider trachelectomy and pelvic lymphadenectomy if desiring fertility
IIA2 same as IB3: usually chemoradiation as larger tumour with higher chance of recurrence and positive margins

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11
Q

Treatment of cervical cancer stage IIB +

A

Chemoradiation is standard of care
- CCRT - concurrent platin-based chemoradiation
- EBRT + brachytherapy + weekly cisplatin

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12
Q

Cervical cancer stage III

A

Tumour extends to lower 1/3 of vagina OR pelvic side wall OR has caused hydronephrosis or renal impairment OR involves pelvic/para-aortic lymph nodes
(30%)

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13
Q

Cervical cancer stage IIIA, B, C

A

IIIA - to lower 1/3 or vagina
IIIB - to pelvic side wall OR caused hydronephrosis/renal impairment
IIIC - involves pelvic or paraaortic lymph nodes:
–IIIC1 - pelvic LNs
–IIIC2 - para-aortic LNs

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14
Q

Cervical cancer stage IV

A

tumour extends beyond true pelvis or involves mucosa of bladder or rectum
IVA - spread to adjacent pelvic structures
IVB - spread to distant pelvic structures
(10%)

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15
Q

Treatment of Stage IVB cervical cancer

A
  • chemotherapy and antiangiogenesis factor (abastin/bevacizumab)
    – 2 x platinum based chemo
    – consider radiation as well
    – antiangiogenesis factors - not funded
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16
Q

Cervical cancer incidence

A
  • 3rd most common gynaecological malignancy (after endometrial and ovarian)
  • overall 4th most common malignancy in women (after breast, colorectal, lung)
  • 2.5% of cancers in women
  • 1 in 90 without cervical screening
  • 1 in 600 with screening
  • Overall, 1 in 160
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17
Q

Aetiology of cervical cancer

A
  • 99.7% due to persistent infection with oncogenic HPV
  • 80% of women have HPV infection at some point, 10% of these have persistent infection
  • 16 and 18 account for 70%
  • 31, 33, 35, 39, 45, 52 and 58 account for 19%
  • smoking and HIV can modify ability to clear infection
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18
Q

Risk factors for cervical cancer

A

Sexual factors:
- early onset of sexual activity
- multiple sexual partners
- high risk sexual partner
- hx of STI (esp HPV)
Social factors:
- smoking
- low SES
- poor nutrition
Genetic predisposition
Gynae hx
- OCP use
- “DES daughter”
- HIV
- VAIN/VIN

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19
Q

Cofactors that increase the risk of progression of cervical abnormalities in women with persistent oncogenic HPV

Study These Flashcards
A
  • cigarette smoking (SCC not adeno)
  • multiparity (>5 term pregnancies
  • early age at first term pregnancy
  • use of OCP
  • immune deficiency - HIV, medications
20
Q

prevention of cervical cancer

Study These Flashcards
A
  • HPV vaccination
  • cervical cancer screening programme
21
Q

Spread of cervical cancer

Study These Flashcards
A
  • Direct:
    –> down to vagina, anteriorly to bladder, laterally to parametrium, posteriorly to bowel
  • Lymphatic:
    –> external iliac (43%), obturator (26%), parametrial (21%), paraortic in late stages
  • Haematogenous
    –> to lung, liver and bone
22
Q

Lymph node anatomy

23
Q

Types of cervical cancer

Study These Flashcards
A
  • Squamous cell carcinoma: 70-80%
  • Adenocarcinomas: 15-20%
  • Rare forms: 6% (melanomas, sarcoma, lymphomas, small cell cacinoma)
24
Q

Clinical evaluation of cervical cancer - history

Study These Flashcards
A
  • Abnormal bleeding - postcoital, intermenstrual, postmenopausal
  • Persistent, offensive blood stained discharge
  • Pain or pressure symptoms in late disease
  • Renal failure if ureteric obstruction
  • Thrombosis in pelvic veins may cause swollen leg
25
Cervical cancer clinical evaluation - examination
Trying to assess tumour size, vaginal involvement, parametrical involvement, groin - Speculum examination: --> SCC - exophytic, friable lesions --> AC - hard, barrel shaped cervix - Bimanual --> fixed, immobile cervix --> parametrial lesions - PR --> hard, irregular mass anteriorly
26
Cervical cancer - investigations
- Colposcopy --> cervical cytology --> cervical bx - edge of visible lesion (avoid central necrotic portion) --> endocervical currette - Bloods --> FBC, UEC, LFTs - Imaging (not required for staging but now included in FIGO 2018 update) --> MR pelvis - most helpful to assess tumour size, local invasion, pelvic LN spread --> CT PET C/A/P - if visible cervical disease, to look for nodal metastatic disease (false negative in 4-15%). In countries with high prevalence of TB and HIV, large nodes not necessarily metastatic therefore consider FNA or biopsy --> If resources don't allow for MRI/CT - perform CXR and assessment of hydronephrosis with renal tract US if presence of frank invasive tumour --> pretreatment imaging HAS been shown to reduce the need for adjuvant chemoradiation, reducing cost and improving overall long term QOL - Examination under anaesthetic +/- colp +/- signmoidoscopy if imaging not available
27
Staging cervical cancer
Primarily clinical - EUA - Cystoscopy if pt symptomatic - Sigmoidoscopy if pt symptomatic Where resources allow, imaging can contribute to staging but is not required (USS, CT, MRI, PET according to available resources)
28
Staging and 5-year survival
CIN - 100% Stage I - confined to cx: 85% Stage II - disease beyond cx but not to pelvic wall or lower 1/3 of vagina: 65% Stage III - disease to pelvic wall or lower 1/3 vagina: 35% Stage IV - invades bladder, rectum or metastasis: 7% (medium duration of survival w distant mets = 7 months)
29
Staging of cervical cancer and % stage at presentation
47% present stage I 28% present stage II 21% present stage III 4% present stage IV Spread to distant organs is rare - 2% of cases
30
Grading cervical cancer
Type: - SCC - Adenocarcinoma - Serous - Adenosquamous carcinoma - Glassy cell carcinoma - Adenoid cystic carcinoma - Small cell carcinoma - Undifferentiated carcinoma Grade: - GX - cannot be assessed - G1 - well differentiated - G2 - moderately diff - G3 - poorly or undifferentiated
31
Treatment principles in cervical cancer management
- primarily surgical or radiation - chemo is useful adjunct - treatment to be individualised based on: --> fertility desires --> suitability for surgery
32
Cervical cancer and counselling regarding fertility preserving surgery
- preserving fertility doesn't guarantee a live birth or even a pregnancy - consider oncologic safety - no randomised studies - consider pt chx: proven fertility, strong desire for fertility, age - newest evidence suggests the better pregnancy outcomes with cone than trachelectomy (decreased prematurity, decreased IVF and scarring because blood supply preserved)
33
Risks of LLETZ/Cone for cervical cancer (fertility sparing)
For IA1 only Risks: - incomplete resection, increased recurrence, need for further surgery or radiation
34
Risks of trachelectomy for cervical cancer (Fertility sparing)
- removal of upper 1/3 of vagina, parametrium, cervix. Reanastomose uterus to vagina and place cerclage. Can be performed vaginally, open or laparoscopically - IA1, IA2, IB1: fertility desired, 2cm disease, negative endocervical margin, no lymph vascular space invasion. - Risks: may need IVF. Would need CS birth. May cause cervical stenosis. Risk PTL. Dysmenorrhea
35
Extrafascial 'simple' hysterectomy for cervical CA
- IA1 - IB1 - removal of uterus and cx, no vagina, ureters not mobilised, divide cardinal ligaments and uterosacrals at cervical border, divide bladder base, rectum not mobilised, any surgical approach
36
Radical hysterectomy for cervical CA
- removal of uterus and cervix and upper 1/3 vagina, ureters tunnelled through broad ligament, cardinal ligaments divided at pelvic side wall, uterosacral divided at sacral origin, bladder mobilised to mid vagina, rectum mobilised to below cervix. Any surgical approach. - IB2 - IVA - Longer term risks: lymphoedema, lymphocysts, sexual dysfunction, fistula formation
37
Management according to stage of cervical CA principles
- dual therapy with surgery and chemoradiation generally discouraged due to significant morbidity - but can be used for loco regional recurrence or for alleviating distressing sx in palliative pts. - reasons for increased morbidity with radiation post surgery: lymphoedema and adhesions causing immobility of normal tissue exposing them to greater radiation.
38
Surgical management of cervical CA according to stage - IA1
- cone or LLETZ with adequate margin or simple hysterectomy
39
Surgical management of cervical CA according to stage - IA2
- modified radical hysterectomy + pelvic lymphadenectomy - may be simple hysterectomy or SNLB in low risk - if desiring fertility, may be cone + laparoscopic lymphadenectomy or trachelectomy with pelvic lymphadenectomy (<2cm)
40
Surgical management of cervical CA according to stage - IB1
- radical hysterectomy with pelvic lymphadenectomy - if desiring fertility, may be trachelectomy with pelvic lymphadenectomy (<2cm)
41
Surgical management of cervical CA according to stage - IB2
- surgery or radiation as primary rx (surgery preferred) - radical hyst + pelvic lymphadenectomy - SNLB remains experimental
42
Surgical management of cervical CA according to stage - IB3
- usually chemoradiation - larger tumours, higher likelihood of high risk factors that increase risk of recurrence/positive surgical margins - would usually require both surgery and chemoradiation - dual modality increases pt morbidity
43
Surgical management of cervical CA according to stage - IIA1
- surgery or radiation as primary rx (surgery preferred) - rad hyst + pelvic lymphadenectomy - SNLB experimental
44
Surgical management of cervical CA according to stage - IIA2
- usually chemoradiation - larger tumorus, higher risk of recurrence/positive margins - would usually require both surgery and chemorad - dual modality = increased pt morbidity
45
Chemoradiation for rx cervical CA by stage - IA, IB1, IB2, IIA
- if there are contraindications to surgery or aneasthesia, surgery and radiation have equally good results in terms of local control and survival
46
Chemoradiation for rx cervical CA by stage - IB3, IIA2
- surgery is feasible but not encouraged as 80% require adjuvant chemoradiation - and the combination increases morbidity - chemoradiation is standard of care
47

Gynae Oncology (2 decks)

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