Cervical Cancer

Refers to neoplasia arising from the cervix

Aetiology

  • The vast majority of cervical squamous cell cancers are caused by persistent human papillomavirus (HPV) infection
    • HPV 16 and 18 cause 70% of cervical cancer - E6 and E7 proteins
      • Part of the vaccination program in the UK

Risk factors

  • Smoking
  • Age of onset of intercourse
  • 'High risk' male
  • Long-term (> 8 years) combined oral contraceptive pill use
  • Multiple partners
  • Other sexually transmitted infections
  • Immunodeficiency (e.g. HIV)

Pathophysiology

  • The majority (70%) of cervical cancers are squamous cell carcinomas
    • Develops from pre-existing CIN, therefore most cases should be preventable by screening
    • Local spread - uterine body, vagina, blader, ureters, rectum
    • Lymphatic spread is early - pelvic, para-aortic nodes
    • Haematogenous spread is late - liver, lungs, bone
  • Of the remainder, 15% are adenocarcinoma and 15% are mixed in type

Clinical presentation

Symptoms

  • Often asymptomatic, particularly in the early stages of disease, and many cases are detected through routine screening
  • Most common presenting symptom of cervical cancer is abnormal vaginal bleeding (e.g post-coital, intermenstrual or post-menopausal)
  • Other symptoms:
    • Pelvic pain
    • Abnormal vaginal discharge (blood-stained, foul-smelling)
    • Dyspareunia
    • Weight loss
    • Ureteric obstruction/renal failure
    • Haematuria/urinary infections

Signs

  • Speculum examination - evidence of bleeding, discharge and ulceration
  • Bimanual examination - pelvic masses
  • GI examination - hydronephrosis, hepatomegaly, rectal bleeding, mass on PR

Investigations

Pre-menopausal

  • Test for chlamydia trachomatis infection
    • If positive - treat infection
    • If negative - colposcopy and biopsy

Post-menopausal

  • Urgent colposcopy and biopsy

Staging

Histology + further imaging scans:
  • Stage 1a - microscopic
  • Stage 1b - visible lesion
  • Stage 2a - vaginal involvement
  • Stage 2b - parametrial involvement
  • Stage 3 - lower vagina or pelvic sidewall
  • Stage 4 - bladder/rectum or metastases

Management

  • Up to stage 1a2 and individual desiring fertility - LLETZ/cone biopsy
  • Up to stage 1a2 and individual completed family - hysterectomy
  • Stage 1b and individual desiring fertility - trachelectomy
  • Stage 1b and individual completed family - radical hysterectomy
  • More than stage 1b - chemoradiotherapy