CARCINOMA CERVIX

CECT[Ref Harrison 1711,/e p. 608]

According to the FIGO guidlines for clinical staging of cervical carcinoma, diagnostic studies include  :-Intravenous urography (pyelography).

– Cystoscopic examination of bladder and urethra

Proctosigmoidoscopic study

– Barium enema

Colposcopic study of the vagina and vaginal formices in early stage disease. Colposcopic findings may be used for assigning a stage to the tumour for instance FIGO stage HA.

– Chest radiograph and electrocardiographic studies are used to determine cardiopulmonary disease particularly in oder patients. Pulmonary function studies can be important especially for evaluating patients who are candidates for extensive surgery.

Remember

• CT scan, MRI lymphangiography and PET scan may offer information helpful for treatment planning but these findings do not change the FIGO stage of the disease.
• Pelvic examinations and clinical staging as defined by FIGO cannot detect metastasis such as paraaortic lymph node metastasis. Consequently there is growing body of literature showing the superiority of cross-sectional imaging computed Tomography (CT) and magnetic resonance imaging (MRI) over clinical staging in delineating the extent of the disease in patient with cervical cancer.
• The official FIGO guidelines do not incorporate the use of either CT or MRI findings into the staging of cervical cancer.
• This is due to the FIGO guideline that staging methods should be universally available so that staging can be standardized means of communication between different institutions wordwide.

The women in question is a case of carcinoma cervix is showing non specific signs of uremia such as altered sensorium and hiccups.

CT scan is not required for staging of squamous cell carcinoma of the cervix. The staging is based on clinical findings; also chest radiograph, intravenous pyelogram, cystoscopy and proctoscopy can be used in the staging.          

Reference:
1. Oncology: An Evidence-Based Approach By Alfred E. Chang, Pages 875-78
2. Shaws textbook of Gynaecology 13 edition, Pages 381-92

Carcinoma cervix is associated with minimum risk of metastasis to the ovary amongst the options provided. Ovarian metastasis from cervical squamous cell carcinoma is rare (0-0.5 %).

Ref: The Ovary By P. C. K. Leung, E. Y. Adashi, 2004, Page 567.

In Ca cervix lymphatics drain to Obturator, External iliac, and Hypogastric lymph nodes.

HPV strains for carcinoma cervix are HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56 & 58

Post coital bleeding is the earliest symptom of Ca cervix. Vaginal bleeds in the form of menorrhagia or metrorrhagia may be the most common symptom. Pelvic pain is usually suggestive of advanced disease.

Involvement of the upper two thirds of the vagina, without parametrial involvement is stage IIA. With parametrial involvement is stage IIB. For some IIA radical hysterectomy may be considered and for IIB, chemoradiation is preferred.

Ref: Cain J., ElMasri W.M., Gregory T., Kohn E.C. (2010). Chapter 41. Gynecology. In F.C. Brunicardi, D.K. Andersen, T.R. Billiar, D.L. Dunn, J.G. Hunter, J.B. Matthews, R.E. Pollock (Eds), Schwartz’s Principles of Surgery, 9e.

Ans. is ‘a’ i.e.,Abdominal TB; ‘b’ i.e., Ca cervix; ‘c’ i.e., Endometriosis

Elevated level of CA-125 is seen in

* Epithelial ovarian Cancer

* Non ovarian tumors :- Cancers of endometrium, cervix, fallopian tubes, pancreas, breast, lung and colon.

* Non malignant conditions:- Pregnancy, mensturation, peritonitis, endometriosis, pelvic inflammatory disease (abdominal TB) and uterine fibroids.

Ans. is ‘d’ i.e., All of the above

Exfoliative cytology is used for ‑

1. Cervical Ca.                               3. Bronchogenic Ca.                             5. Prostatic Ca.
2. Endometrial Ca.                         4. Bladder Ca.                                      6. Stomach Ca.

Ans. is ‘a’ i.e., Ca cervix

o This question is tricky one and is different from previous one.

o In this question examinar is asking about the cancers which can be prevented by screening.

o The cancers, which have well known precancerous condition, can be diagnosed and treated at pre-cancerous stage to prevent the development of cancer : –

i)      Cervix —>            CIN

ii)     Colon      —>        Polyp

o On the other hand, in previous explanation, examinor had asked about the cancers for which survival can be prolonged by screening. This is done by early diagnosis and treatment of cancer which has already been developed.

o So, two different questions can be framed : ‑

1) Screening can increase the survival (screening is useful) in : –

          Colon (Colorectal) carcinoma

          Breast Carcinoma                             } Greatest

          Cervical carcinoma

          Prostate carcinoma                           l Moderate

          Kidney carcinoma

2) Screening can prevent

          Colon carcinoma

Cervical carcinoma Breast, Prostate and kidney cancers cannot be prevented by screening, however, the survival rate can be increased by screening which caught them in early stage.

Ans. C i.e. Renal failure

Carcinoma cervix

• Arises from: Squamo-columnar junction
• Earliest symptom: Post-coital bleeding
• MC site: Ectocervix
• MC agent: Human Papilloma Virus 16
• Other type of HPV which are associated with cervical Ca: HPV 18, 31, 45, 51, 52 and 53
• Predisposing factors: HPV, HSV and HIV infections
• Lymph nodes affected: Obturator, hypogastric and external iliac
• Time taken for conversion of CIN to invasive Ca: 10 years
• MC type: Squamous cell Ca
• Best method for diagnosing: Cervical biopsy
• 100% cure rates are seen in: CIS
• MC cause of death: Renal failure
• Best method of screening: Pap smear
• Management of stage II (disease extends beyond cervix, but not to the pelvic wall/ lower third of vagina):

– Extended hysterectomy,

– Chemotherapy and

– Intracavitary brachytherapy

• Stage III is: Disease extends to the pelvic wall or lower third of the vagina or causes hydronephrosis
• Management of stage IIIB:

– Radiotherapy and

– Chemotherapy

Ans. A: Stage II a

Ans. is ‘a’ i.e., Smoking

Risk Factors associated with carcinoma cervix are as follows :‑

• HPV infection – HPV 16: Squamous cell carcinoma, HPV 18: Adenocarcinoma o Early coitarche
• Increased parity
• Multiple sexual partners
• Smokers
• Lack of regular PAP smear screening
• Long term use of combined oral contraceptive pills