Gyne Onc: Cervical Cancer

Front 1

Cervical cancer is what number most common gynecologic malignancy in:

a) North America
b) Worldwide

Back 1

a) #3
b) #1 (#2-3 most common cancer worldwide)

In NA, cervical cancer is not in the top ten most common cancers in women (Br, Lu, Colon, Thyroid...)

In women aged 20-40 cervical cancer is #2 cause of cancer death

Front 2

How is cervical cancer staged?

Back 2

Clinically

Front 3

Why is it thought that developed countries contribute only ~4% of the annual incidence of cervical cancer versus >85% from developing nations?

Back 3

Cervical cancer screening/Pap test

Front 4

Risk factors for cervical cancer

Back 4

Demographics - Low SES, black race, access to health care
HPV positivity (high-risk type)
Early coitarche
multiple sexual partners
Increased parity
Smoking
Lack of regular Pap screening

Front 5

What is the relative risk of developing cervical cancer in a women who is high-risk HPV positive versus one who is negative for:

a) SCC
b) AIS

Back 5

a) RR = 190
b) RR = 110

Front 6

a) What percentage of invasive cervical cancer are caused by HPV 16 & 18?

b) HPV 16 is more associated with cervical SCC or AIS?
c) HPV 18 is more associated with cervical SCC or AIS?

Back 6

a) 60% and 15% (=75%)

b) SCC

c) AIS

Front 7

What HPV viral proteins are important for oncogenesis?

Back 7

E6 - binds Rb (tumour suppressor)
E7 - binds p53 (tumour suppressor)

E1 & E2 are important for viral replication in cells.

Front 8

Is LVSI included in the staging of cervical cancer?

Back 8

No

(is a poor prognostic factor though)

Front 9

a) What percentage of cervical cancer is SCC?
b) Where does SCC typically arise from?
c) Is SCC being diagnosed relatively more often now than 30 yrs ago?
d) What are the two most common subtypes of cervical SCC?

Back 9

a) 75%
b) transformation zone/SCJ/ectocervix
c) No - AIS incidence has been increasing
d) Keratinizing and non-keratinizing

Front 10

a) List subtypes of cervical AIS

b) What percentage of cervical cancer is AIS?

Back 10

a)
Mucinous (and subsubtypes)
Endometrioid
Serous
Clear cell
Mesonephric

b) 20-25%

Front 11

Is SCC or AIS the more high-risk cell type?

Back 11

AIS

Front 12

Following therapeutic conization or hysterectomy, what are poor-prognosis factors for cervical cancer that will dictate further adjuvent treatment?

Back 12

Stage
Lymph node status (within stages independent factor)
LVSI
Cell type (e.g. AIS)
Age
Tumour size

Front 13

Woman presents to ED with a bleeding cervical mass, undiagnosed cervical cancer.
List management options.

Back 13

1) Monsels
2) Packing (with urinary foley)
3) Radiation
4) Embolization (may reduce effectiveness of subsequent radiation (hypoxia)

Front 14

a) What is the rate of detection of high grade dysplasia on Pap?
b)

Back 14

a) 50-80%
b) 30-50%

Front 15

What percentage of women with cervical cancer have not been correctly screened? (e.g. never screened, not screened within 5 yrs, sporadic screening?)

Back 15

>50%

Front 16

Give three reasons a Pap result may be judged unsatisfactory

Back 16

1) Scanty cellularity
2) Obscuring inflammation or blood
3) Unlabeled or otherwise unable to be processed by the laboratory

Front 17

What are "allowable" components of a cervical cancer staging process/workup?

Back 17

pelvic EUA
Cold knife cone
Cystoscopy
Sigmoidoscopy
CXR
IVP

Front 18

What is the 5 yr survival of cervical cancer:
a) Stage IA
b) Stage IB
c) Stage IIA
d) Stage IIB
e) Stage III
f) Stage IVA

Back 18

a) 100%
b) 90%
c) 70%
d) 45%
e) 20-40%
f) 20-40%

Front 19

a) Stage IA cervical cancer is also known as? Define stage IA1 and IA2.

Back 19

a)
Microinvasive disease.
IA1: <=3mm deep, <=7mm wide
IA2: 3-5mm deep, <=7mm wide

Front 20

What is the risk of nodal mets in IA1 cerivcal cancer:

b) without LVSI
c) with LVSI

Back 20

b) <1.5%
c) ~5%

Front 21

What are options for treatment of cervical cancer:

a) Stage IA1
b) Stage IA2

Back 21

a)
Simple hysterectomy (LN if LVSI) - done childbearing
Conization +/- LN (if LVSI)
Brachytherapy

b)
Radical hysterectomy + LN
Radical trachelectomy + LN
Brachytherapy

Front 22

For what stage of cervical cancer can surgery (hysterectomy) be considered?

Back 22

<= Stage IIA

Front 23

Define Stage IB1 and IB2 cervical cancer

Back 23

Confined to cervix
a) IB1 - <= 4cm tumour size
b) IB2 - >4cm tumour size

Front 24

a) Define Stage II cervical cancer

b) IIA1
c) IIA2
d) IIB

Back 24

a) Invades beyond uterus but not to pelvic wall or to lower third of vagina (upper 2/3 proximal vagina).

b) invades upper 2/3 vagina, <=4cm
c) invades upper 2/3 vagina, >4cm
d) invades parametria

Front 25

What are treatment options for stage IB2 - IIA2 cervical cancer?

Back 25

1) Radical hysterectomy + pelvic LN + PALN + adjuvant chemo-radiation
2) Pelvic RT + chemo (sensitizer - cisplatin) + brachytherapy

Front 26

Define:
a) Stage IIIA cervical cancer
b) Stage IIIB cervical cancer

Back 26

IIIA - Tumor involves lower third of the vagina, with no extension to the pelvic wall
IIIB - pelvic sidewall, hydronephrosis, renal failure

Front 27

Define:
a) Stage IVA cervical cancer
b) Stage IVB cervical cancer

Back 27

a) Stage IVA - invasion of bladder or rectal mucosa
b) Stage IVB - distant metastases (outside pelvis - NOT lymph nodes)

Front 28

What are risk factors/prognostic factors following surgery for cervical cancer that might prompt adjuvant treatment?

Back 28

Histology (high-risk subtypes)
Tumour size
Depth of stromal invasion
Lymphovascular space invasion (LVSI)
Nodal status
Parametrial margin status
Vaginal margin status

***Stage (staging is not based on surgery so doesn't technically apply)

Front 29

List possible complications following surgery for cervical cancer (e.g. radical hysterectomy)

Back 29

Ureteral stricture
Urterovaginal fistula
Bladder dysfunction
Constipation
Wound breakdown
Lymphocyst
Lymphedema

Front 30

What is the post-operative treatment for women who have positive LN diagnosed at surgery (e.g. hysterectomy with nodal dissection) for cervical cancer?

Back 30

1) Whole pelvic radiation w/ Cisplatin sensitization
2) Brachytherapy

Front 31

If grossly positive pelvic nodes are found at the time of planned hysterectomy for cervical cancer, what are intraoperative options?

Back 31

1) Abandon surgery and treat with post-op chemoradiation
2) Complete surgery and treat with post-op chemoradiation

Front 32

For bulky stage IB2 cervical cancer treated with radiation, is there a survival benefit to adjuvant hysterectomy?

Back 32

Possibly - if tumour initially <7cm, did better with hyst. If >7cm, did worse with hyst.

Front 33

a) List indications for pelvic exenteration

b) What is the 5 year survival for exenteration in these populations?

Back 33

a)
1) Primary treatment - rarely if local invasion of bladder/bowel and no mets
2) Recurrent disease - central recurrence, no mets, expected to do well

b) ~50%

Front 34

Describe follow-up for patients with cervical cancer treated with surgery or chemoradiation

Back 34

Pelvic exam
LN exam
Vault/cervix Pap
Consider hormone therapy

Front 35

List one regimen used in the treatment of recurrent metastatic cervical cancer

Back 35

Cisplatin
Ifosfamide
Taxol