Cervical Cancer

Jing Zeng and Lilie Lin

Background

What is the annual incidence of cervical cancer in the U.S.?

~11,000 cases/yr of cervical cancer in the U.S.

What is the mean age of presentation for cervical cancer?

The mean age of presentation for cervical cancer is 47 yrs in the U.S.

Name 5 lifestyle factors associated with an increased risk of cervical cancer.

Lifestyle factors associated with increased risk of cervical cancer:

Early onset of sexual activity
Multiple sexual partners
Exposure to high-risk partners
Hx of STD
Smoking
High parity
Prolonged use of oral contraceptives

HPV is detectable in what % of cervical cancer?

HPV is detectable in >99% of cervical cancer.

Roughly what % reduction in mortality has been achieved with PAP screening for cervical cancer?

There has been an ~70% reduction in cervical cancer mortality with PAP screening.

What does ASCUS stand for (on a PAP result), and how should it be managed?

ASCUS stands for atypical squamous cells of unknown significance. About two thirds can resolve spontaneously. Pts can undergo repeat PAP in 6 mos and then colposcopy if abnl.

How should LGSIL seen on PAP be managed?

LGSIL resolves spontaneously ~40% of the time; therefore, like with ASCUS, pts can undergo repeat PAP in 6 mos with colposcopy if abnl.

How should an HGSIL result from a PAP be managed?

All pts with high-grade SIL should undergo colposcopy with Bx. One third of these pts can still resolve spontaneously, but waiting without further investigation is not recommended due to concern for progression.

What % of HGSIL progress to invasive cancers?

~22% of HGSIL progress to invasive cancer. This is in contrast to ASCUS (<1%) and LGSIL (~5%).

What % of cervical cancers are caused by HPV 16 and 18?

>70% of cervical cancers are caused by HPV 16 and 18.

What HPV subtypes cause most cases of benign warts?

HPV subtypes 6 and 11 cause most cases of benign warts.

In the U.S., what % of cervical cancers are squamous cell carcinomas vs. adenocarcinomas?

With regard to cervical cancers in the U.S., 70% are squamous cell carcinomas, while ~25% are adenocarcinomas.

Name 3 histologic subtypes of adenocarcinoma of the cervix.

Subtypes of adenocarcinoma of the cervix:

Mucinous
Endometrioid
Clear cell
Serous

Name 3 common presenting Sx of cervical cancer.

Common presenting Sx of cervical cancer:

Abnl vaginal bleeding
Postcoital bleeding
Abnl vaginal discharge

What specific area of the cervix is the most common point of origin for cervical cancer?

The transformation zone is the most common point of origin for cervical cancer. It is a dynamic area between the original and present squamocolumnar junction.

Workup/Staging

What should be included in the workup for a pelvic mass?

Pelvic mass workup: H&P, including a careful pelvic exam in the office, basic labs, and EUA with Bx, with cystocopy and proctoscopy for any visible lesions. Studies such as CT, PET, MRI can be obtained for Tx planning purposes (but do not enter FIGO staging of the pt).

What are the areas at risk for local extension of cervical cancer?

Cervical cancer can spread locally to the corpus, parametria, and vagina. These should be carefully assessed during a physical exam. Tumor size and parametrial involvement are best assessed by rectovaginal exam.

Name 3 routes of lymphatic drainage from the cervix.

Routes of lymphatic drainage from the cervix:

Lat to the external iliac nodes
Post into common iliac and lat sacral nodes
Post-lat into internal iliac nodes

What imaging studies are allowed in FIGO staging of cervical cancer? What common imaging modalities are not allowed?

CXR and intravenous pyelogram data are allowed in FIGO staging of cervical cancer, as are procedures such as cystoscopy, proctoscopy, and hysteroscopy. CT, PET, MRI, bone scan, lymphangiography, and laparotomy/laparascopy data are not allowed to be used for staging but can be used in Tx planning.

What is the utility of PET scans in cervical cancer?

PET is generally fairly sensitive (85%–90%) and specific (95%–100%) for detection of para-aortic (P-A) nodes in pts with locally advanced cervical cancer. There is less agreement about its utility in detecting pelvic nodal mets.

In what group of cervical cancer pts is evaluation of the urinary tract required?

Cervical cancer pts with more than microscopic Dz require imaging of the urinary tract. This can be performed with CT, MRI, or intravenous pyelogram.

What is the FIGO (2008) staging for cervical cancer?

Stage IA: microscopic Dz, with ≤5 mm DOI and ≤7 mm horizontal spread. It is further delineated into IA1 (tumors ≤3 mm depth and ≤7 mm wide) and IA2 (tumors >3 mm but ≤5 mm deep and ≤7 mm wide)
Stage IB: clinically visible tumor or >IA2, with IB1 ≤4 cm, and IB2 being bulky tumors >4 cm
Stage IIA: invades beyond uterus but not to pelvic wall, lower 3^rd of vagina, or parametrial invasion, with IIA1 lesions ≤4 cm and IIA2 lesions >4 cm
Stage IIB: invades beyond uterus and into parametria but not into pelvic wall or lower 3^rd of vagina
Stage IIIA: invades lower 3^rd of vagina but no extension into pelvic wall
Stage IIIB: invades pelvic sidewall and/or causes hydronephrosis or nonfunctioning kidney
Stage IVA: invades beyond true pelvis or mucosa of bladder or rectum (must be Bx proven); bullous edema of bladder or rectum does not count
Stage IVB: DMs

How does the AJCC (TNM) staging system for cervical cancer compare with the FIGO system?

In AJCC cervical cancer staging, the T stage corresponds to the FIGO stage, except for FIGO stage IVB. AJCC stage 3 includes T3N0-1, and stage 4 includes T4NX or M1 Dz.

What factors are predictive of pelvic nodal involvement in cervical cancer?

Factors that predict for nodal involvement in cervical cancer include DOI, FIGO stage, and LVSI (10% without vs. 25% with).

Estimate the risk of pelvic LN involvement based on the following DOIs of a cervical cancer: <3 mm, 3–5 mm, 6–10 mm, and 10–20 mm.

Risk of pelvic nodal involvement by DOI: