Cervical Cancer

Epi & Risks - Cervix Culprits

• Global: 4th commonest female cancer; India: 2nd, ~20% global burden.
• Main Culprit: Persistent high-risk HPV (hrHPV) - types 16 & 18 (most oncogenic).
• Key Cofactors:
  • Early coitarche (<18 yrs), multiple sexual partners.
  • Smoking, immunosuppression (e.g., HIV).
  • OCP use >5 yrs, multiparity.
  • Low socioeconomic status.

⭐ HPV types 16 and 18 account for approximately 70% of all cervical cancers worldwide.

Patho & HPV - Viral Villainy

• High-risk HPV: Types 16 (SCC), 18 (AdenoCa) are key.
• Viral Oncoproteins:
  • E6 → degrades p53 (tumor suppressor).
  • E7 → inhibits Rb (retinoblastoma protein).
• Mechanism: ↓p53 & ↓Rb function → ↑cell proliferation → neoplasia.
• Progression: CIN (Cervical Intraepithelial Neoplasia) → Invasive Carcinoma.
• Histotypes: Squamous Cell Carcinoma (SCC, 75%), Adenocarcinoma (20%).

⭐ HPV 16 is the most oncogenic type, strongly associated with Squamous Cell Carcinoma (SCC).

Screening & Prevention - Guarding the Gateway

• Screening (India: Age 30-65 yrs):
  • Pap Smear: q3-5 yrs.
  • HPV DNA Test (hrHPV 16,18): Primary/Co-test q5 yrs.
  • VIA/VILI: q5 yrs (low-resource).
• Abnormal: Colposcopy & Biopsy.
• HPV Vaccination (Prophylactic, 9-26 yrs):
  • Types: Bivalent (HPV 16,18); Quadrivalent (+6,11); Nonavalent (+HPV 31,33,45,52,58).
  • Schedule: 2 doses (9-14y); 3 doses (≥15y).

  ⭐ HPV types 16 & 18 cause ~70% of cervical cancers; prophylactic vaccination is key for primary prevention.

Symptoms & Dx - Spotting the Signs

• Symptoms:
  • Post-coital bleeding (PCB) - most common
  • Intermenstrual or postmenopausal bleeding
  • Foul-smelling vaginal discharge
  • Pelvic/back pain, dyspareunia (late signs)
• Diagnosis:
  • Speculum exam: Visible cervical lesion (growth, ulcer)
  • Punch biopsy: Confirmatory histopathology
  • Staging: MRI (local spread), CT/PET-CT (metastasis)

⭐ Post-coital bleeding is the most frequent early symptom of cervical cancer.

FIGO Staging - Cancer Cartography

• FIGO 2018/2019: Clinical staging.
• Stage I: Confined to cervix.
  • IA: Microscopic. IB: Clinically visible.
• Stage II: Beyond uterus; not pelvic wall/lower ⅓ vagina.
  • IIA: No parametrial. IIB: Parametrial.
• Stage III: Pelvic wall, lower ⅓ vagina, hydronephrosis, or LNs.
  • IIIC: Nodal mets (IIIC1: Pelvic; IIIC2: Para-aortic).
• Stage IV: Beyond true pelvis or bladder/rectal mucosa.
  • IVA: Adjacent. IVB: Distant.

⭐ FIGO 2018 allows imaging/pathology for nodal status (Stage IIIC).

Treatment Tactics - Battling Back

• CIN/AIS: LEEP/Cone biopsy.
• Stage IA1: Cone biopsy or simple hysterectomy.
• Stage IA2, IB1, IB2 (tumor ≤4cm): Radical hysterectomy + LND OR primary RT/CRT.
• Stage IB3 (tumor >4cm), IIA (tumor >4cm), IIB-IVA (Locally Advanced): Definitive Chemoradiation (CRT).
  • Cisplatin-based chemo.
• Stage IVB/Recurrent: Palliative CT/RT, immunotherapy (e.g., Pembrolizumab if PD-L1+).

⭐ For locally advanced cervical cancer (FIGO stages IB3 to IVA), concurrent chemoradiation (CRT) with weekly Cisplatin is the standard, improving survival over radiation alone.

High‑Yield Points - ⚡ Biggest Takeaways

• Persistent HPV infection (esp. types 16, 18) is the primary etiological factor.
• Screening via Pap smear and HPV DNA testing is crucial for early detection.
• Most common type: Squamous Cell Carcinoma (SCC); adenocarcinoma is second.
• Key symptom: Post-coital bleeding. Other symptoms: intermenstrual/post-menopausal bleeding, foul discharge.
• FIGO staging is clinical, not primarily surgical, guiding treatment.
• Treatment depends on stage: surgery (e.g., hysterectomy) for early, chemoradiation for advanced disease.
• HPV vaccination offers effective primary prevention against oncogenic types.