127. Ferenal, Christine Lorraine S.

April 20, 2021

NMD 3

Davao Medical School Foundation

Department of Obstetrics and Gynecology

3rd year NMD

April 20, 2021 1 PM to 3 PM

TOPIC: 48-Year-old with postcoital bleeding

Comprehensive Gynecology 7th edition Chapters 28 Intraepithelial Lesions of the Lower

Genital Tract and Chapter 29 Malignant Diseases of the Cervix

CASE:

A 48-year-old G5P5 (5005) consults for postcoital bleeding for 4 months and foul brownish
discharge.
Her coitarche is at age 18, and to date, she has a total of 5 sexual partners. She has no history
of Pap smear.
She also complains of back pain and loss of appetite.
Her menstrual cycle is regular with monthly subsequent menses lasting for 5 days.
On pelvic examination, the external genitalia were grossly normal.
Speculum examination: There is a 3 cm friable polypoid cervical mass was noted at 9 o'clock
position; no active bleeding noted.
Internal examination:
The vagina is smooth. A 3 cm friable polypoid cervical mass is palpable at 9 o'clock position of
the cervix.
Corpus is small, and there were no adnexal masses nor tenderness noted.
On rectovaginal examination, both parametria were smooth and pliable.

1. What are the salient features? (5 pts.)

• 48-year-old G5P5 (5005)

• Postcoital bleeding for 4 months
• Foul brownish discharge
• Coitarche at the age of 18
• 5 sexual partners
• No history of Pap smear
• Backpain
• Loss of appetite
• Regular menstrual cycle with monthly subsequent menses lasting for 5 days
• SE: 3 cm friable mass polypoid cervical mass noted at 9 o'clock position of the cervix; no
active bleeding noted
• IE: 3 cm friable polypoid cervical mass palpable at 9 o'clock position of the cervix; corpus
small, no adnexal masses or tenderness noted
127. Ferenal, Christine Lorraine S. April 20, 2021
NMD 3

• RE: both parametria were smooth and pliable

2. What is the impression/diagnosis? (4 pts.)

G5P5 (5005); Carcinoma of the Cervix

3. Enumerate the differential diagnoses? Give 5. (5 pts.)

• Cervical fibroids
• Endometriosis
• Cervical polyp
• Pelvic Inflammatory Disease
• Cervicitis

4. What diagnostic procedure will confirm the impression/diagnosis? (5 pts.)

The diagnosis is established by biopsy of the tumor; a specimen can be easily obtained
during an office examination. A Kevorkian, Eppendorf, Tischler, or similar punch biopsy
instrument is convenient to use.

5. What are the risk factors for cervical carcinoma? Give 5. (5 pts.)
• Early Sexual Debut (Early age at sex <14 y/o)
• Multiple Sexual Partners (>6)
• Exposure to STD (HPV)
• High Parity (7 or more)
• No screening

6. Discuss the natural history and spread of Cervical Carcinoma (10 pts.)
Carcinoma of the cervix is initially a locally infiltrating cancer that spreads from the cervix
to the vagina and paracervical and parametrial areas. Similar to carcinomas occurring
elsewhere in the female genital tract, the tumors may be grossly ulcerated and may have an
exophytic growth pattern or cauliflower-like appearance extruding from the cervix. They may
alternatively be endophytic as well, in which case they are asymptomatic, particularly in the
early stage of development, and tend to be deeply invasive when diagnosed. These usually
start initially from an endocervical location and often fill the cervix and lower uterine segment,
resulting in a barrel-shaped cervix. The latter tumors tend to metastasize to regional pelvic
nodes and, because of the tendency of late diagnosis, are often more advanced than the
exophytic variety.
The path for distant spread is through lymphatics to the regional pelvic nodes.
Bloodborne metastases from cervical carcinomas do occur but are less frequent and are usually
seen late in the course of the disease.
Initially, cervical carcinomas spread to the primary pelvic nodes, which include the
pericervical node; presacral, hypogastric (internal iliac), and external iliac nodes; and nodes in
the obturator fossa near the vessels and nerve. From this primary group, tumor spread
proceeds secondarily to the common iliac and paraaortic nodes. Rarely, the inguinal nodes are
involved; however, if the lower third of the vagina is involved, the median inguinal nodes should
be considered a primary node.
127. Ferenal, Christine Lorraine S. April 20, 2021
NMD 3

7. Discuss the pathophysiology of Cervical Carcinoma. (5 pts.)

HPV is the causative agent in cervical cancer. More than 75% of cases are due to high-
risk HPV 16 and 18. Infection with high-risk HPV types interfere with the function of cell proteins
and also with the expression of cellular gene products. The genes that are downregulated are
primarily those involved in regulation of cell growth, some keratinocyte specific genes and
interferon responsive genes. Infection starts when HPV infects the basal cells of the stratified
squamous epithelium. Once inside the host cell, HPV DNA replicates as the basal cells
differentiate and progress to the surface epithelium. HPV replication begins with host cell factors
which then interact with the LCR region of the HPV genome and begin transcription of the viral
E6 and E7 genes. These gene products then degranulate the host cell growth cycle by binding
and inactivating tumor suppressor proteins, cell cyclins, and cyclin dependent kinases. Due to
the said process above, it would eventually lead to large number of mitoses and dysplastic cells,
which would then progress to malignancy.

8. Enumerate the major histologic types of Cervical Carcinoma. (10 pts.)

Major Categories of Cervical Carcinoma
Squamous Cell Carcinomas Adenocarcinomas Mixed Carcinomas
● Large cell ● Typical (endocervical) ● Adenosquamous
(keratinizing or ● Endometrioid ● Glassy cell carcinoma
nonkeratinizing) ● Clear cell
● Small cell ● Adenoid cystic
● Verrucous (basaloid cylindroma)
● Adenoma malignum
(minimal deviation
adenocarcinoma)

9. Tabulate (Put in a table) the 2018 FIGO Staging of Cervical Carcinoma. (10 pts.)
Stage Description

I The carcinoma is strictly confined to the cervix uteri (extension to the

corpus should be disregarded)

IA Invasive carcinoma that can be diagnosed only by microscopy, with

maximum depth of invasion <5 mm

IA1 Measured stromal invasion <3 mm in depth

IA2 Measured stromal invasion ≥3 mm and <5 mm in depth

IB Invasive carcinoma with measured deepest invasion ≥5 mm (greater

than stage IA), lesion limited to the cervix uteri

IB1 Invasive carcinoma ≥5 mm depth of stromal invasion and <2 cm in

greatest dimension

IB2 Invasive carcinoma ≥2 cm and <4 cm in greatest dimension

127. Ferenal, Christine Lorraine S. April 20, 2021
NMD 3

IB3 Invasive carcinoma ≥4 cm in greatest dimension

II The carcinoma invades beyond the uterus, but has not extended onto
the lower third of the vagina or to the pelvic wall

IIA Involvement limited to the upper two‐thirds of the vagina without

parametrial involvement

IIA1 Invasive carcinoma <4 cm in greatest dimension

IIA2 Invasive carcinoma ≥4 cm in greatest dimension

IIB With parametrial involvement but not up to the pelvic wall

III The carcinoma involves the lower third of the vagina and/or extends to
the pelvic wall and/or causes hydronephrosis or non‐functioning kidney
and/or involves pelvic and/or paraaortic lymph nodes

IIIA Carcinoma involves the lower third of the vagina, with no extension to
the pelvic wall

IIIB Extension to the pelvic wall and/or hydronephrosis or non‐functioning

kidney (unless known to be due to another cause)

IIIC Involvement of pelvic and/or paraaortic lymph nodes, irrespective of

tumor size and extent (with r and p notations)

IIIC1 Pelvic lymph node metastasis only

IIIC2 Paraaortic lymph node metastasis

IV The carcinoma has extended beyond the true pelvis or has involved
(biopsy proven) the mucosa of the bladder or rectum. A bullous edema,
as such, does not permit a case to be allotted to stage IV

IVA Spread of the growth to adjacent organs

IVB Spread to distant organs

10. 5 Give 5 prognostic factors in Cervical Carcinoma. (5 pts.)

• FIGO Stage
• Tumor size
• Lymph Node Status
• LVSI (Lymph-vascular space invasion)
• Histologic Type
127. Ferenal, Christine Lorraine S. April 20, 2021
NMD 3

11. What is the primary therapeutic approach in this patient based on the 2018 FIGO
guidelines? Other options? (5 pts.)
Radical hysterectomy and pelvic lymphadenectomy are recommended in early-stage
diseases (IA, IB1, and IIA1). For Stage IA, 1B1, IIA1, other treatment option is pelvic External
Beam Radiation (EBRT) +/- Concurrent platinum-containing chemotherapy (Level 1a).

12. What are the follow-up plans for this patient? Give 5. (5 pts.)?
• Physical and pelvic examination every 3 months for the first 2 years, every 6 months
from years 3 to 5, and yearly thereafter
• More frequent examinations are done if abnormal symptoms or signs develop
• Pap smear annually unless an abnormality is detected on the Pap smear
• PET/CT repeated at the 3 to 6 months post chemoradiation therapy
• Chest x-rays done annually

13. How can cervical cancer be prevented? Give 6. (6 pts)

PRIMARY PREVENTION:
• Human Papillomavirus vaccination
• Education to reduce high-risk sexual behavior
• Measures to avoid exposure to HPV and other STI
• Avoidance of tobacco smoking

SECONDARY PREVENTION:
• Cervical cytology testing
• Primary Human Papillomavirus testing

14. What are the 2012 guidelines in the United States for screening of Cervical Cancer? (10
pts.)
The current guidelines in the United States recommend screening women for cervical
cancer between the ages of 21 and 65 (Saslow, 2012). Cervical cancer screening should not be
performed in women younger than 21 years of age, regardless of age of onset of sexual activity.
The screening guidelines are as follows:
● 21 to 29 years: Pap testing every 3 years. No HPV testing.
● 30 to 65 years: Co-testing with Pap and HPV every 5 years (preferred) or Pap
testing alone every 3 years.
● Screening is not recommended for women >65 years of age who have had three
consecutive negative Pap tests or two consecutive negative HPV tests, provided
they have had no history of high-grade dysplasia (CIN2/3) or cancer (CIN2+) in
the past 20 years. However, women presenting at age 65 years of age or older
who have not had previous screening should undergo Pap and HPV testing.
● Screening with Pap test or HPV testing is not recommended for women who
have had a hysterectomy with removal of the cervix and who do not have a
history of CIN2+.
Of note, these guidelines do not apply to those special populations with additional risk
factors and other complicating history
127. Ferenal, Christine Lorraine S. April 20, 2021
NMD 3

15. Describe how to do a Pap smear (10 pts.)

Papanicolaou smear is performed by:
● Placing the speculum into the vagina and scraping cervical cells using spatula or
endocervical brush
● Sample from transformation zone; including the squamocolumnar junction
● Conventional cervical cytology is prepared by smearing collected cells directly
onto a glass slide with the collection device followed by immediate fixation.
● Liquid-based cytology involves transfer of collected cells from the collection
device into a liquid transport medium with subsequent processing and transfer
onto a glass slide. Cells are distributed over a smaller area, and debris, mucus,
blood, and cell overlap are largely eliminated, allowing computer-assisted
screening.