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A 42-year-old woman presents with 4 months of postcoital bleeding and intermittent watery vaginal discharge. She has never had a Pap smear and has been sexually active since age 16 with multiple partners. She smokes 10 cigarettes per day. Speculum examination reveals a friable, bleeding 2cm lesion on the anterior lip of the cervix.
Questions
a) What is the most likely diagnosis and what two risk factors are prominent? (2 marks)
Diagnosis: Cervical cancer (postcoital bleeding + friable cervical lesion + never screened). Risk factors: early sexual activity (age 16, multiple partners = HPV exposure) and smoking (impairs local immunity, promotes HPV persistence).
b) What is the definitive diagnostic investigation? (1 mark)
Colposcopy with directed biopsy — the lesion is biopsied under magnification after acetic acid application. Histopathology confirms the diagnosis (squamous vs adenocarcinoma, grade, invasion depth).
c) What is the molecular pathogenesis? (2 marks)
Persistent infection with high-risk HPV (16 and 18). HPV E6 oncoprotein degrades p53 (blocking apoptosis). HPV E7 oncoprotein inactivates retinoblastoma protein (Rb) (removing the cell cycle brake). Uncontrolled proliferation → CIN → invasive carcinoma over 10 to 15 years.
d) Describe the FIGO staging system and how this patient would be staged. (3 marks)
FIGO staging (CLINICAL, not surgical):
- Stage I: confined to cervix
- Stage II: beyond cervix (parametrium, upper vagina)
- Stage III: lower vagina, pelvic wall, hydronephrosis
- Stage IV: bladder, rectum, or distant metastases
This patient (2cm lesion on cervix, no spread): Stage IB1 (visible lesion up to 4cm confined to cervix). Staging involves: pelvic exam ± EUA, cystoscopy, proctoscopy, ± MRI/CT.
e) What treatment options are available for Stage IB1? (2 marks)
- Radical hysterectomy (Wertheim) + pelvic lymphadenectomy — preferred if completed family and wants to avoid radiation effects.
- Chemoradiotherapy (cisplatin + EBRT + brachytherapy) — equivalent survival outcomes.
- Radical trachelectomy (fertility-sparing) — if desires future fertility and meets criteria.