Cervical cancer — structured SAQ (15 marks)

(a) FIGO 2018 stage assignment (3 marks)

One mark for the stage, one for the IB subgroup with rationale, one for the nodal substage with notation. ^[1]

• Stage IIIC1 (r). The tumour is over 2 cm with parametrial invasion (Stage IIB feature) AND involves a pelvic lymph node (right external iliac) — the nodal involvement upstages it to IIIC1.
• The 'r' notation records that the nodal status was determined by imaging (MRI), not surgical pathology.
• The IB subgroup (if asked) is IB2 — tumour 2 cm or greater and under 4 cm in greatest dimension (3.5 cm).
• Parametrial invasion alone (without the node) would be IIB; the nodal disease makes it IIIC1.

(b) Standard definitive treatment (4 marks)

One mark per element: the modality, EBRT, brachytherapy, cisplatin. ^[2][3]

• Concurrent chemoradiotherapy (surgery is not appropriate for Stage IIIC1 disease).
• EBRT to the pelvis, 45 to 50 Gy in 25 to 28 fractions, with para-aortic field extension if para-aortic nodes are involved (here they are not).
• Intracavitary brachytherapy boost to a total equivalent dose of at least 80 Gy (EQD2) to the tumour.
• Cisplatin 40 mg/m2 intravenously weekly during EBRT (typically 5 to 6 cycles) as a radiosensitiser.
• The CCCMAC meta-analysis showed a 6 percent absolute 5-year survival benefit over radiotherapy alone.

(c) FIGO 2018 IB subgroups and the size threshold (3 marks)

One mark for the three subgroups verbatim, one for the IIB threshold, one for the rationale. ^[1]

• IB1: invasive carcinoma at least 5 mm and under 2 cm in greatest dimension.
• IB2: invasive carcinoma at least 2 cm and under 4 cm.
• IB3: invasive carcinoma at least 4 cm.
• The 2 cm threshold matters because radical surgery for tumours over 2 cm carries higher recurrence, and tumours over 4 cm (IB3) are universally treated with chemoradiotherapy.
• Stage IA2 and IB1 (tumour up to 2 cm) are the surgical candidates (Wertheim radical hysterectomy or radical trachelectomy for fertility); IB2 and above are chemoradiotherapy candidates.

(d) Complications of pelvic chemoradiotherapy — 4 of each (3 marks)

Half a mark each, maximum 3 marks; 6 correct items suffice. ^[2]

• Early (acute): radiation proctitis and diarrhoea; radiation cystitis; skin desquamation; bone-marrow suppression (especially with concurrent cisplatin).
• Late: vaginal stenosis and atrophy; radiation enteritis with stricture or fistula; radiation cystitis and haemorrhagic cystitis; ovarian failure (hence ovarian transposition in young women before treatment).
• Cisplatin-specific: nausea, nephrotoxicity, ototoxicity, myelosuppression.

(e) Survival and prognostic factors (2 marks)

One mark for the survival figure, one for two prognostic factors. ^[1]

• 5-year survival for Stage IIB is approximately 55 to 65 percent; for IIIC1 with pelvic nodal disease it is closer to 30 to 45 percent depending on nodal burden.
• Prognostic factors other than stage: tumour size, nodal status and burden, depth of stromal invasion, lymphovascular space invasion, and histology (adenocarcinoma slightly worse stage-for-stage).