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 whole pelvis, with para-aortic field extension if para-aortic nodes are involved (here they are not).
• Intracavitary brachytherapy to a total combined dose per protocol.
• Weekly cisplatin with hydration during EBRT as a radiosensitiser per the current protocol (confirm exact doses, fractionation and cycles against the current statement).
• 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 size thresholds mark the treatment watershed: surgery is preferred for IB1, IB2 and IIA1 (in IB2/IIA1 surgery or radiotherapy have similar outcomes), while IB3 (at least 4 cm) and above take concurrent chemoradiotherapy, because larger tumours usually need adjuvant radiation after surgery and combined modalities compound major morbidity.
• Stage IA2 to IIA1 are the surgical candidates (Wertheim radical hysterectomy or radical trachelectomy for fertility, open approach); IB3 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): diarrhoea and radiation proctitis; radiation cystitis; bone-marrow suppression (transient grade 3/4 haematologic effects in about one in five with concurrent cisplatin).
• Late (5-year grade 3 to 5): gastrointestinal 8.5 percent; genitourinary 6.8 percent; vaginal 5.7 percent; fistulae 3.2 percent. Data on late toxicity with concurrent chemotherapy are otherwise sparse.

(e) Survival and prognostic factors (2 marks)

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

• Nodal disease confers a worse prognosis than node-negative disease at the same local extent (the rationale for the IIIC split); tumour over 4 cm, lymphovascular space invasion and outer-third stromal invasion raise pelvic recurrence.
• In locally advanced disease, 5-year overall survival was 73 percent with concurrent chemoradiotherapy versus 58 percent with radiotherapy alone (Morris) — quote as population estimates, not individual prediction.