Paper II
Question
A 42-year-old woman, who did not have a medical checkup for many years, noted the onset of post coital bleeding. On examination, she was found to have an ulcerated growth on the anterior lip of cervix. (
- (a) What is the likely diagnosis and why. ( 2 mark(s)
- (b) How could this disease have been detected early. ( 4 mark(s)
- (c) Discuss the etiopathogenesis of this disease. ( 6 mark(s)
- (d) Describe the microscopic types of this lesion. 3 mark(s)
Answer
(a) Likely diagnosis and why
- Invasive squamous cell carcinoma of the cervix
- Justification: Post-coital bleeding is a classic presenting symptom of cervical carcinoma (from friable, ulcerated tumour tissue on the cervical surface bleeding on contact); an ulcerated growth on the cervix in a middle-aged woman without regular screening is highly suggestive of this diagnosis, particularly given the well-established association with unscreened populations
(b) How could this disease have been detected early
- Regular cervical cytology screening (Papanicolaou/Pap smear) — detects premalignant dysplastic changes (cervical intraepithelial neoplasia) years before progression to invasive carcinoma, allowing curative treatment at the preinvasive stage
- HPV DNA testing — co-testing with cytology, or as primary screening, detects high-risk HPV infection before cytological abnormalities develop
- HPV vaccination — primary prevention against high-risk HPV types (16, 18) responsible for the majority of cervical cancers
- Regular gynaecological examination/colposcopy for women with abnormal screening results
(c) Etiopathogenesis
- Human papillomavirus (HPV) infection is the central and necessary causative factor, particularly high-risk types 16 and 18 (accounting for the majority of cases)
- The viral E6 protein binds and promotes degradation of the tumour suppressor p53, preventing apoptosis of cells with DNA damage
- The viral E7 protein binds and inactivates the retinoblastoma protein (Rb), releasing E2F and driving uncontrolled cell cycle progression
- Persistent high-risk HPV infection of the transformation zone (squamocolumnar junction) causes progressive dysplastic change — low-grade squamous intraepithelial lesion (LSIL/CIN1) → high-grade squamous intraepithelial lesion (HSIL/CIN2-3) → invasive carcinoma, typically over years to decades
- Cofactors that increase risk: multiple sexual partners/early coitarche (increased HPV exposure), smoking, immunosuppression (HIV), multiparity, long-term oral contraceptive use, and lack of screening (as in this patient)
(d) Microscopic types
- Squamous cell carcinoma (most common, ~70-80% of cases) — further subtyped as large cell keratinizing, large cell non-keratinizing, and small cell (basaloid) types
- Adenocarcinoma (~15-20%, increasing in relative frequency) — arising from the endocervical glandular epithelium
- Adenosquamous carcinoma — mixed glandular and squamous differentiation
- Neuroendocrine (small cell) carcinoma — rare, highly aggressive