4th Edition

Chapter 17: The dignified Rwandan

A 42-year-old Rwandan Tutsi female asylum seeker had been the victim of indescribable horrors during the civil war of the early 1990s including acquiring HIV infection. She was a dignified woman who during the course of her follow-up in an HIV clinic described intermenstrual bleeding. Her HIV was well controlled on combination antiretroviral therapy. Although it is standard practice for women living with HIV to have cervical screening annually, she had not had a smear for 3 years.

At colposcopy she was found to have clinically visible tumour confined to the cervix and a biopsy-confirmed well-differentiated squamous cell cancer with HPV 16. She then had a staging CT scan.

Just before sending her for a chest X-ray, the casualty doctor did a urinary pregnancy test which was positive. Instead of sending her for a CXR, the doctor requested a transvaginal ultrasound and a quantitative serum HCG which was 100,000 IU/L.

  • 1. What does the CT scan show?

    Correct answer:
    Colposcopy and staging confirmed a stage IB cervical cancer confined to the lower cervix. She had a radical hysterectomy and pelvic lymph node dissection. This involves removal of the entire uterus, upper third of the vagina and bilateral pelvic lymph nodes.

A histological examination was done.

  • 2. What characteristic feature of squamous cell cancer is shown on the histological examination?

    Correct answer:
    Characteristic keratin pearls that are circular whorls of squamous cells around a central nest of acellular keratin.

No adjuvant treatment was necessary, but the Home Office turned down her asylum application.

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