EP22.43: Atypical presentation in a case of HPV independent cervical cancer: a case report

Cervical cancer is responsible for 8% of female cancer deaths every year. Almost all cervical cancers are caused by HPV, however, approximately 5% of tumours are not associated with HPV infection. HPV negative cervical cancer is associated with significantly worse prognosis with lymph node involvement and distant metastasis at an early stage compared to HPV positive. We present a rare case of HPV independent cervical cancer. A 31-year-old nulliparous (smoker) female presented with pain lower abdomen and irregular and heavy bleeding since change of implant 4 months ago. She had history of extensive genital warts since 2020 (biopsy confirmed HPV associated lesions without malignancy). Her last cervical smear done 3 years ago was normal. Local examination showed extensive genital warts and speculum examination showed bulky cervix without any obvious growth. CT scan of abdomen and pelvis showed inflammatory charges around uterus and adnexa suggestive of pelvic inflammatory disease, with bulky cervix and left hydronephrosis. A transvaginal scan was requested for further characterization of lesions, which showed bulky heterogenous cervix with significant increase in vascularity with normal ET. There was thickening of posterior urinary bladder with hypervascularity. A MRI was done for further information which showed bulky uterus with extensive infiltrative lesion (8x5cm) on cervix extending to anterior uterine body and fundus. The left ureter was encased within the cervical mass with consequent left-sided hydronephrosis. Cervical biopsy was done from multiple sites which showed changes of CIN 3 and Focal invasive squamous cell carcinoma of the cervix, negative for HPV and P16. Patient was immediately referred to higher centre for chemoradiation therapy. To conclude, HPV independent cervical cancer constitutes a rare entity with a different molecular profile. Clinical examination alone may sometimes miss a sinister condition and role of imaging cannot be underemphasised.