13 - Cervical CA Flashcards
When is squamous metaplasia most active?
During adolescence and pregnancy
Greater risk for abnormal change during this time because the cells are transitioning (the more copies you make on a photocopier, the higher the chance of there being errors)
What is the region between the original columnar epithelium and the squamous epithelium called? (Cervix)
The transformation zone
Where does nearly all cervical neoplasia develop?
Within the transition zone o the SCJ
MCC of vulvar, vaginal, and anal neoplasia?
HPV
How does old age lead to cervical dysplasia?
Older age -> decreased immunocompetence -> allows genetic mutations over time -> cancer
What is Diethylstilbestrol?
A known cause of cervical CA
Anyone exposed to it between 1938 and 1971 has increased risk for clear cell adenocarcinoma of the vagina and cervix
Risk factors for cervical neoplasia
Poor, older minorities
Early age coitarche, multiple partners, smoker, poor diet
HPV infection, COCP’s, parity, immunosuppression, inadequate screening
What is cervical intraepithelial neoplasia?
Squamous epithelial lesions that are potential precursors of invasive CA
CIN 1
Mild dysplasia
Abnormal cells in lower third of the squamous epithelium
Manifestation of HPV
Most are transient, unlikely to progress
CIN 2
Moderate dysplasia
Abnormal cells extend from basement membrane to middle third
Mixture of low and high grade
~40% regress spontaneously within 2 yrs
Considered “precancerous”
CIN 3
Severe dysplasia
Abnormal cells extending from basement membrane to upper third
Risk of invasive CA -> 30% in 30 yrs
Possible downsides of doing cervical CA screenings:
Finding out you’ve got an STD
Anxiety caused by a (+) test
Possibly txt’ing a lesion that may have just resolved on its own
Bleeding from txt / add’l painful procedures
What is the MC’ly transmitted disease in the US?
HPV
It’s a double-stranded DNA virus
There’s more than 150 types
~40 types of HPV infect the lower genital tract
Prevalence of HPV in women aged 14-59
1 in 4
Prevalence of HPV in women age 20-24
45% !!!!
HPV types 6 and 11 are considered:
Low risk for cancer
6 and 11 are more likely to cause warts, laryngeal papillomas; rarely - if ever - are they oncogenic
HPV types 16, 18, 31, 33, 35, 45, and 58 are considered:
High risk for cancer
Need to have a persistent infection of one of the HR strains for cervical CA development
These strains account for ~95% of cervical CA’s worldwide
Which HPV strain is most oncogenic?
16
Followed by 18
16+18 = 70% of cervical CA’s worldwide
Are lesbians less likely to get HPV?
Sorry, gals - women who have sex with women have the same rate of HPV infection as women who have sex with men
If so many young women get infected with HPV at some point why isn’t everyone getting cervical CA?
Most women clear the infection, and it needs to be a PERSISTENT infection in order to turn into CA
This is especially true in young women, which is why we changed the initial PAP age to 21 yrs
HPV isn’t like herpes - you don’t necessarily have to have it for life
How long do you need to have a persistent 16/18 HPV infection for squamous intraepithelial lesion to develop?
> 6 months
How do we test for HPV?
Pap exam - detect HPV nucleic acids by various tests
When do we screen for HPV?
Women over 30yrs
Triage or surveillance of certain cytology abnormalities
Post-treatment surveillance
Different HPV vaccines
Cervarix - 16/18
Gardasil - 6/11/16/18
Gardasil 9 - 6/11/16/18/31/33/45/52/58
Give at age 9 through 26
Instructions to patient before pap?
No sex, no douching, no tampon use, no intravaginal creams for 2 days prior to test
Screening age 21 - 29
Pap Q 3 yrs
Screening age 30 - 65
Pap with HPV (co-testing) q5 yrs
Or pap alone q3 yrs
Screening over 65?
Not necessary if no hx of cervical change AND
3 negative paps in a row OR 2 negative co-tests in past 10 yrs
What is the Bethesda System?
Pap smear reporting system
Bethesda epithelial cell descriptions
Squamous cell: Unsure: ASC Low-grade: LSIL High-grade: HSIL SCC
Glandular cell:
Atypical: AGC
Adenocarcinoma in situ: ASI
Adenocarcinoma
If completed PAP is abnormal, reflexively order:
HPV testing
What is the MC abnormality on a pap?
Atypical Squamous Cells of Undetermined Significance (ASC-US)
Suggests intraepithelial lesion, but doesn’t fulfill criteria
Often preceded a CIN 2-3 lesion
If ASC-US (+) HPV -> colposcopy
If ASC-US (-) HPV -> repeat in one yr
What do you do if the pap result is LGSIL?
Low-grade squamous intraepithelial lesion
If no HPV test or (+) HPV test -> colposcopy indicated for women over 25 yrs
If negative HPV test -> repeat co-test in one yr
What do you do with a pap result of ASC-H?
Basically it doesn’t meet criteria but we can’t r/o lesion, either
Colposcopy indicated
What do you do with a pap result of HSIL?
High-Grade Squamous Intraepothelial lesion
Features of CIN 2 and CIN 3
Colposcopy warranted regardless of HPV status
Consider immediate loop electrosurgical excision procedure (LEEP)
If you get a pap result that says “AGC”, what does that mean?
Atypical glandular cells
Increased risk of neoplasia (especially endometrial)
Increased breast, colon CA risk
Requires colposcopy AND endocervical sampling
If over 35, also get endometrial sampling
What about paps for preggos?
Same guidelines as normal
HOWEVER
With ASC-US and LSIL may consider deferring further eval until 6 weeks post-partum
Colposcopy as indicated
NO endocervical curettage !
If ASC-H -> do NOT defer colpo until postpartum
Barney style - what are pap’s and colpo’s for?
Pap is screening
Colposcopy is diagnostic
Before doing a colposcopy, you should always:
Get a urine HCG
Basic steps of colposcopy
Clean cervix (3% acetic acid) -> causes neoplastic areas to turn white
Green filter accentuates vascular changes
Grab your samples (bx) and ECC performed (curettage)
What is the colposcopy exam is unsatisfactory?
Gotta do a LEEP or CKC (cold knife cone)
Clinical objectives of colposcopy
Provide a magnified view of the lower genital tract (LGT)
Identify cervical squamocolumnar junction
Detect lesions suspicious for neoplasia
Direct lesion bx
Monitor patients with current or past LGT neoplasia
Clinical indications for colposcopy
Grossly visible LGT lesion
Abnormal cervical CA screen
In utero diethylstillbestrol exposure
Relative contraindications to colposcopy?
Upper or lower reproductive tract infection
Uncontrolled severe hypertension
Uncooperative or overly anxious patient
Different txts for abnormal paps
LLETZ (large loop excision of the transformation zone)
Laser
Cryosurgery
Electrocoagulation
Cervical conization (CKC, LEEP)
Potential complications of all those crazy abnormal pap treatments
Bleeding, infection
Cervical stenosis
Cervical incompetence
Slides 126 - 136
Lots of flow charts - sorta confusing - not sure how to translate into cards, sorry
What is the MC gynecologic CA worldwide?
Cervical cancer
Once the dysplasia is no longer reversible, we call it “cancer”
Takes multiple years of persistent dysplasia to progress into cervical CA
Why is screening for cervical CA so important?
Because most early cancers are asymptomatic
What is exophytic growth?
If it arises from the ectocervix
What is endophytic growth?
If it arises from the endocervix
Early stage cervical CA txt’d with:
Surgery
Advanced stage cervical CA txt’d with:
Surgery AND chemoradiation
What is a particularly poor prognostic indicator in the setting of cervical CA?
Lymphovascular spread
The majority of cervical CA’s are which type?
Squamous cell
Arise from the ectocervix
What’s the deal with cervical adenocarcinoma
Less common than squamous but more serious
Often occult due to the location where they develop
Which type of cervical CA is large, highly aggressive, with low survival?
Neuroendocrine tumors
How can you control abnormal bleeding of cervical CA?
Monsel paste and vaginal packing
Possible presentations of cervical CA? (Lots of variation)
May note watery, purulent or bloody discharge
Polypoid mass, papillary tissue, or barrel-shaped cervix
May have enlarged uterus
Lymphadenopathy (suggests spread)
Hydronephrosis (tumor compressing ureter)
LBP -> compression of sciatic nerve
Constipation
Can invade local tissue -> bladder, rectum
Possible lab findings in cervical cancer
Anemia Hematuria Electrolyte abnormalities Elevated liver enzymes (2/2 mets) Creat/BUN - renal impairment / obstruction
Possible rads findings in cervical CA
CXR -> lung mets
IVP - hydronephrosis
CT scan - nodal or distant organ mets
MR - local parametrial invasion; nodal mets
PET - nodal or distant organ mets
Cervical CA stage 5-yr survival rates
IA - 100% IB - 88% IIA - 68% IIB - 44% III - 18-39% IVA - 18-34%
Cervical CA txt’s
Hysterectomy - varying degrees of extended tissue removed
Radiation
Chemo
Cervical CA txt during pregnancy
If early stage may be able to postpone txt until delivery
If advanced: multiple modalities available, many result in fetal loss
Less risk of baby issues if txt started after 1st trimester
General follow-up for cervical CA patient:
Q 3 mos for 2 yrs, then
Q 6 mos for 3 yrs, then
Q 12 mos
Full body lymph node check
Cervical / vaginal cuff pap annually x 20yrs post-txt
If cervical CA pt has had radiotherapy, that should you advise them to do?
Have sex 3 times a week, or use a vaginal dilator
This will reduce fibrosis and shortened, non-functional vagina
Can a post-cervical CA patient receive hormone therapy?
Yup - cervical CA is NOT estrogen-mediated, therefore no contraindication
You got cervical cancer
Sorry you didn’t get the cancer that everyone celebrates with pretty pink water bottles and car magnets.
Would you rather be a cookie or a shake?
They are both bad. You would end up eating yourself.
