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Senior - OB 3 > 13 - Cervical CA > Flashcards

13 - Cervical CA Flashcards

1
Q

When is squamous metaplasia most active?

A

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)

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2
Q

What is the region between the original columnar epithelium and the squamous epithelium called? (Cervix)

A

The transformation zone

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3
Q

Where does nearly all cervical neoplasia develop?

A

Within the transition zone o the SCJ

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4
Q

MCC of vulvar, vaginal, and anal neoplasia?

A

HPV

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5
Q

How does old age lead to cervical dysplasia?

A

Older age -> decreased immunocompetence -> allows genetic mutations over time -> cancer

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6
Q

What is Diethylstilbestrol?

A

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

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7
Q

Risk factors for cervical neoplasia

A

Poor, older minorities

Early age coitarche, multiple partners, smoker, poor diet

HPV infection, COCP’s, parity, immunosuppression, inadequate screening

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8
Q

What is cervical intraepithelial neoplasia?

A

Squamous epithelial lesions that are potential precursors of invasive CA

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9
Q

CIN 1

A

Mild dysplasia

Abnormal cells in lower third of the squamous epithelium

Manifestation of HPV

Most are transient, unlikely to progress

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10
Q

CIN 2

A

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”

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11
Q

CIN 3

A

Severe dysplasia

Abnormal cells extending from basement membrane to upper third

Risk of invasive CA -> 30% in 30 yrs

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12
Q

Possible downsides of doing cervical CA screenings:

A

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

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13
Q

What is the MC’ly transmitted disease in the US?

A

HPV

It’s a double-stranded DNA virus

There’s more than 150 types

~40 types of HPV infect the lower genital tract

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14
Q

Prevalence of HPV in women aged 14-59

A

1 in 4

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15
Q

Prevalence of HPV in women age 20-24

A

45% !!!!

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16
Q

HPV types 6 and 11 are considered:

A

Low risk for cancer

6 and 11 are more likely to cause warts, laryngeal papillomas; rarely - if ever - are they oncogenic

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17
Q

HPV types 16, 18, 31, 33, 35, 45, and 58 are considered:

A

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

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18
Q

Which HPV strain is most oncogenic?

A

16

Followed by 18

16+18 = 70% of cervical CA’s worldwide

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19
Q

Are lesbians less likely to get HPV?

A

Sorry, gals - women who have sex with women have the same rate of HPV infection as women who have sex with men

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20
Q

If so many young women get infected with HPV at some point why isn’t everyone getting cervical CA?

A

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

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21
Q

How long do you need to have a persistent 16/18 HPV infection for squamous intraepithelial lesion to develop?

A

> 6 months

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22
Q

How do we test for HPV?

A

Pap exam - detect HPV nucleic acids by various tests

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23
Q

When do we screen for HPV?

A

Women over 30yrs

Triage or surveillance of certain cytology abnormalities

Post-treatment surveillance

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24
Q

Different HPV vaccines

A

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

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25
Instructions to patient before pap?
No sex, no douching, no tampon use, no intravaginal creams for 2 days prior to test
26
Screening age 21 - 29
Pap Q 3 yrs
27
Screening age 30 - 65
Pap with HPV (co-testing) q5 yrs Or pap alone q3 yrs
28
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
29
What is the Bethesda System?
Pap smear reporting system
30
Bethesda epithelial cell descriptions
``` Squamous cell: Unsure: ASC Low-grade: LSIL High-grade: HSIL SCC ``` Glandular cell: Atypical: AGC Adenocarcinoma in situ: ASI Adenocarcinoma
31
If completed PAP is abnormal, reflexively order:
HPV testing
32
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
33
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
34
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
35
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)
36
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
37
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
38
Barney style - what are pap’s and colpo’s for?
Pap is screening Colposcopy is diagnostic
39
Before doing a colposcopy, you should always:
Get a urine HCG
40
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)
41
What is the colposcopy exam is unsatisfactory?
Gotta do a LEEP or CKC (cold knife cone)
42
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
43
Clinical indications for colposcopy
Grossly visible LGT lesion Abnormal cervical CA screen In utero diethylstillbestrol exposure
44
Relative contraindications to colposcopy?
Upper or lower reproductive tract infection Uncontrolled severe hypertension Uncooperative or overly anxious patient
45
Different txts for abnormal paps
LLETZ (large loop excision of the transformation zone) Laser Cryosurgery Electrocoagulation Cervical conization (CKC, LEEP)
46
Potential complications of all those crazy abnormal pap treatments
Bleeding, infection Cervical stenosis Cervical incompetence
47
Slides 126 - 136
Lots of flow charts - sorta confusing - not sure how to translate into cards, sorry
48
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
49
Why is screening for cervical CA so important?
Because most early cancers are asymptomatic
50
What is exophytic growth?
If it arises from the ectocervix
51
What is endophytic growth?
If it arises from the endocervix
52
Early stage cervical CA txt’d with:
Surgery
53
Advanced stage cervical CA txt’d with:
Surgery AND chemoradiation
54
What is a particularly poor prognostic indicator in the setting of cervical CA?
Lymphovascular spread
55
The majority of cervical CA’s are which type?
Squamous cell Arise from the ectocervix
56
What’s the deal with cervical adenocarcinoma
Less common than squamous but more serious Often occult due to the location where they develop
57
Which type of cervical CA is large, highly aggressive, with low survival?
Neuroendocrine tumors
58
How can you control abnormal bleeding of cervical CA?
Monsel paste and vaginal packing
59
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
60
Possible lab findings in cervical cancer
``` Anemia Hematuria Electrolyte abnormalities Elevated liver enzymes (2/2 mets) Creat/BUN - renal impairment / obstruction ```
61
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
62
Cervical CA stage 5-yr survival rates
``` IA - 100% IB - 88% IIA - 68% IIB - 44% III - 18-39% IVA - 18-34% ```
63
Cervical CA txt’s
Hysterectomy - varying degrees of extended tissue removed Radiation Chemo
64
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
65
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
66
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
67
Can a post-cervical CA patient receive hormone therapy?
Yup - cervical CA is NOT estrogen-mediated, therefore no contraindication
68
You got cervical cancer
Sorry you didn’t get the cancer that everyone celebrates with pretty pink water bottles and car magnets.
69
Would you rather be a cookie or a shake?
They are both bad. You would end up eating yourself.

Senior - OB 3 (6 decks)

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