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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
Q

Instructions to patient before pap?

A

No sex, no douching, no tampon use, no intravaginal creams for 2 days prior to test

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26
Q

Screening age 21 - 29

A

Pap Q 3 yrs

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27
Q

Screening age 30 - 65

A

Pap with HPV (co-testing) q5 yrs

Or pap alone q3 yrs

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28
Q

Screening over 65?

A

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
Q

What is the Bethesda System?

A

Pap smear reporting system

30
Q

Bethesda epithelial cell descriptions

A 
Squamous cell:
Unsure: ASC
Low-grade: LSIL
High-grade: HSIL
SCC

Glandular cell:
Atypical: AGC
Adenocarcinoma in situ: ASI
Adenocarcinoma

31
Q

If completed PAP is abnormal, reflexively order:

A

HPV testing

32
Q

What is the MC abnormality on a pap?

A

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
Q

What do you do if the pap result is LGSIL?

A

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
Q

What do you do with a pap result of ASC-H?

A

Basically it doesn’t meet criteria but we can’t r/o lesion, either

Colposcopy indicated

35
Q

What do you do with a pap result of HSIL?

A

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
Q

If you get a pap result that says “AGC”, what does that mean?

A

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
Q

What about paps for preggos?

A

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
Q

Barney style - what are pap’s and colpo’s for?

A

Pap is screening

Colposcopy is diagnostic

39
Q

Before doing a colposcopy, you should always:

A

Get a urine HCG

40
Q

Basic steps of colposcopy

A

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
Q

What is the colposcopy exam is unsatisfactory?

A

Gotta do a LEEP or CKC (cold knife cone)

42
Q

Clinical objectives of colposcopy

A

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
Q

Clinical indications for colposcopy

A

Grossly visible LGT lesion

Abnormal cervical CA screen

In utero diethylstillbestrol exposure

44
Q

Relative contraindications to colposcopy?

A

Upper or lower reproductive tract infection

Uncontrolled severe hypertension

Uncooperative or overly anxious patient

45
Q

Different txts for abnormal paps

A

LLETZ (large loop excision of the transformation zone)

Laser

Cryosurgery

Electrocoagulation

Cervical conization (CKC, LEEP)

46
Q

Potential complications of all those crazy abnormal pap treatments

A

Bleeding, infection

Cervical stenosis

Cervical incompetence

47
Q

Slides 126 - 136

A

Lots of flow charts - sorta confusing - not sure how to translate into cards, sorry

48
Q

What is the MC gynecologic CA worldwide?

A

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
Q

Why is screening for cervical CA so important?

A

Because most early cancers are asymptomatic

50
Q

What is exophytic growth?

A

If it arises from the ectocervix

51
Q

What is endophytic growth?

A

If it arises from the endocervix

52
Q

Early stage cervical CA txt’d with:

A

Surgery

53
Q

Advanced stage cervical CA txt’d with:

A

Surgery AND chemoradiation

54
Q

What is a particularly poor prognostic indicator in the setting of cervical CA?

A

Lymphovascular spread

55
Q

The majority of cervical CA’s are which type?

A

Squamous cell

Arise from the ectocervix

56
Q

What’s the deal with cervical adenocarcinoma

A

Less common than squamous but more serious

Often occult due to the location where they develop

57
Q

Which type of cervical CA is large, highly aggressive, with low survival?

A

Neuroendocrine tumors

58
Q

How can you control abnormal bleeding of cervical CA?

A

Monsel paste and vaginal packing

59
Q

Possible presentations of cervical CA? (Lots of variation)

A

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
Q

Possible lab findings in cervical cancer

A 
Anemia
Hematuria
Electrolyte abnormalities
Elevated liver enzymes (2/2 mets)
Creat/BUN - renal impairment / obstruction
61
Q

Possible rads findings in cervical CA

A

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
Q

Cervical CA stage 5-yr survival rates

A 
IA - 100%
IB - 88%
IIA - 68%
IIB - 44%
III - 18-39%
IVA - 18-34%
63
Q

Cervical CA txt’s

A

Hysterectomy - varying degrees of extended tissue removed

Radiation

Chemo

64
Q

Cervical CA txt during pregnancy

A

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
Q

General follow-up for cervical CA patient:

A

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
Q

If cervical CA pt has had radiotherapy, that should you advise them to do?

A

Have sex 3 times a week, or use a vaginal dilator

This will reduce fibrosis and shortened, non-functional vagina

67
Q

Can a post-cervical CA patient receive hormone therapy?

A

Yup - cervical CA is NOT estrogen-mediated, therefore no contraindication

68
Q

You got cervical cancer

A

Sorry you didn’t get the cancer that everyone celebrates with pretty pink water bottles and car magnets.

69
Q

Would you rather be a cookie or a shake?

A

They are both bad. You would end up eating yourself.

Senior - OB 3 (6 decks)

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