17) Gynae-oncology: Cervical Flashcards
Lifetime risk of cervical cancer
<1% (1 in 142)
Percentage of cervical cancer which is considered preventable
99.8%
What percentage of cervical cancer is associated with high risk HPV?
> 95%
Which are some of the high risk hpv subtypes?
16,18,31,33,35
When is HPV vaccination given?
12-13 year old girls
Which strains of HPV does the current vaccine protect against?
Gardasil - 6,11,16,18
What is the predicted effect of vaccination implementation?
50% decline in high grade CIN and 70% decline in cancer
What is the most common type of cervical cancer?
Squamous cell (70%)
What percentage of CIN1/2/3 will regress or invade?
CIN 1: 60% regress, 1% invade
CIN 2: 40% regress, 5% invade
CIN 3: 33% regress, 30% invade
Management of cervical cancer
1A1: LLETZ only
1A2: LLETZ/cone/simple hysterectomy + nodes
1B/2A: Radical hysterectomy + nodes OR radical radiotherapy (Radical trachelectomy if fertility preserving)
2B-4A: Radiotherapy and chemotherapy
4B: Palliative radiotherapy
Chance of nodal involvement in 1A1 cervical cancer
<1%
Chance of nodal involvement in 1A2 cervical cancer
5%
What percentage of women having treatment for cervical cancer have significant complications of treatment?
27%
What percentage of women experience GI complications of treatment for gynaecological cancers?
> 50%
What percentage of women experience bowel obstruction after radiotherapy for cervical cancer?
14.5%
What percentage of women experience bowel fistulae after treatment?
8%
What percentage of women have ureteric injury at time of radical hysterectomy?
1%
What percentage of women have ureteric obstruction secondary to fibrosis from radiotherapy?
1%
What percentage of women have radiation cystitis?
26%
What percentage of women have long term voiding difficulties requiring ISC?
2-3%
What percentage of women have a vesico-vaginal fistula?
<2%
When do patients with vesico-vaginal fistula usually present and how are they managed?
Usually present D5-D14 post-op and up to 50% heal with conservative management
Percentage of dyspareunia following radiotherapy for cervical cancer
55%
How often is cervical screening performed?
3 yearly 25-50, 5 yearly 50-65, after 65 only if recent abnormal smear.
What percentage of people will contract HPV?
80%
What percentage of people will clear HPV and over what time frame?
90% will clear HPV, median time frame 8 months, 9% at 2 years.
What happens to patient based on initial smear?
If HPV negative - back to routine recall.
If HPV positive then sample tested for cytology. If cytology positive (at any grade) then colposcopy. If cytology negative then rescreen in 12 months.
When should a patient with positive HPV but negative cytology be referred to colposcopy?
If this has been the result on 3 consecutive occasions (so at 24 months).
What percentage of smears are inadequate and how should they be managed?
<2%
Repeat within 3 months.
If 2 x consecutive inadequate smears then refer to colposcopy (see 6 weeks).
How often should women with HIV have smears?
Annually
What to do if colposcopy examination is inadequate?
If low risk cytology then repeat colposcopy in 12 months.
If high risk cytology then do a LLETZ.
What to do if colposcopy examination reveals no abnormality/biopsy is negative?
If low risk cytology then routine recall.
If high risk cytology then discuss plan at MDT (2 months).
What to do if colposcopy examination reveals CIN 1?
Repeat HPV in 12 months.
When can a patient who has had CIN 1 return to routine recall?
If the first test at 12months is negative HPV (or second test at 24 months is negative HPV).
Or if ongoing positive HPV then after 24 months if cytology always negative.
When should patient who has had CIN 1 be re-referred to colposcopy?
On any occasion with HPV +ve and cytology positive.
When to follow up a patient after treatment for CIN 2 (or higher)?
6 months
What happens to patient who has smear at 6 months after treatment for CIN 2 (or higher)?
If HPV negative back to routine recall.
If HPV positive then to colposcopy.
When to follow up patient after treatment for CGIN?
Recall at 6m and 12m.
If HPV negative on both then can go back to routine recall.
If HPV positive and cytology positive at 6m - colp.
If HPV positive at 12m (irrespective of cytology) - colposcopy.
Who should receive follow up for 10 years?
Women being followed up for cervical cancer (6m, 12m then annual for 9 years) or who had treatment for CGIN and a persistent positive HPV 12 months later.
Guidance after LLETZ
Avoid tampons and sex 4 weeks
Avoid swimming 2 weeks
When is an excision biopsy recommended?
Most of ectocervix replaced by high grade abnormality
Low grade colposcopy change with high grade dyskaryosis
If lesion extends into canal
When should a punch biopsy be done?
If cytology indicates moderate dyskaryosib or worse and always if atypical transformation zone
When can cry-cautery be used and how?
Low grade CIN via double freeze thaw freeze
How big should an excision biopsy be?
Ectocervical - depth 7-10mm.
Type 1 and 2 lesions - depth <15mm.
What to do about cervical screening in pregnancy?
Defer routine screening.
If abnormal cytology pre-pregnancy then do cold in late first or early second trimester.
If previously colposcopy abnormal don’t delay follow up.
Which women need up-to-date smears before they can progress with treatment for another reason?
Hysterectomy (for unrelated reason)
Any condition likely to require transplant
Cytotoxic drugs to be started for rheumatology
What percentage of renal transplant patients have abnormal cytology?
15% (5 x increased compared to normal)
What percentage of people will have negative hrHPV screen on initial smear?
85-90%
When should vault smears be done after hysterectomy?
If specimen shows completely excised CIN (regardless of previous smears) - vault smears at 6m and 18m.
If specimen shows incompletely excised CIN1 - 6m,12m,24m.
If specimen shows incompletely excised CIN 2/3 - 6m,12m,24m + further 8 years.
If patient was not on routine recall and there is no CIN in the specimen - vault smear 6m.
What percentage of cervical cancers and vulval cancers do HPV subtypes 16 and 18 account for?
70-80% cervical
40-50% vulval
What is the risk of developing cervical cancer if HPV compared to uninfected women?
400 x higher HPV 16
250 x higher HPV 18
What is the minimum time span between infection by HPV and development of premalignant lesion with true malignant potential.
7 years
What is the effect of cervical screening on mortality from cervical cancer?
60-70% reduction
What is the underlying pathological abnormality in dyskaryosis?
High nuclear:cytoplasmic ratio.
What is the transformation zone and what are the different types?
TZ is the area between the old and new squamo-columnar junction.
Type 1 TZ: Fully visible
Type 2 TZ: Endocervical component which is fully visible.
Type 3 TZ: Endocervical component which is not fully visible.
Which HPV subtypes are commonly associated with CGIN?
HPV 18 and 45
What is the recurrence rate after treatment for CGIN compared to CIN?
18% v 5%
Why is CGIN more likely to recur after treatment than CIN?
Presence of “skip lesions”
Incidence of second trimester miscarriage in pregnancy after trachelectomy?
7%
Percentage of cases of cervical cancer <45 years
50%
Percentage of term deliveries after trachelectomy
55%
Percentage of PTB after trachelectomy
20-30%
