218 - Vulvar and Cervical Malignancy

Question 1

When should cervical cancer screening (PAP smear) be started?

What is the approprate interval?

When should it be stopped?

Answer 1

Start at 21 y/o

• Every 3 years
• If 30-65 y/o AND cotesting PAP + HPV, every 5 years

Stop ≥ 65 if adequate screening and no h/o HGSL or worse in the last 20 years

Stop if no cervix and no h/o HGSL or worse in the last 20 yeasrs

Question 2

What is the risk of invasive carcionma from an untreated CIN3 (cervical lesion)?

A treated CIN3?

Answer 2

Untreated -> 30% 30-year risk

Treated -> less than 1% risk

=> important to screen and treat!

Question 3

When is an immediate colposcopy warranted after a PAP smear?

Answer 3

If LSIL or or worse is found

Note: ASC-US does NOT warrant colposcopy; just screen at shorter interval

Question 4

What is the shape of HPV’s capsid?

Answer 4

Icosahedral

For some reason this was emphasized, not sure if he was joking or not but here ya go ¯_(ツ)_/¯

Question 5

During a colposcopy, how does one know which parts of the cervix should be sampled?

Answer 5

Squirt acetic acid on the cervix

Look for acetowhite change - these are the areas that are most concerning for abnormality

Question 6

What are the indications for surgical removal of a surgical legion?

Answer 6

Basically, anything HGSIL or worse

(Including HGSIL)

• Any type of CIN
• Any possitive margins on biopsy, LEEP, ECC
• Any invasive SCC
  
  • For this, consider hysterectomy planning

Question 7

List 3 common presenting symptoms of invasive cervical cancer

Answer 7

• Abnormal vaginal bleeding
• Post-coital bleeding
• Vaginal discharge

Pelvic pain, difficulty urinating/defecating, back pain, leg swelling are signs of advanced disease

Question 8

To which lymph nodes will cervical cancer spread?

Answer 8

Pelvic and para-aortic nodes

Question 9

When can cervical cancer be treated surgically?

When should chemo/radiation be used instead?

Answer 9

Surgery: If legion is ≤ 4 cm, no node involvement

Chemo/radiation if larger than this

Question 10

Is lichen sclerosis associated with HPV?

Answer 10

NO

• 2 types of vulvar cancer
  
  • HPV-associated: arises in the setting of HPV (younger people, less common)
  • Non-HPV associated: arises in the setting of lichen sclerosis (old people, more common

Key is that there are two separate pathways to vulvar cancer, one that is driven by HPV, the other that is associated with lichen sclerosis

Question 11

To which lymph nodes will vulvar cancer spread?

Answer 11

Inguinal and pelvic