Abnormal Smear Flashcards
What is the purpose of screening?
- To detect disease among healthy population without symptoms of disease
- Ultimately to decrease mortality due to the disease screened
Criteria for Disease appropriate for screening
- High prevalence of disease
- Known natural history, precursor lesion and course of progression
- Detection of early stage disease amenable to cure
- Method used is simple, acceptable, risk-free and cost- effective
Screening of malignancies on the NHS (UK)
- Cervical (25–64years)
- Breast (50–70years)
- Bowel (60–70years)
Commonest cancer affecting women under the age 35
Carcinoma of the cervix
Cervical cancer screening guidelines
- Computerised call and recall system
- First invitation at 25 years age
- Three yearly until 49 years age
- Five yearly until 64 years age
HPV subtypes associated with genital warts
6 and 11 can cause genital warts in more than 90% cases
HPV subtypes associated with cervical cancer
High risk: 16 and 18 cause 70 % of cervical cancer
Over 95% of cervical SCCs associated with high risk HPV types (16,18,31,33,45);
Cervical smear results classification
- Normal
- Borderline nuclear abnormality (BNA) • Low grade (Mild)
- High grade (Moderate and Severe)
- High grade ? Invasion
- Glandular changes
Smear test - what are Koilocytes?
HPV infected cells- vacuoles in cytoplasm
Smear test - what is dyskaryosis?
MILD: Cells with slightly increased nuclear cytoplasmic ratio
MODERATE: increased nuclear cytoplasmic ratio
SEVERE: markedly increased nuclei with mitotic figures
Colposcopy: What does Acetowhite area indicate?
increased nuclear activity
Colposcopy: What does iodine negative area indicate?
less cytoplasmic glycogen
What is a LLETZ procedure?
Large loop excision of Transformation Zone
Cervical Intraepithelial Neoplasia GRades
CIN:Is a Histological Term
• CIN 1 : Abnormal cells affecting the lower one-third of the epithelium
• CIN 2: Abnormal cells affecting the lower (Basal ) two-thirds of the epithelium
• CIN 3 : Abnormal cells affecting > than two- thirds and up to full thickness
• CGIN: Cervical Glandular Intra-epithelial Neoplasia- precursor to adenocarcinoma.
Treatment of High Grade CIN
Excision therapy- recommended, as disease excised
Ablative therapy- Not recommended- risk of residual disease
HPV triage
Women with borderline changes or mild dyskaryosis will have reflex HPV testing
– High risk HPV positive refer to colposcopy
– HPV negative routine screening
Explain the concept of HPV as test of cure
Cervical cytology and HPV testing 6 months after treatment (LLETZ or biopsy for CIN1)
– HPV negative and cytology normal, borderline or mild return to routine screening
–HPV positive and cytology normal, borderline or mild colposcopy referral
– Moderate dyskaryosis or worse repeat colposcopy
what is the Pathology/Aetiology of cervical cancer?
- Squamous cell carcinomas 90% • Adenocarcinomas 10% • Adenocarcinomas has worse prognosis Aetiology-
- Not familial
- CIN (Cervical Intraepithelial Neoplasia) is preinvasive stage
- HPV (Human Papilloma Virus) is found in all cervical cancers
- Smoking
- Immunosuppression (HIV/Steroids) accelerates process of invasion from CIN.
- HPV (16/18) Vaccination likely to prevent cases in future.
Clinical Features of cervical cancer
• Post-coital bleeding
• Offensive vaginal discharge • Intermenstrual bleeding
• Postmenopausal bleeding • Pain is not an early feature
• Later stages- • Uremia
• Haematuria
• Rectal bleeding and pain
Examination- cervical mass/ulcer or normal cervix
Spread of cervical cancer
- Local - to parametrium/vagina/lateral pelvic side wall
- Lymphatics-to pelvic lymph nodes
- Blood borne- rare and occurs late
outline Staging of Cervical cancer
I The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded)
II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina
III The tumor extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or non-functioning kidney
IV he carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to stage IV
How is cervcal cancer investigated?
- Full Blood Count
- Urea
- Electrolytes
- Chest X-Ray
- Blood is cross matched before surgery
Treatment of cervical cancer
- Surgery
- Radiotherapy
- Chemotherapy
• Stage 1a(i) –cone biopsy in younger women who wants to preserve their fertility.
• As lymph node spread is only 0.5%
• Postoperative haemorrhage and preterm labour are the main
risks
• Simple hysterectomy in older women
1a(i) Cone biopsy or simple hysterectomy 1a(ii)-1b(i) Laparoscopic lymphadenectomy and radical hysterectomy 1a(ii)-2a Radical hysterectomy (if lymph nodes negative) or chemo-radiotherapy 2b and above or lymph nodes positive Chemo-radiotherapy alone
Indications for chemo-radiotherapy in cervical cancer
- Lymph nodes positive on MRI or after lymphadenectomy • If lymph nodes negative as an alternative to hysterectomy • Surgical resection margins not clear
- Palliation for bone pain or haemorrhage (radiotherapy)
what is a Radical Hysterectomy (Wertheim’s hysterectomy)-
- Pelvic node clearance
- Hysterectomy
- Removal of the parametrium
- Upper third of the vagina Complications:
- Haemorrhage
- Ureteric and bladder damage • Fislulae
- Voiding problems
- Accumulation of lymph.
what is a Radical trachelectomy?
• Women who wish to conserve fertility
• Involves removing 80% of cervix and upper vagina.
• Laparoscopic pelvic lymphadenectomy is performed first and if nodes are negative than only radical trachelectomy is performed.
• If nodes are positive, chemo-radiotherapy is used.
• It is appropriate for stage 1a(ii)-1b(i) provided the tumour is
<20mm in diameter.
• Cervical suture is inserted to prevent preterm labour in pregnancy.
• If excisional margins are incomplete then chemo-radiotherapy is needed.
Poor prognostic indicators for cervical cancer are
- Lymph node involvement
- Advanced clinical stage
- Large primary tumour
- Poorly differentiated tumour • Early recurrence
