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Obs & Gyn > Cervical and vulval oncology > Flashcards

Cervical and vulval oncology Flashcards

1
Q

describe the incidence of cervical cancer

A

two peaks

25-29 yo

> 80yo

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2
Q

what is cervical cancer strongly associated with

A

Human papillomavirus

BOTH SEXES aged 12-13 are vaccinated against certain strains to reduce the risk

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3
Q

what cancers are HPV associated with

A

anal, vulval, vaginal, penis, mouth and throat cancers

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4
Q

what cancers are HPV associated with

A

anal, vulval, vaginal, penis, mouth and throat cancers

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5
Q

what are the most important strains of HPV 2

*what percentage of cervical cancer are these strains responsible for

A

type 16

type 18

-there are over 100 strains

*-type 16 & 18 are responsible for 70% of cervical cancer

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6
Q

how does HPV promote the development of cancer (basic pathophys)

A

HPV inhibits tumour suppressor genes P53 and pRb

HPV produces two proteins E6 & E7
-E6 inhibits P53
-E7 inhibited pRb

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7
Q

how can risk factors for cervical cancer be classified 3

A

RF assoc w increased risk of catching HPV

RF associated with later detection of precancerous and cancerous changes
-ie non-engagemetnt in screening

other risk factors

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8
Q

what risk factors cause an increased risk of catching HPV 4

A

early sexual activity

increaed number of sexual partners

sexual partners who have had more partners

not using condoms

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9
Q

what is a signifcatn risk factor for cervical cancer outwith HPV risk

A

non-engagement with cervical screening

*many cases are preventable with early detection and treatment fo precancerous changes

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10
Q

other risk factors for cervical cancer not assoc with HPV 6

A

smoking

HIV

combined contraceptive pill (if used for more than 5 years)

increased no of full-term pregnancies

FHx

exposure to diethsubestol during fetal development (was previously used to prevent miscarraiges)

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11
Q

what aspects of a cervical cancer history are important to identify risk factors 4

A

attendance to smears

number of sexual partners

family history

smoking

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12
Q

presenation of cervical cancer 5

A

-many are asympotmatic and detected at smears

otherwise:
-abnormal vaginal bleeding (intermenstural, postcoital or postmenopausal)

vaginal discharge

pelvic pain

dysparenuia - pain or discomfort with sex

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13
Q

as the symptoms of cervical cancer are very non-specific what important investigations can be completed 1

A

examine the cervix with a speculum

-swabs can be taken at this time to exclude infection

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14
Q

when there is an abnormal appearance of the cervix sugesstive of cancer an urgent cancer referral for colposcopy should be made

-what appearances would prompt this referral 4

A

ulceration

infalmmation

bleeding

visible tumour

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15
Q

what grading system is used to assess premalignant changes in cervical cancer

A

cervical intraepithelial neoplasia grading system

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16
Q

when is the cervical intraepithelial neoplasia grading system used

A

diagnosed at colposcopy NOT with cervical screening

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17
Q

regarding the cervical intraepithelial neoplasia grading system define grade 1

A

mild displaysia

affecting 1/3 thickness of the epithelial layer
-likely to return to normal without treatment

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18
Q

regarding the cervical intraepithelial neoplasia grading system define grade II

A

moderate diysplaisa

-affecting 2/3 of the thickness of the epithelial layer
-likely progress to cancer if untreated

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19
Q

regarding the cervical intraepithelial neoplasia grading system define grade III

A

severe dysplasia
-very likley to porgress to cancer if untreated

*can also be called cervical carcinoma in situ

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20
Q

what is an important distinction to dyspplasia found on colposcopy

A

dyskaryosis on smear results

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21
Q

describe the process of cervical screening and how testing identifies possible cancer

A

speculum examination adn collection of cells form cervix with small brush

cells are deposited form brush into preveervation fluid

fluid then transported to lab

-samples initially tested for high risk HPV before examined
-if HPV negative, cells not examined, smear considered negative and women returned to routine screening programme
-if HPV positive= cells examined under microscopy for precancerous changes (dyskaryosis)

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22
Q

what is the timeframe for cervical screening

A

every 3 years for 25-49 yo

every 5 years for 50-64

*-also includes transgeneder men who still have cervix

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23
Q

what are some exceptions to the cervical screening programme 4

A

women with HIV - annual screen

women with previous CIN (dysplasia)- may require additional tests (test cure after treatment)

immunocomrpirsed women may need additional screening

pregnant women due a smear- wait 12 weeks post partum

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24
Q

give an overview of the specturm of cytology results in cervical smear testings

A

Inadequate
Normal
Borderline changes
Low-grade dyskaryosis
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
Possible invasive squamous cell carcinoma
Possible glandular neoplasia

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25
Q

what else can be picked up on cervical smears

A

infections:
-bacterial vaginosis
-candidiasis
-trichomoniasis

actinomyces-like organisms can be discovered in women with an intrauterine device
-do not require treatment unless symptomatic
-? removal of device

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26
Q

summary of the manngemtn of cervical smear results 4

A

Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy

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27
Q

what staining can be completed during colposcopy 2
-what does each staining show

A

acetic acid
-causes abnormal cells to appear white

iodine solution
-causes normal areas to appear brown
-abnormal cells will not stain

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28
Q

what else can be completed during a colposcopy other than staining

A

punch biopsy
or
large lopp excision of the transformation zone

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29
Q

what happens during a large loop excision of the transformation zone (LLETZ)

A

performed under local aneasthetic

involves using a loop of wire with electrical current to revmoeve abnormal epithelial tissue from the cervix
-the electrical current cauterisites the tissue and stops it bleeding

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30
Q

side effects of large loop excision of the transformation zone (LLETZ) 3
*-what should be avoided after this procedure 2

A

bleeding and abnormal discharge

dependent on depth of tissue removed can increase risk of preterm labour

*intercouse and tampons should be avoided after to reduce risk of infection

31
Q

when is a cone biospy used (in the context of cervical oncology) 2

A

treatment of cervical intraepitheial neoplasia (CIN) and very early stages of cervical cancer

32
Q

describe a cone biopsy cone biospy used (in the context of cervical oncology)

A

involves general anaestheic

surgeon removes cone-shaped piece of cervix using a scalpel
-sample is sent to hsiotlogy to assess for malignancy

33
Q

risks of cone biospy used (in the context of cervical oncology) 5

A

pain

bleeding
infection

scar formation with stenosis of the cervix

increased risk of miscarriage and preterm labour

34
Q

regarding staging for cervical cancer
define stage I

A

confined to cervix

35
Q

regarding staging for cervical cancer
define stage II

A

invades uterus and upper 2/3 of vagina

36
Q

regarding staging for cervical cancer
define stage III

A

invades pelvic wall or lower 1/3 of the vagina

37
Q

regarding staging for cervical cancer
define stage IV

A

invades the bladder,rectum or beyond the pelvis

38
Q

regarding management of cervical cancer
-treatment for cervical intraepithelial neoplasia and early stage 1A (2)

A

LLETZ
or
cone biopsy

39
Q

regarding management of cervical cancer
-treatment for stage 1b-2a (3)

A

radical hysterectomy and removale of local lymphd nodes
with chemo and radio

40
Q

regarding management of cervical cancer
-treatment for stage 2b-4a (2)

A

chemo and radio

41
Q

regarding management of cervical cancer
-treatment for stage 4b (4)

A

managemnet may involve a combination of surgery
radiotherpay
chemo
palliative care

42
Q

what type of operation can be used in adnaced cervical cancer

A

pelvic exenteration
-involves removing most or all of the pelvic organs including the vagina,cervix,uterus,fallopian tubes ,ovaires ballder and rectum

43
Q

what can be used in combination with other chemotherapies for metastatic or recurrent cervical cancer

A

bevacizumab (avastin)
-monocolonal antibody
-also used in several other cancers

44
Q

what does bevacizumab (avastin) act on

*what else can it be used for

A

tagets vascular endothelial growth factor A (VEGF-A)
is responsible for development of new blood vessels

therefore reduces the development of new blood vessels

*-wet age-related macular degeneration

45
Q

what strains does the HPV vaccine act against and why

A

strains 6 and 11 for genital warts

strains 16 and 18 for cervical cancer

46
Q

overview of parental concern regrding HPV vaccine

A

A common exam task is to counsel parents about their child receiving the HPV vaccine. They are upset because they believe this implies their daughter or son is sexually promiscuous. Focus on the fact it needs to be given before they become sexually active and that it protects them from cervical cancer and genital warts. HPV is very common and infection is the number one risk factor for cervical cancer.

47
Q

define the transformation zone of the cervix

A

inner surface (canal) is lined by columnar epithelium

continuous with squamous epithelimin lining the outer part of the cervix

junction is the transformation zone (TZ)

48
Q

how does HPV affect the trasnformation zone

A

HPV interferenes with physiological metaplasia in the TZ

-leads to dysplasia (CIN) and squamous cell carcinoma

49
Q

most common type of cervical cancer
-next most common type

A

squamous cell carcinoma

-adenocarcinoma

50
Q

treatment for cervical intraepitheliam neoplasia 2

A

CIN1 given time to resolve

CIN2 and 3- high grade changes and treatment offered

treatment
-destructive - cold coagulation, cryotherapy
-excisional - LLETZ, cold knife cone, laser excision

51
Q

follow up after cervical intraepithelial neoplasia

A

community smear at 6 months with HPV test

52
Q

examination types in possible cervical cancer 6

A

supraclavicular

abdominal

speculum

bimanual

PR- to assess parametrium

colposcopy

53
Q

what accounts for 90 % of vulval cancers
-otherwise what can it be

A

squamoous cell carcinoma

-less commonly malignant melanomas

54
Q

risk factors for vulval cancer 4

A

advanced age (over 75)

immunosuppression

HPV infection

lichen sclerosus

55
Q

premaliangt condition for vulval cancer

A

vulval intraepithelial neoplasia
-affecting the squamous epithelium of the skin

-similar to cervical intraepithelial neoplasia

56
Q

what vulval intraepithelial neoplasia is associated with HPV infection
-who gets it

A

high grade squamous intraepithelial lesion
-usually women age 35-50

57
Q

what vulval intraepithelial neoplasia is asscoaited with lichen sclerosis

A

differentiaitated VIN
-typically older women (age 50-60yo)

58
Q

abnormaites seen in each type of vulval intraepithelial neoplasia 3

A

1 - usual type (thickened)

2- warty

3-basaloid

4-differetiated

59
Q

what is rquired for diagnosis of vulval intraepithelial neoplasia 1

A

biopsy

60
Q

what are treatment options for vulval intraepithelial neoplasia 4

A

watch and wait with close followup

wide local excision (surgery) to remove lesion

imiquimod cream

laser ablation

61
Q

presenation of vulval cancer 7

A

*-cna be incidential in older women ie during cathertieritision in a patient with dementia

otherwise:

vulval lump

ulceration

bleeding

pain

itching - 2/3 of cases

lymphadenopathy in the groin

62
Q

what part of the vagina is most commonly affected by vulval cancer
-how can this appear 4

A

labia majora

-irregular mass
-fungating lesion
-ulceration
-bleeding

63
Q

diagnosis of vulval cancer

A

biopsy
-incisional
-excision

64
Q

prinicples of vulval intraepithelial neoplasia managemnt

A

exclude and prevent invasive disease

relieve syx

eradicatre HPV

preserve anatomy and function

65
Q

signs of vulval cancer 6

A

mass

ulceration

colour changes

elevation and irregularity of surface

inguinal lymphadenopathy

lower limb. lymphadoedema

66
Q

regarding staging of vulval cancers
define stage 1

A

cancerous cells found in vulva or perineum (region between anus and vulva) only

67
Q

regarding staging of vulval cancers
define stage 2

A

cnacer spread to urethra, anus or vagina

68
Q

regarding staging of vulval cancers
define stage 3

A

cancer spread to near by lymph nodes

69
Q

regarding staging of vulval cancers
define stage 4

A

cancer spread beyond lymph nodes to other parts of the body

70
Q

managemnt of vulval cancer

A

surgical
-prinicples local diesaes control and detection and treatment of loco rreional lymph node metatisi

chemo
-NACT to reduce tumour size prior to surgery
-primary-prior to radiotehrpay
-adjuvant- post operative

71
Q

what is the surgical technique best for vulval cancer

A

triple incision

WLE- wide local excision
-inguinal lymphadenopathy

72
Q

-complications of lymphadenectomy 5

A

short term
-delayed wound healing
-infection
-wound breakdown

long term
-lymphedema
-recurrent infection

73
Q

and vulval define the sentinel lymph node theory

A

sentinel node (SLN) is first node(s) in the lymphatic system that drains the locus of primary tumour

-SLN is representative of the nodal basin

-if SLN is negative then you do not need to perform a formal lymphadenopathy

Obs & Gyn (23 decks)

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