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m4 obgyn > Cervical Ca screening & prevention > Flashcards

Cervical Ca screening & prevention Flashcards

1
Q

Squamocolumnar junction

A

Junction between squamous and columnar epithelium
- Plays an important role in development of the transformation zone

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2
Q

Main site for development of cervical cancer

A

Transformation zone

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3
Q

Development of transformation zone

A

During puberty -> increase in estrogen
Original SCJ moves outwards outwards (eversion) -> exposes columnar epithelium to the outside acidic vaginal environment -> cervical ectropion
‘Harsh’ environment of vagina promotes squamous metaplasia (of what is the exposed columnar epithelium) -> formation of new SCJ

Transformation zone: region bound by original and new SCJ

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4
Q

Human Papillomavirus (HPV)

A

Double stranded DNA virus
HPV 16 + 18 a/w cervical ca

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5
Q

Important facts about HPV infection

A
  1. HPV infections alone does NOT mean cancer
    - HPV infections are TRANSIENT
  2. PERSISTENT infection increases risk of future cervical ca
    - takes up to 30 years from HPV infection to CIN to cancer
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6
Q

What does persistent infection mean?

A

Inability of body to get rid of HPV infection leading to chronic infection that eventually develops into pre-cancer then cancer over time

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7
Q

Risk factors of cervical ca

A

Increase exposure to HPV infection
- HPV infection (16/18) ++
- Multiple sexual partners
- Early age of 1st coitus < 20y/o

Reduce ability for body to eradicate HPV infection
- STI
- Smoking
- Immunosuppression

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8
Q

Primary prevention of cervical ca

A

HPV vaccination
- prevent infection from high risk HPV

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9
Q

Secondary prevention of cervical ca

A

Pap smear, HPV DNA test
- Detects presence of abnormal cells (pap)
- Detects presence of virus (HPV DNA test)

KIV Colposcopy (diagnostic test)
- Detects CIN and treatment to prevent from progressing to cancer

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10
Q

Pap smear

A

DETECTION OF CIN
- Liquid based cytology to look for abnormal cells
- SCREENING test
- For asymptomatic women
- Cervical pre-cancers are asymptomatic
- Helps with risk stratification

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11
Q

Sensitivity of Pap smear test

A

50%

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12
Q

Management of Pap smear result (normal women)

A

All cytology results require refer to colposcopy except
1. Negative for intra-epithelial lesion and malignant cells
2. Atypical squamous cells of undetermined significance (ASC-US)
- Repeat PAP in 6 months and only refer to colposcopy after 2x ASCUS

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13
Q

Management of HPV DNA test results

A
  1. HPV negative -> 5 yearly HPV
  2. HPV 16/18 +ve -> colposcopy
  3. HPV NON-16/18 +ve -> Do reflex cytology (PAP smear)
    a. Cytology negative -> 1 year HPV
    i. If 1 year HPV +ve -> colposcopy
    ii. If 1 year HPV -ve -> 5 yearly HPV
    b. Cytology positive -> colposcopy

*For immunocompromised women -> ALL HPV positive results refer to colposcopy

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14
Q

HPV DNA testing in cervical ca screening

A

DETECTION OF CIN
- Objective test
- SCREENING test
- HPV 16/ 18 via the Roche Cobas test
- Higher sensitivity (strong negative predictive value)
- Helps with risk stratification

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15
Q

2 types of HPV DNA test available

A
  1. Hybrid capture 2
    - Tells you either you are
    positive or negative for High
    risk HPV only
    - You will not know which
    type
  2. Genotyping
    - Tells you whether you are positive or negative for HPV
    infection and which type it is
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16
Q

Cervical ca screening methods

A

For all women who ever had sexual intercourse
25-29 y/o: PAP smear every 3 years
30-69 y/o: HPV test alone every 5 years

17
Q

Cervical ca screening for immunocompromised women

A

For all immunocompromised women who ever had sexual intercourse
- ALL women with history of HIV
- ALL women with history of solid organ transplant
- Women on more than 2 immunosuppressants meds

25-29 y/o: PAP smear yearly
≥30 y/o: HPV test every 3 years

18
Q

What is HPV vaccine?

A
  • Viral like particle - no virus in vaccine, empty protein coat
  • Offers protection from future cancer
  • Prophylactic, does not treat current infection
19
Q

Types of HPV vaccine

A

1: Cervarix (protects from HPV 16, 18)
2: Gardasil (protects from HPV 16, 18, 6, 11)
3: Gardasil 9 (protects from HPV 16, 18, 6, 11 + 5 more HPV types)

20
Q

Why is there a need for HPV vaccine?

A

Highly effective in preventing cervical pre-cancer

21
Q

How good is the HPV vaccine?

A
  • At least 70% protection against cervical cancer
  • MUST still go for regular cervical cancer screening when you are eligible
  • It does not cover all cancer causing HPV infection but the most common ones with highest risks
  • MUST complete injection regime to get best protection.
22
Q

Is the HPV vaccine safe?

A

Safe
- Common S/E: pain, swelling and redness at injection site

23
Q

How is the HPV vaccine given?

A
  • Can be given to girls and boys
  • Approved for use in Singapore from 9 to 26 year olds
  • Most effective if given BEFORE a person becomes sexually active
  • Lifetime protection. No booster currently required.
24
Q

Dosing regimen for HPV vaccine

A

Age 9 to 14 years old:
2 dose regime (0 and 6 months)

Age 15 years old and above:
3 dose regime (0, 1-2 and 6 months)

25
Q

Who will benefit from the vaccine?

A

BEFORE sexually active

Limited benefits observed in:
– Sexually active women
– Up to 45 years old
– Women who had abnormal pap smear
– Women who had treatment for pre-cancer cells

26
Q

Colposcopy procedure

A

Cervix examined with low power microscopy with bright illumination

Purpose of colposcopy
- Diagnostic procedure to confirm CIN (precancerous)**/ invasive CA
- locates lesions on cervix
- indicates severity of CIN
- allows selection of sites of the lesion for biopsy
- facilitates local ablative and excisional therapy

Note: If you can already see a suspicious fungating mass on speculum exam, there is no need for colposcopy evaluation bc a punch/cone biopsy is performed instead. Colposcopy is only used for assessing margins and extent of atypical surface changes on cervix in absence of suspicious mass

27
Q

Important colposcopy solutions used

A

Saline
- moistening and cleansing
- does not modify appearance of cervical epithelium
- evaluate abnormal blood vessels and leukoplakia before acetic acid application

Acetic acid
- denatures protein (in nucleus) of cervical epithelial cells
- abnormal cells have bigger nucleus
- the higher the dysplasia, the more dense acetowhite the lesion will appear

Lugol’s solution
- looking for poor iodine intake
- iodine stains glycogen (in cytoplasm)
- abnormal calls have smaller cytoplasm

28
Q

Colposcopy features suggestive of CIN

A

Acetowhite
Abnormal blood vessel patterns
- Punctation
- Mosaicism
- Atypical blood vessels (microinvasion until proven otherwise)

29
Q

Treatment of CIN

A

CIN 1 can regress back to normal
Treat CIN 2 and 3
- Ablative therapy vs excisional therapy

30
Q

Note: CIN is precancerous condition, NOT cancer
Treat before it turns to cancer

A

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m4 obgyn (40 decks)

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