Cervical Cancer

Question 1

What are the two types of cells in the cervix and where do they meet?

Answer 1

1. Endocervix - columnar (glandular) epithelium
2. Ectocervix - squamous epithelium
3. Squamocolumnar junction

Question 2

What happens to the cervix during puberty and pregnancy?

Answer 2

Hormonally induced eversion of the cervix, lower pH of the vagina results in the formation of the transformation zone.

Question 3

Why is dysplasia more common in the transformation zone of the cervix?

Answer 3

Columnar epithelium undergoes normal metaplasia. Cells undergoing metaplasia are more likely to develop dysplasia.

Question 4

What is the agent responsible for inducing dysplasia in the cervix?

Answer 4

Human papilloma virus

Question 5

What is the name for dysplasia occurring in the cervix and what are the symptoms?

Answer 5

1. Cervical intraepithelial neoplasia (CIN)

2. Usually asymptomatic

Question 6

What may cervical intraepithelial neoplasia progress to if left untreated?

Answer 6

Invasive squamous cell carcinoma

Question 7

What are the four typical (but not inevitable) steps for progression of cervical cancer?

Answer 7

1. Columnar mucosa
Vaginal acid metaplasia
2. Metaplastic squamous mucosa
Persistent HPV infection
3. CIN (pre-cancer)
4. Squamous cell carcinoma (cancer)

Question 8

What are the high risk and low risk subtypes of HPV infection?

Answer 8

1. High risk - 16 and 18 - associated with 70% of cervical cancers
2. Low risk - 6 and 11 - associated with anogenital warts

Question 9

In which age group is cervical the most common type of cancer in women?

Answer 9

18-35

Question 10

What is this a presentation of?
Vaginal bleeding (post-coital, intermenstrual), offensive vaginal discharge, 18-35 year old woman.

Answer 10

Cervical cancer

Question 11

What are the risk factors for cervical cancer?

Answer 11

1. Sexually active - first intercourse at early age
2. Skin to skin contact
3. Persistent HPV infection
4. Smoking
5. History of STIs
6. HIV, immunocompromised

Question 12

How is suspected cervical cancer investigated?

Answer 12

1. Biopsy to confirm diagnosis - will give type and grade

2. Examination under anaesthesia and abdominal/pelvis CT scan for staging (FIGO)

Question 13

What is the definitive treatment for cervical cancer?

Answer 13

1. Wertheim’s hysterectomy - total abdominal and lymph node clearance
2. Adjunct radiotherapy and annual smears

Question 14

What is the follow-up for cervical cancer after treatment?

Answer 14

Every 3 months for 1st 2 years, every 6 months for year 3 and 4, then at 5 years

Question 15

What are the two types of cervical cancer and what percentage of cases does each represent?

Answer 15

1. Invasive squamous cell carcinoma (80%) - CIN is precursor

2. Adenocarcinoma (20%) - cervical glandular intraepithelial neoplasia is precursor

Question 16

What is the vaccine for HPV and when is it given?

Answer 16

1. Gardasil quadrivalent (6, 11, 16, 18)
2. All children between ages 12-13 (3 doses needed if over 15), man also get if they have sex with men or if they are sex workers.

Question 17

What is the method of cervical screening and when is it done?

Answer 17

1. Liquid based cytology - brush collects TZ cells, stain cells on slides
2. Women screened every 3 years from 25-49, every 5 years from 50-64, HIV+ screening every year

Question 18

What is the abnormality of cell nucleus in cervical cancer called?

Answer 18

Dyskaryosis

Question 19

What are the three types of dyskaryosis in a cervical smear?

Answer 19

1. Low grade (mild) - predicts CIN 1
2. High grade (moderate) - predicts CIN 2
3. High grade (severe) - predicts CIN 3

Question 20

What are the two different management plans for a low vs high grade smear?

Answer 20

1. Low grade - re-screen in 1 year

2. High grade - refer for colposcopy

Question 21

Why can CIN not be diagnosed on a cervical smear?

Answer 21

It is a histological diagnosis and so a biopsy is required via colposcopy.

Question 22

What is the management for CIN 2 and 3?

Answer 22

1. Excision of TZ with cutting diathermy under local anaesthesia (large loop excision of the transformation zone)
2. Offered a repeat smear and high risk HPV test 6 months later, if clear then return to normal screening.

Question 23

How is a pregnant women with CIN 2 or 3 managed?

Answer 23

Can have colposcopy but not large loop excision of the transformation zone and should wait until 12 weeks postpartum.

Question 24

Why is large loop excision of the transformation zone contraindicated in pregnancy?

Answer 24

Can increase risk of premature birth (cervical incompetence) or a prolonged labour (cervical stenosis from the procedure).