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Gynaecology > Cervical Cancer > Flashcards

Cervical Cancer Flashcards

1
Q

Where on cervix does cervical cancer occur?

A

Transformation zone

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2
Q

Most common cause of cx ca

A

HPV 16,18!

Also 31,33, 45!, 52

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3
Q

HPV vaccine options

A
  • Cervarix (bivalent 16, 18)
  • Gardasil (quadrivalent 16,18,6,11)
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4
Q

How often do Pap smear ideally

A

3 consecutive years 1 year after sexual debut. If those are all normal, every 3 years.

Continue until at least 65 -70 years old

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5
Q

Cytology grading of cervical cancer

A

Bethesda system

  • normal +/- infectious changes
  • ASCUS (atypical squamous cells of undetermined significance - infectious or atypia )
  • HSIL (high grade squamous intraepithelial lesion)
  • LSIL
  • AGUS (atypical glandular cells of undetermined significance)
  • adenocarcinoma in situ
  • invasive squamous or adenocarcinoma
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6
Q

histology grading of cervical cancer

A
  • squamous atypia
  • HPV infection koilocytosis

Nb. Confined to epithelium. Precursor.
* CIN 1 (cervical intraepithelial neoplasm) - lower 1/3, most negress
* CIN 2 - lower 2/3 , 1/3 regress
* CIN 3 - full thickness, most progress

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7
Q

How is cervical cytology obtained to be graded by Bethesda system

A

Pap smear

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8
Q

How is cervical histology obtained

A

Biopsy

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9
Q

Cytology is a _ mechanism

A

Screening

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10
Q

Histology is a _ tool

A

Diagnostic

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11
Q

How can biopsy of cervix be taken

A
  • Colposcopy

* cone biopsy - if colposcopy C/I or not done

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12
Q

Mx if cytology show ascus+ HPV?

A

Repeat smear in 3-6 months.

If N, repeat annually.

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13
Q

Mx if histology show CIN 1 and HPV +?

A

Repeat Pap smear in 3-6 months.

If N, follow up + repeat annually

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14
Q

Mx if histology CIN2 or CIN 3?

A

Colposcopy

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15
Q

rx cervical cancer

A
  • LETZ/laser/cone biopsy

* hysterectomy

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16
Q

follow up after cervical cancer

A

2 cervical smears 4 months apart

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17
Q

FIGO Stage 1 of cervical cancer

A

1-confined to cervix

A-depth dependent (≤ 5mm deep, ≤ 7 mm wide)
A1 - ≤ 3 mm deep, ≤ 7 mm wide
A2- 3 - 5 mm deep, ≤ 7 mm wide.

B-width dependent (≥5mm deep, ≤ 7mm wide)
B1- 5mm - 2 cm diameter
B2- 2-4 cm diameter
B3- > 4 cm diameter

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18
Q

Stage 2 cervical cancer

A

2 a- vertical spread. Cervix → vag fornix. Upper 2/3 vagina
A1 - upper 2/3 of vag and ≤4cm
A2 - upper 2/3 vag and >4cm.
2b- horizontal spread. Extend to parametria but not pelvic side wall

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19
Q

Stage 3 cervical cancer FIGO

A

3-lower vag, pelvic sidewall, ureters, LNs

3a- vertical. → lower 1/3 vag

3b- horizontal to pelvic side wall (+/- hydro ureter → hydronephrosis not explained by other causes )

3c - pelvic and para-aortic LN involvement
- C1 -pelvic LN involvement
- C2 - para-aortic LN involvement
→ p: diagnosed by biopsy histology
→ r: diagnosed by radiology (pet Ct)

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20
Q

Stage 4 cervical cancer

A

4a-bladder/rectal involve

4b-distant metastasis

21
Q

Rx stage 1 cervical cancer (4)

A

1a1:
- cone biopsy/ lletz ;
- observation if desire fertility + negative margins on cone biopsy (3 MM. ) and no evidence lymphovascular invasion;
- trachelectomy or simple hysterectomy preferred! (Add ln assessment if LvSI or > 3mm depth)

1a2:
- radical hysterectomy + bilateral pelvic ln dissection! or
- radical trachelectomy + pelvic ln dissection (better if want fertility )
- medically inoperable /refuse: pelvic external beam radiation with brachytherapy
- adjuvant chemoradiation if high risk features on final path review (ie lymphovascular invasion,positive margins, pelvic nodes) with cisplatin

1b1 or 1b2
- surgery: radical hysterectomy + bilateral pelvic ln dissection preferred l
- radiation: pelvic radiotherapy and brachytherapy
- chemoradiation (cisplatin)

1b3
- primary concurrent chemoradiation with brachytherapy oR
- radical hysterectomy with pelvis node dissection

22
Q

stage 2 rx cervical cancer

A

2 a:
- primary chemoradiation or
- radical hysterectomy with partial vaginectomy

2b
- primary chemoradiation or
- radical hysterectomy with resection of parametria and all involved nodes

23
Q

Rx stage 3 cervical cancer

A

Primary chemo radiation

24
Q

Rx stage 4 cervical cancer

A

4a
- primary chemoradiation with brachy therapy

4b
- chemotherapy or palliative

25
Q

Most common type gynae cancer

A

Squamous cell carcinoma of cervix

26
Q

When is LLETZ done (2)

A
  • High grade abnormal smears
  • recurrent low grade smears
27
Q

When is cone biopsy done (6)

A

• LSIL where colposcopy unavailable-cont abn smears.
• unsatisfactory colposcopy
• biopsy indicates microinvasive carcinoma
• suspected endocervical adenocarcinama
• diagnose precancerous conditions of cervix
• treat precancerous cervical conditions eg stage 1a1 cervical cancer.
Only really used when large sample required

28
Q

What is removed in cone biopsy

A

Portion of cervix surrounding endocervical canal and entire transformation zone.

29
Q

3 methods of cone biopsy

A

During colposcopy

  1. loop electrical excision procedure
  2. Cold knife excision
  3. Laser excision
30
Q

Important post-procedure information to tell patient after cone biopsy

A

No sex for 2-6 weeks

Only use sanitary pads (not tampons) for 2-6 weeks.

31
Q

Most common cancer of South African women

A

Cervical cancer

32
Q

Name 2 species of HpV and examples

A

Alpha 9 = squamous cell carcinoma!
- hpv 16 and relatives (31, 33, 35, 52,67)
- type 35 over-represented

Alpha 7 = adenocarcinomas!
- hpv 18 and relatives (39, 45!, 59, 68, 70)

33
Q

Most prevalent Histological type cervical cancer?

A

Squamous cell carcinoma

34
Q

How screen for cervical cancer? (3)

A

Cytology
- scrape
- Pap smear

Low sensitivity + specificity

Alternative: HPV DNA testing! Better sensitivity. And PCR for type in > 30 years
Alternative: visual screening by inspection. Iodine stain and observe for yellow change in epithelium. Not great but used when few resources.

35
Q

State policy for frequency of pap smears?

A

3 smears per woman per lifetime.

Ages 30,40, 50

36
Q

Name 5 causes false positive abnormal Pap smear

A
  • Atrophy
  • infections, esp trichomoniasis
  • folic acid deficiency
  • previous radiotherapy
  • lab error
37
Q

Name 5 causes false negative Pap smear

A
  • Smear not taken from transformation zone
  • too few cells on slide
  • deficient fixation of smear
  • slide covered with blood/pus
  • lab errors
38
Q

Pathogenesis of premalignant cervical lesions?

A
  • Metaplasia: caused by normal Puberty. Estrogen → outgrowth of columnar epithelium → exposed scj to acidity of vagina
  • dysplasia: when HPV present
  • typically hpv → atypia → LSIL → hsil
    (Majority regress but not all, especially not from HSIL )
39
Q

Name 4 risk factors cervical cancer

A
  • early age first coitus
  • multiple partners
  • smoking
  • Immune suppression eg HIV
40
Q

Management for abnormal Pap smears?

A

Ideally all for colposcopy and lletz.

41
Q

Name 6 treatment options for premalignant lesions

A

Local destruction
- cryotherapy
- laser

Local excision
- lletz (first choice)
- cone biopsy

Surgery
- simple hysterectomy
- radical hysterectomy

42
Q

Name 5 symptoms and epidemiology cervical cancer

A

Age 20-100 (average 45 - 60)

  • none
  • abnormal smear
  • bleeding!
  • discharge
  • pain = late complaint!
43
Q

Name 3 signs cervical cancer

A
  • Normal to cachectic
  • paraneoplastic syndromes common: excessive anaemia, fever, cachexia
  • On cervix: ulcer / exophytic / endophytic growth
44
Q

Name 5 indications lletz

A
  • Unsatisfactory colposcopy (transformation zone not fully visualised), especially if suspect high grade lesion; colposcopist unable to rule out invasive disease
  • suspected microinvasion
  • lesion extend into endocervical canal
  • suspected adenocarcinoma in situ
  • Recurrence after previous excision or ablative procedure
  • lack correlation between cytology and colposcopies/biopsies, especially if suspect high grade lesion
  • endo cervical curettage showing CIN or glandular abnormality
45
Q

How perform lletz? (7)

A
  • Position pt in dorsal lithotomy position with grounding pad on upper thigh
  • insert speculum, sterile procedure
  • infiltrate cervix with 1% lidocaine with epinephrine 1:100 000 dilution,
  • place acetic acid 3-5% or Lugol’s solution (iodine) on cervix with cotton swab to visualise lesion
  • set electrosurgical generator at 30 - 50 watts on blend 1
  • excise loop ideally in 1 pass. Should excise entire transformation zone to depth 5-8 MM.
  • colposcopic reassessment
46
Q

Name 4 complications lletz

A
  • Intraoperative bleeding (treat with electrocautery, packing, silver nitrate
  • post op bleeding ( pack afterwards)
  • infection
  • cervical stenosis and insufficiency
47
Q

Prevention cervical cancer?

A
  • Primary (entire population): HpV vaccination, education
  • secondary (screen in asymptomatic: Pap smear (cytology) , HpV molecular tests. If identify risk, reduce by excise / freeze / cauterise tissue.
  • tertiary (early diagnosis + treatment cancer): routine examination
48
Q

Clinical presentation cervical cancer? (7)

A

Symptoms

  • Contact/post coital bleeding (earliest)
  • vaginal discharge
  • AUB: intermenstrual or hmb
  • late: abdominal /back pain, swollen legs, weight loss, groin nodes, loss bladder /bowelcontrol

Signs

  • speculum: initially red area with abnormal surface centrally, later appear enlarged / irregular or replaced by exophytic tumour
  • pv: late stage - tumour replaced cervix, tumour and cervix immobile, tumour invade surrounding tissue
  • bleeds when touched
49
Q

Investigations confirmed cervical cancer? (7)

A
  • FBC: anaemia, iron deficiency
  • UCE (worse prognosis)
  • HIV
  • LFT:
  • ultrasound kidneys: hydronephrosis, bladder invasion
  • MRI / ct/pet ct abdomen and pelvis: lymph nodes involvement,liver…
  • chest xray (metastasis), especially from stages 1 b 2

Gynaecology (40 decks)

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