Cervical Cancer Flashcards
Where on cervix does cervical cancer occur?
Transformation zone
Most common cause of cx ca
HPV 16,18!
Also 31,33, 45!, 52
HPV vaccine options
- Cervarix (bivalent 16, 18)
- Gardasil (quadrivalent 16,18,6,11)
How often do Pap smear ideally
3 consecutive years 1 year after sexual debut. If those are all normal, every 3 years.
Continue until at least 65 -70 years old
Cytology grading of cervical cancer
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
histology grading of cervical cancer
- 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
How is cervical cytology obtained to be graded by Bethesda system
Pap smear
How is cervical histology obtained
Biopsy
Cytology is a _ mechanism
Screening
Histology is a _ tool
Diagnostic
How can biopsy of cervix be taken
- Colposcopy
* cone biopsy - if colposcopy C/I or not done
Mx if cytology show ascus+ HPV?
Repeat smear in 3-6 months.
If N, repeat annually.
Mx if histology show CIN 1 and HPV +?
Repeat Pap smear in 3-6 months.
If N, follow up + repeat annually
Mx if histology CIN2 or CIN 3?
Colposcopy
rx cervical cancer
- LETZ/laser/cone biopsy
* hysterectomy
follow up after cervical cancer
2 cervical smears 4 months apart
FIGO Stage 1 of cervical cancer
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
Stage 2 cervical cancer
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
Stage 3 cervical cancer FIGO
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)
Stage 4 cervical cancer
4a-bladder/rectal involve
4b-distant metastasis
Rx stage 1 cervical cancer (4)
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
stage 2 rx cervical cancer
2 a:
- primary chemoradiation or
- radical hysterectomy with partial vaginectomy
2b
- primary chemoradiation or
- radical hysterectomy with resection of parametria and all involved nodes
Rx stage 3 cervical cancer
Primary chemo radiation
Rx stage 4 cervical cancer
4a
- primary chemoradiation with brachy therapy
4b
- chemotherapy or palliative
Most common type gynae cancer
Squamous cell carcinoma of cervix
When is LLETZ done (2)
- High grade abnormal smears
- recurrent low grade smears
When is cone biopsy done (6)
• 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
What is removed in cone biopsy
Portion of cervix surrounding endocervical canal and entire transformation zone.
3 methods of cone biopsy
During colposcopy
- loop electrical excision procedure
- Cold knife excision
- Laser excision
Important post-procedure information to tell patient after cone biopsy
No sex for 2-6 weeks
Only use sanitary pads (not tampons) for 2-6 weeks.
Most common cancer of South African women
Cervical cancer
Name 2 species of HpV and examples
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)
Most prevalent Histological type cervical cancer?
Squamous cell carcinoma
How screen for cervical cancer? (3)
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.
State policy for frequency of pap smears?
3 smears per woman per lifetime.
Ages 30,40, 50
Name 5 causes false positive abnormal Pap smear
- Atrophy
- infections, esp trichomoniasis
- folic acid deficiency
- previous radiotherapy
- lab error
Name 5 causes false negative Pap smear
- Smear not taken from transformation zone
- too few cells on slide
- deficient fixation of smear
- slide covered with blood/pus
- lab errors
Pathogenesis of premalignant cervical lesions?
- 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 )
Name 4 risk factors cervical cancer
- early age first coitus
- multiple partners
- smoking
- Immune suppression eg HIV
Management for abnormal Pap smears?
Ideally all for colposcopy and lletz.
Name 6 treatment options for premalignant lesions
Local destruction
- cryotherapy
- laser
Local excision
- lletz (first choice)
- cone biopsy
Surgery
- simple hysterectomy
- radical hysterectomy
Name 5 symptoms and epidemiology cervical cancer
Age 20-100 (average 45 - 60)
- none
- abnormal smear
- bleeding!
- discharge
- pain = late complaint!
Name 3 signs cervical cancer
- Normal to cachectic
- paraneoplastic syndromes common: excessive anaemia, fever, cachexia
- On cervix: ulcer / exophytic / endophytic growth
Name 5 indications lletz
- 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
How perform lletz? (7)
- 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
Name 4 complications lletz
- Intraoperative bleeding (treat with electrocautery, packing, silver nitrate
- post op bleeding ( pack afterwards)
- infection
- cervical stenosis and insufficiency
Prevention cervical cancer?
- 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
Clinical presentation cervical cancer? (7)
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
Investigations confirmed cervical cancer? (7)
- 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
