Cervical cancer Flashcards
Cervical cancer, percentage of total female cancers
13% of gyn cancers
4% when including breast cancer
Risk factors for cervical disease
- Sexual activity (includes HPV infection)
- Immune deficiency (HIV, steroids, smoking)
- Poor screening
Usual presentation of early cervical cancer
Abnormal screening
Progression of squamocolumnar junction over time
Recedes into endocervix
Endocervix cell types
Columnar
Ectocervix cell types
Squamous
Alternative HPV testing guideline for paps
HPV alone every 5 years starting at 25 y/o
When to discontinue pap screening
65 y/o IF no hx of CIN2-3 in last 20 years, no hx of cervix cancer, no DES
Koilocytosis is pathognomonic for ___
LSIL
Proportion of cervical cancer caused by HPV 16/18
70%
Low-risk HPV associated with condyloma and CIN1
HPV 6/11
Duration of HPV infection
Median 8 mos
70% resolve by 12 mos
>90% resolve by 24 mos
Progression of HPV to invasive cancer takes how long?
10-20 yrs
Advantage to HPV primary screening
Sensitive (good NPV), improve detection of glandular cell abnormalities
Disadvantage to HPV primary screening
Low specificity (low PPV), increased referrals for colpo
Trial that made HPV primary testing more acceptable
ATHENA
Acetowhite epithelium is ___
Intracellular keratin
How Lugol’s works
Stains glycogen brown in normal cells
What Lugol’s shows better
Vessels
Dysplasia development histologically
Starts at the basement membrane and makes its way to the epithelial surface (CIN1 is one layer at membrane and CIN is almost to surface (CIS includes epithelium)
Indications for ECC
Inadequate colpo, concern for endocervical extension
Cure rate of conization (LEEP, CKC, laser cone)
95%
When not to do laser ablation or cryotherapy
If colpo unsatisfactory
When to do conization
CIN 2-3 or high-grade screen with low-grade histology
Outcomes from positive margins following excision
67% resolve spontaneously
Management for positive margins following excision
Pap + ECC in 6 mos (then repeat excision if CIN 2-3) OR just repeat excision in 6 wks (preferred only for AIS)
What if CIN1 persists beyond 2 yrs?
Continue follow-up vs excision
At what age does endometrial cells on pap matter?
40 y/o
What to do if premenopausal with endometrial cells on pap?
Asymptomatic > routine follow-up
Symptomatic > endometrial sampling
What to do if postmenopausal with endometrial cells on pap?
Endometrial sampling regardless of symptoms
What to do for AGC
HPV test, colpo, and ECC; add endometrial sampling if >35 y/o or risk factors
What to do for atypical endometrial cells
HPV test, colpo, ECC, endometrial sampling
What to do if AGC or AIS and no e/o invasive disease
Excisional procedure
What to do if AIS on excisional procedure
Hysterectomy vs cautious observation if fertility desired
LEEP during pregnancy?
Acceptable for CIN3 vs waiting till 6 wks postpartum
When to start screening for HIV pos
Within one year of starting sexual activity
When to stop screening for HIV pos
Never
What is more common in HIV with CD4<500?
Glandular cell abnormalities
Conization should be done before hysterectomy in setting of CIN IF…
Unsatisfactory colpo
Suspicion for cancer
ECC w/ CIN2-3
Evidence of high-grade glandular neoplasia
Proportions of squamous vs adenocarcinoma of cervix
Squamous 70%
Adeno 20-25%
Tools for FIGO staging of cervical cancer
EUA, cystoscopy, proctoscopy, IVP, CXR (or may substitute CT or PET)
Mnemonic for cervical cancer staging
Down and out
FIGO stage I-IV locations
I - cervix
II - uterus / upper vagina
III - lower vagina / pelvic sidewall
IV - outside of pelvis
Survival rates by staging
I - 90%
II - 70%
III - 40%
IV - 15%
Stage I divisions
IA1 - <3 mm IA2 <5 mm IB1 >5 mm and <2 cm wide IB2 >5 mm and 2-4 cm wide IB3 >5 mm and > 4 cm wide
Stage II divisions
IIA1 - upper 2/3 vagina, <4 cm
IIA2 - upper 2/3 vagina, >4 cm
IIB - parametrial involvement
Stage III divisions
IIIA - lower 1/3 of vagina
IIIB - pelvic sidewall
IIIC1 - pelvic LN
IIIC2 - paraortic LN
Stage IV divisions
IVA - adjacent organs
IVB - distant spread
Treatment for IA1
Hysterectomy
Treatment for IA2
Modified radical hysterectomy + PLND
Treatment for IB1
Rad hysterectomy + PLND
Treatment for IB2 and above
Chemo-RT + brachytherapy
Most common early complications of radical hysterectomy
UTI, ileus, fever, DVT
Most common late complications of radical hysterectomy
Urinary retention, lymphedema, sexual dysfunction
When to use radiation as adjuvant therapy
Positive LN at time of surgery, risk factors like large tumor, deep invasion, parametrial extension, positive margins
How chemoradiation works
Low-dose chemo sensitizes cells to radiation
Management of acute bleeding in cervical cancer
Vaginal packing with Monsel’s
Embolization
“Hot shot” or traditional brachytherapy
How to treat cervical cancer at 24 wga or above
Consider neoadjuvant chemotherapy
Deliver by Classical C/S
How to treat cervical cancer <24 wks and no desire to continue pregnancy
Stage I-IIA: rad hyst + LND
Stage IIB - IVA: pelvic chemo-RT, SAB vs D&E, brachytherapy
Surveillance post-treatment for cervical cancer
Every 3 months x 2 yrs
Every 6 mo to 5 yrs
Annually after that
What to do for vaginal bleeding after radiation treatment for cervical cancer
Colpo, pack with Monsel’s, embolization, hysterectomy (last resort because risk for complications)
Treatment for central recurrence
Radiation (if s/p rad hyst) Pelvic exenteration (if s/p radiation)
Treatment for lateralized pelvic recurrence
Chemo-RT (if s/p rad hyst)
Chemo (if s/p radiation)
Treatment for distant recurrence
Systemic chemo
