Cervical Cancer Flashcards

1
Q

What is ectropion?

Why does it occur?

A
  • during puberty, rising levels of oestrogen cause the cervix to evert
  • the columnar tissue lining the cervical canal is everted onto the surface of the cervix
  • the area of columnar tissue in the centre of the cervix is known as ectopy / ectropion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the transformation zone?

How is it related to ectropion?

A
  • the columnar cells on the surface of the cervix undergo squamous metaplasia
  • this is a normal process caused by acidic conditions in the vagina
  • the point where the columnar cells transform into squamous cells is the transformation zone
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How might cervical intraepithelial neoplasia (CIN) develop?

A
  • CIN can develop if oncogenic HPV affects the transformation zone
  • CIN forms instead of normal squamous tissue
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Where are samples taken from in cervical screening?

When can this be difficult?

A
  • samples are taken from the transformation zone of the cervix
  • this is more difficult in postmenopausal women
  • the transformation zone is not visible with a speculum as it retracts
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the most common cause of cervical cancer?

A

human papilloma virus (HPV)

  • this is a sexually transmitted infection
  • types 16 and 18 are responsible for 70% cervical cancers
  • most cases of HPV resolve spontaneously within 2 years

it is also associated with anal, vulval, vaginal, penis, mouth + throat cancers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the vaccination schedule against HPV?

A
  • 12- and 13- year old girls are offered a bivalent vaccine against HPV 16 + 18
  • this prevents 90% genital warts and 60-70% CIN
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the risk factors for cervical cancer associated with increased risk of catching HPV?

A
  • unprotected sex
  • sexually active from a young age
  • multiple sexual partners
  • sexual partners who have had more partners
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the biggest risk factor for cervical cancer?

A

non-engagement with cervical screening

  • many cases of cancer are preventable with early detection + treatment of precancerous changes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the other risk factors associated with cervical cancer?

A
  • smoking
  • HIV (immunosuppression)
  • COCP use for > 5 years
  • increased number of full term pregnancies
  • family history
  • exposure to diethylstilbestrol during fetal development (used prior to 1971)

people with HIV are offered yearly smear tests due to increased risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the presenting symptoms that may be associated with cervical cancer?

A
  • abnormal vaginal discharge (persistent, offensive, blood-stained)
  • abnormal bleeding (PCB, PMB or IMB)
  • dyspareunia
  • pelvic pain (late disease)

many of these symptoms are non-specific and NOT caused by cancer

PCB = post-coital bleeding
IMB = intermenstrual bleeding
PMB = post-menopausal bleeding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

If someone presents with cancer-associated symptoms, what should be done?

A

speculum examination

  • this allows visualisation of the cervix
  • swabs can be taken to exclude infection

this should be followed by bimanual and PR examination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What signs on speculum examination are red flags?

A
  • ulceration
  • inflammation
  • bleeding
  • visible tumour
  • if any of these are seen, an urgent 2WW referral for colposcopy should be made
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is involved in a cervical smear test?

A
  • a speculum is inserted and a small brush is used to collect cells from the transformation zone of the cervix
  • this aims to pick up precancerous changes (CIN) in the cervical epithelial cells
  • the cells are deposited in preservation fluid
  • they are examined under a microscope for dyskaryosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Before the cells from the smear test are examined microscopically, what is done?

A
  • the cells are initially tested for high-risk HPV
  • if this is negative, the cells are not examined
  • the woman is returned to the routine screening programme
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Who is offered cervical screening?

A
  • every 3 years aged 25-49
  • every 5 years aged 50-65
  • women > 65 can request a smear test
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How is dyskaryosis assessed?

A
  • nuclear enlargement
  • variation in size / shape of the nuclei
  • hyperchromasia
  • reduction in cytoplasm, altering the nuclear:cytoplasmic ratio
"clustering / layering up" of the cells can be seen

hyperchromasia - the nuclei appear dark / smudged / opaque when stained

17
Q

What else may be detected / reported on the smear result?

A
  • trichomonas
  • candidiasis
  • bacterial vaginosis
  • actinomyces-like organisms in women with an intrauterine device
18
Q

What are the 4 different potential outcomes of a smear test?

A

inadequate sample:

  • repeat smear after at least 3 months

HPV negative:

  • continue routine screening

HPV positive with normal cytology:

  • repeat HPV test in 12 months

HPV positive with abnormal cytology:

  • refer for colposcopy
19
Q

What is cervical intraepithelial neoplasia?

A
  • a grading system for the level of dysplasia (premalignant change) in the cells of the cervix
  • this is diagnosed at colposcopy, and not on screening

  • dysplasia is found during colposcopy
  • dyskaryosis is found on cervical smear test
20
Q

What is meant by CIN I?

A

mild dysplasia

  • this affects 1/3 thickness of the epithelial layer
  • likely to return to normal without treatment

  • when confined to the epithelial layer, this is a pre-invasive change
  • it becomes cancer when it invades below the epithelial layer
21
Q

What is meant by CIN II?

A

moderate dysplasia

  • this affects 2/3 thickenss of the epithelial layer
  • likely to progress to cancer if not treated
22
Q

What is meant by CIN III?

A

severe dysplasia

  • this affects the whole epithelial layer
  • very likely to progress to cancer
  • sometimes called cervical carcinoma in situ
23
Q

What is involved in colposcopy?

A
  • a speculum is inserted and a colposcope is used to magnify the cervix
  • the whole transformation zone is examined
  • stains - aceitic acid and iodine solution - are used to differentiate abnormal areas
24
Q

Why is acetic acid used and what is a positive result?

A
  • abnormal cells will stain white (acetowhite)
  • this occurs in cells with increased nuclear-to-cytoplasmic ratio
  • e.g. CIN / cervical cancer
25
Q

What is involved in Schiller’s iodine test?

A
  • an iodine solution is used to stain the cervix
  • healthy cells will stain brown
  • abnormal areas will not stain
26
Q

How is a biopsy taken during colposcopy?

A
  • a punch biopsy
  • or a large loop excision of the transformational zone (LLETZ)
27
Q

What is involved in a large loop excision of the transformational zone (LLETZ)?

A
  • local anaesthetic is given during colposcopy
  • a loop of diathermy wire is used to remove abnormal epithelial cells
  • the electrical current cauterises the tissue to prevent bleeding
28
Q

What advice is given to women following a LLETZ procedure?

A
  • bleeding / abnormal discharge can occur for several weeks following the procedure
  • avoid tampon use / sexual intercourse due to increased infection risk
  • increased risk of preterm labour
29
Q

What is involved in a cone biopsy?

A
  • a cone-shaped piece of the cervix is removed using a scalpel
  • the sample is sent for histology to assess for malignancy

  • this can lead to pain, bleeding and infection
  • scar formation can lead to stenosis of the cervix
  • increased risk of miscarriage / preterm labour
30
Q

How common is cervical cancer and what is the survival like?

A
  • 12th most common cancer in women
  • most common in women under 35
  • 67% 5-year survival
  • 90% survival in women < 40

uterine and ovarian cancers are more common

31
Q

What other organs does cervical cancer tend to spread to?

A

direct / local spread:

  • vagina
  • bladder
  • parametrium
  • bowel

bloodborne spread:

  • lungs + liver
32
Q

What lymph nodes does cervical cancer tend to spread to?

A
  • parametrial nodes
  • internal, external + common iliac nodes
  • obturator nodes
  • pre-sacral nodes
  • para-aortic nodes
33
Q

What staging system is used for cervical cancer?

A

international federation of gynaecology and obstetrics (FIGO) staging system

34
Q

What are the 4 stages of cervical cancer according to FIGO?

A

stage 0:

  • carcinoma in-situ / CIN

stage I:

  • confined to the cervix

stage II:

  • invades upper 2/3 of vagina or uterus

stage III:

  • invades pelvic wall or lower 1/3 of vagina

stage IV:

  • invades bladder, bowel or beyond the pelvis
35
Q

What is the management for early stage cervical cancer?

A
  • radical hysterectomy with removal of local lymph nodes
  • this is followed with chemotherapy + radiotherapy
  • if women require future fertility, cone biopsy can be repeated with pelvic node dissection
36
Q

What is the current vaccination programme for HPV?

A
  • it is given to all girls and boys around the age of 12-13
  • this is before they become sexually active
  • strains 6 and 11 cause genital warts
  • strains 16 and 18 cause cervical cancer