Cervical cancer Flashcards
1
Q
Types of cervical cancer
A
- Squamous cell carcinoma (66%)
- Cervical adenocarcinoma (15%)
2
Q
Aetiology of cervical cancer
A
- Persistent infection with human papillomavirus (HPV)
- Types 16 and 18 (~70%)
Oncogenic HPV infection → Viral gene integration → Uncontrolled cell proliferation → Cervical intraepithelial neoplasia (CIN) → Cervical cancer
3
Q
Natural history of HPV infection and cervical cancer
A
- HPV infection is extremely common, particularly in young girls who are sexually active
- Most infections clear spontaneously after weeks or months
- Persistent HPV infection may lead to pre-malignant disease of the cervix (CIN)
- Regression of pre-malignant lesions does occur, more common in women <30
- Cervical cancer is a late, rare complication of persistent HPV infection
- Can take 10-15 years to develop
4
Q
Risk factors for cervical cancer
A
- Acquiring HPV infection, particularly types 16 and 18
- Multiple sexual partners
- Early first intercourse
- Partner with multiple sexual partners
- Not using a condom
- Immunocompromised
- Inadequate cervical screening
Risk factors for progression to cervical cancer:
- Smoking
- High parity (>5)
- Prolonged use of COCP
5
Q
Complications of cervical cancer
A
- General
- Pain
- Nausea
- Fatigue
- Urinary/faecal incontinence
- Loss of fertility
- Malodour
- Sexual problems (and following treatment)
- Loss of libido / change in sexual activity
- ↓ capacity for orgasm
- Vaginal dryness / bleeding / dyspareunia
- Atrophic vaginitis
- Lymphoedema
- Advanced disease
- Pain.
- Renal failure from bilateral ureteric obstruction.
- Deep vein thrombosis.
- Haemorrhage
- Malodour due to necrotic tissue.
- Fistulae (vesicovaginal, rectovaginal)
6
Q
Clinical features of cervical cancer
A
- Asymptomatic
-
Non-menstrual bleeding
- Intermenstrual bleeding.
- Postcoital bleeding (risk of cervical cancer increases with age).
- Postmenopausal bleeding.
- Blood-stained vaginal discharge.
- Pelvic pain/dyspareunia.
- On examination
- Cervix may appear inflamed or friable and bleed on contact
- Visible lesion
- Foul smelling, blood-stained discharge
7
Q
Cervical screening and prevention
A
- Screening
- Age 25 - 49 (every 3 years)
- Age 50 - 64 (every 5 years)
- Women >65 continue screening if a recent smear is abnormal, until 3 negative cytology results, or if they have not been screened since 50
- Prevention
- HPV vaccine (girls 12-13 years old)
- Gardasil (3 doses IM over ~6 months)
- 16 and 18
- 6 and 11 (genital warts)
- Cervarix
- 16 and 18 only
- Gardasil (3 doses IM over ~6 months)
- HPV vaccine (girls 12-13 years old)
8
Q
Why not screen girls <25 years old?
A
- Incidence of HPV infection will be high in this population
- Screening this age group will pick up low grade CIN
- Screening <25 year old women would lead to unnecessary anxiety, colposcopy and treatment for lesions that may have resolved spontaneously
- Don’t know which high grade lesions to treat, so treat them all
- Treatment can affect future fertility
- No evidence that screening this age group improves survival
9
Q
Differential diagnosis of cervical cancer
A
- STIs (chlamydia and gonorrhoea)
- Cervicitis
- PID
- Lower abdo pain
- +/- fever
- Adnexal tenderness
- Cervical excitation
- Endometrial cancer
- Postmenopausal bleeding
- Ectropion (cervical eversion)
- Cervical polyps
- Post-coital bleeding
- Hormonal contraception
- Unscheduled bleeding (particularly when first prescribed)
10
Q
Investigations for cervical cancer
A
- Smear
- Cytological diagnosis - Dyskaryosis (abnormal nuclei)
- Negative
- Abnormal
- Borderline
- Mild, moderate, severe
- Cytological diagnosis - Dyskaryosis (abnormal nuclei)
- Vaginal or speculum exam
- Mass or bleeding
- Colposcopy
- Abnormal vascularity
- White change with acetic acid
- Biopsy
- Histological diagnosis
- CIN I, II, III
- Histological diagnosis
- CT / MRI to stage carcinoma
11
Q
Management of cervical cancer
A
CIN
- Local excision or ablation
- Cervical cancer
- Hysterectomy (simple or radical)
- Chemotherapy (cisplatin) and radiotherapy
- Preservation of fertility
- Cervical conization (excision)
- Large loop excision of transformation zone (LLETZ)
- +/- lymphadenectomy
12
Q
Complications of LLETZ
A
- Bleeding
- Infection
- Cervical stenosis
- Cervical incompetence → midtrimester miscarriage & preterm labour
13
Q
Follow up of cervical cancer
A
- Cytology +/- colposcopy at 6 months
- Cytology at 12 months and anually for 10 years following treatment
- Test of cure (new)
- HPV test at 6 months
- HPV test + cytology at 12-18 months post treatment
- If all 3 tests are negative, return to routine recall
14
Q
Abnormal cervical smear cytology results
A
-
Negative
- Routine recall
-
Borderline/Mild dyskaryosis
- Smear sample tested for HPV
- High-risk HPV +ve → Colposcopy
- -ve → routine recall
-
Moderate
- Colposcopy
-
Severe
- Urgent colposcopy (within 2 weeks)
15
Q
Cervical smear explanation
A
- What is the smear test?
- The smear test is a means of preventing cervical cancer
- During the smear test, a sample of cells is taken from the cervix using a small plastic brush. The cells are then examined under a microscope to look for early changes that, if left untreated, could develop into cancer of the cervix.
- So the smear test is not a test for cervical cancer, it is a test to detect early changes that may lead to cancer if left untreated.
- Will an abnormal result mean I will get cancer?
- 1 in 20 women will have an abnormal smear that requires further investigation. The majority of these will not lead to cervical cancer. Some will resolve spontaneiously, and some will require very simple treatment that will prevent cervical cancer.
- So this highlights the importance of having your smear done regularly so that early treatment can be implemented if needs be.
- How often should I have my smear test?
- First invitation at 25
- 25-49 - every 3 years
- 50-64 - every 5 years
- > 65 - no need unless previous abnormal results
- What do the results of the smear mean?
- The results will test to see the degree of change in the cells, and also the presence of HPV, a virus which is involved in the development of cervical cancer
- HPV is passed on through intercourse, although the majority of cases will resolve spontaneously. Certain types of the virus, however, are more troublesome than others, so we test for them too
- Results
- Normal
- Routine recall
- Inadequate
- Need to be repeated (3 in a row → colposcopy)
- Borderline/mild
- Unlikely to develop cancer
- HPV +ve require colposcopy
- Moderate
- Unlikely, but might need treatment
- Colposcopy
- Severe
- Likely to need treatment
- Urgent colposcopy (2 weeks)
- Normal
- What is colposcopy?
- More detailed exmamination of the cervix
- A special microscope is used to look at the cells in more detail
- Biopsies may be taken to allow even more detailed analysis