Cervical Cancer Flashcards
M/C cancer in women in India
Ca breast > Ca cervix
M/C genital cancer of women in India
Ca cervix
Most common cause of Ca Cervix
HPV - 99%
Screening method used for Ca cervix
Pap smear
Pap smear is taken from which area and Procedure
Done at transformation zone (area b/w endocervix and ectocervix) - then plate them on slide - fixed with 95% alcohol - solution passed through filter - Cells from transformational zone gets filtered
Instrument used for Pap smear
Ayre’s spatula
Also cytobrush and Cytobroom can be used - Liquid based Cytology
Sensitivity of Pap smear as screening method for Ca cervix
47-62%
Incidence has reduced by 75 to 80%
Death reduced by 70%
Most common type of HPV responsible for Ca cervix and Also most malignant HPV
M/C - HPV 16
Most malignant - HPV 18
Transformation zone means
Area between columnar epithelium and Squamous epithelium where columnar cells are converting constantly into Squamous cells
Transformation is how much cm away from external os
1.7 to 2.3cm
When to do Pap smear
For >21 years all women
In India, usually 3 years after begining of sexual activity
21-29 yrs : once in 3 years if Pap smear is negative
Risk factors of Ca Cervix
HIV 1 and 2
HSV 1 and 2
Commercial sexual workers
Partners with STDs
Multiparous women
Immunocompromised
Low socioeconomic status
Smokers
Early Intercourse (<16 yrs) - more exposure
Pap smear frequency after 30 yrs of age and other tests done
Once in 3 years if Pap smear is negative
Co Test - Pap + HPV DNA - once in 5 yrs
Pap smear after 65 yrs of age
Stop doing pap smear, specially if Last 3 pap smears are negative or 2 Co tests went negative
Stain used to see pap smear on microscope
Papanicolaou stain
Abnormal finding in Pap smear
Big nucleus
Reversal of nucleus cytoplasmic ratio
Dysplasia classification
If <1/3 Abnormal cells - Cervical inter epithelial Neoplasia 1 (CIN 1)
If >1/3 and <2/3 Abnormal cells - CIN 2
If >2/3 cells are Abnormal - CIN 3
If all cells are Abnormal - Carcinoma insitu
Bethesda classification
Low grade Squamous interepithelial lesion (LGSIL) - CIN 1
High grade Squamous interepithelial lesion (HGSIL) - CIN 2,3, Carcinoma insitu
CIN 1 can change into CIN 3 and CIN 3 to Ca cervix in how many years
CIN 1 to 3 - 5 years
CIN 3 to Ca cervix - 10 years
What to do if CIN 1 is +ve on Pap smear
CIN is not a precursor
Frequent pap smear once in 6 months
Antiviral or antibiotics
HPV DNA Assessment
Precursors of Ca Cervix
CIN 2 and 3
What to do if CIN 1 +ve for > 2 years
Continue surveillance or
Ablation/treatment
Which test need to do confirm CIN 3
Colposcopic Biopsy or
Can do visual inspection under Acetic acid or Lugol’s iodine
Colposcopic Biopsy procedure
Vaginal Examination under illumination and magnification
Can see if there is any abnormal area
Highlighters used in case of Colposcopic Biopsy to see abnormal areas and Findings
1) Acetic acid - Rapidly dividing areas will become white ij color (Acetowhite areas) - take sample
2) Schillers or Lugol iodine - Stains glycogen rich areas - become Mahogany’s brown color - sample is taken from unstained areas
CIN 3 management if Biopsy finding shows some cells already invading into stroma of cervix
Invasive cancer cervix
Treatment - Radical Hysterectomy
CIN 3 Management if Biopsy finding shows abnormal cells only in surface, no invasion
Biopsy Proven CIN 3
Management -1) Excision of transformation using a large loop AKA Loop electrosurgical excision procedure (LEEP)
2) Laser ablation - requires too much training, expensive
3) Cryocautery
Management of CIN 3 for >35 yrs and >40 yrs patient
> 35 yrs - Conization
40 yrs - Hysterectomy
Clinical features seen in Ca Cervix
Abnormal vaginal bleeding (M/C postcoital)
Dirty foul smelling discharge
Uremia
Pain
Pyometra (Pus in uterus) - M/C bcz of Ca Cervix
Post Menopausal bleeding
Cancer cachexia
Diagnosis method used in case of GSIL/CIN 3, Post coital Bleeding or Carcinoma in situ
Colposcopic cervical Biopsy
Management in case of Adenocarcinoma in situ of cervix
Hysterectomy
Management in case of Vulval interepithelial neoplasia 3 (VIN 3)
Superficial excision or laser ablation
Staging of Ca Cervix is done
Done clinically
Per speculum exam
Per vaginal exam
Per rectal exam
Cystoscopy
Proctoscopy
Imaging - USG, CT, MRI, PET CT
Staging Of Ca Cervix
Stage 1 - Stage 1A (1A1 And 1A2) , Stage 1B (1B1, 1B2 And 1B3)
Stage 2 - Stage 2A (2A1, 2A2), Stage 2B
Stage 3 - Stage 3A, Stage 3B, Stage 3C (C1 and C2)
Stage 4 - Stage 4A, Stage 4B
Stage 1 of Ca Cervix
Limited to Cervix
Stage 1A - Microscopic cancer, A1 - Depth <3mm, A2 - 3-5mm
Stage 1B - Macroscopic/Clinically obvious, B1 - <2cm, B2 - 2 to 4cm, B3 - >4cm
Stage 2 of Ca cervix
Vaginal involvement
Stage 2A - Upper vagina, 2A1 - <4cm, 2A2 - >4cm
Stage 2B - Parametrial Involvement
Stage 3 of Ca cervix
Stage 3 A - lower 1/3rd vagina
Stage 3B - Parametrial involved till pelvic sidewall - ureter might get compressed (Hydronephrosis)
Stage 3C - C1 - Pelvic LN involvement
C2 - Paraaortic LN involvement
Stage 4 of Ca cervix
4A - Bowel and bladder involvement
4B - Distant metastasis
Most common stage of presentation of Ca cervix in India
Stage 3B
Which area of cervix is M/C involved in Ca cervix
Anterior lip of Cervix
Radiotherapy can be done for which stages in case of Ca Cervix
Good for all stages
Chemo radiation is provided in which stages of Ca Cervix
Stages >2B Or >2A2
Treatment of Stage 1A1 without lymphovascular space invasion
Conization or Extrafascial Hysterectomy
Treatment of Stage 1A1 With Lymphovascular space invasion
Radical Trachelectomy or Radical hysterectomy + Pelvic Lymphadenectomy or sentinel LN biopsy (Ext. Iliac LN > Obturator LN)
Treatment of Stage 1A2 and 1B1
Stage 1A2 - >3mm <5mm
Stage 1B1 - >5mm <2cm
Radical Trachelectomy or Radical hysterectomy + Pelvic Lymphadenectomy or sentinel LN biopsy
Treatment of Stage 1B2
> 2cm <4cm
Radical hysterectomy + Pelvic Lymphadenectomy
Treatment of Stage 1B3
> 4cm
Chemo radiation
Treatment of Stage 2A1
<4cm + upper vagina
Radical hysterectomy + Pelvic Lymphadenectomy or chemoradiation
Treatment of Stage 2A2
> 4cm + upper vagina
Chemoradiation
Most common histopathology form of Ca Cervix
Squamous cell carcinoma
Histopathological variants of Ca cervix
Squamous cell carcinoma
Large cell keratising
Large cell non keratising
Small cell variant
Adenocarcinoma cervix
M/C cause of death in Ca cervix
Uremia
2nd and 3rd M/C cause of death in case of Ca Cervix
2nd M/C - Hemorrhage
3rd M/C - Infection
Vaccine for prevention of Ca Cervix and Variants protected by them
Cervarix - 16,18
Gardasil - 6,11,16,18
Gardasil 9 - 9 valent (6,11,16,18 + 31,33,35,45,52,58) - Given to 9-45 years all women
Gardasil 9 effectiveness before and after exposure
Before exposure - 90% effective
After exposure - 40% effective
Gardasil 9 schedule
0 day - 2 months - 6 months
Treatment if pregnant women shows Malignant cell +v3 on pap smear
Conization for confirmation (done >12 wks) - abortion chances decreases
Treatment of Stage 1A in Pregnant women
Go till term - C section - Radical hysterectomy + Lymphadenectomy
Treatment in case of Stage 1B in Pregnant women
Fetal lung maturity >28 wks - C section - Radical Hysterectomy + Lymphadenectomy
4 week wait maximum
Treatment of Stage 2 to 4 in Pregnant women
Radiotherapy
Beyond 28 wks - C section - Radiotherapy
1st trimester - Radiotherapy (Baby will abort himself)
2nd trimester - Try and see if gets viability
