Cervical Cancer Flashcards
The aim of cervical screening is to identify the precursors of cancer. What does it screen?
How is it reported
HPV screening, and if positive, cytological/cellular examination occurs for dyskaryosis where the Bethesda score and degree of dyskaryosis is determined.
Bethesda is reported as LSIL - Low grade squamous intraepithelial lesion or HSIL - High grade
Dyskaryosis is reported as mild, moderate and severe
What are the RFs for CIN?
RF for HPV: Sexual activity with multiple partners, IVDU, immunisuppression (HIV, transplant), smoking, dialysis, other STIs
State all the steps from cervical screening till diagnosis
1) Cervical smear for HPV and Cytology reports for dyskaryosis and bathesda grading
2) Referral to colposcopy, put dyes, looking for features of CIN, Take punch or excisional biopsy via LLETZ and send to histology
3) Histology report will give CIN staging
4) MDT discussion based on results
80% of women will clear HPV virus within 2 years. Go over the full screening protocol for Cervical screening
HPV test is performed.
If negative, normal screening protocol=> 25-29 every 3 years, 30-60 every 5 years, 61+ complete
If positive, cytological examination for dyskaryosis is performed.
If no abnormalities detected: 1st time -> repeat in 3 months. If 2nd time Colposcopy
If abnormalities detected -> Colposcopy
If indeterminate on either HPV or cytology: 1st and 2nd time -> repeat in 3 months. 3rd time -> colposcopy
If Immunisuppresion/renal dialysis: Normal screening is every year. If positive HPV, do colposcopy
Explain the pathophysiology of Cervical intraepithelial neoplasia
Squamous metaplasia is the normal physiological process in puberty whereby oestrogen causing eversion of the endocervix, exposing it to the vaginal environment => metaplasia occurs causing the columnar cells to change into squamous epithelium in the transformation zone.
With HPV, CIN is in the transformation zone instead of typical squamous epithelium
Who gives the CIN score?
Histopathologist
What dyes are used in colposcopy?
1) Aceto-white/acetic acid staining protein white where there is increased about of protein in CIN => more white
2) Iodine stain which stains glycogen brown. Abnormal cells have less glycogen stores => less brown
What is colposcopy. Explain what is done
What are its indications?
An outpatient examination of the cervix indicated by an abnormal smear test, where the examiner visualizes the cervix and applies acetowhite and iodine brown dyes to more closely identify. Its a binocular-shaped scope that can magnify the field of view.
1) The physician identifies colposcopy features associated with CIN
2) Obtain a tissue biopsy via bunch of excisional biopsy (3) of any abnormally appearing areas and sent to histopathologist
3) If colposcopy features are equivalent to a high grade intraepithelial lesion (moderate-severe dyskariosis) then a LLETZ procedure with excisional biopsy send to the lab
Indications:
3rd indeterminate result
2nd negative cytology report
1st positive cytology report
positive HPV in those with immunosuppression or on renal dialysis
What features on colposcopy are associated with CIN?
Classify the features according to relevant CIN scoring
1) Aceto-white staining looking at intensity and borders of stain
2) Abnormal vascular patterns including punctuation and mosaicism
3) Branching
CIN 1 - Faint acetowhite staining + irregular borders
CIN 2 - Dense Acetowhite staining + regular borders
CIN 3 - CIN 2 + Abnormal vascular patterns (Punctuations and mosaicism)
SCC/invasive disease - CIN 3 + Branching
What is the LLETZ procedure?
What are the risks associated with LLETZ?
What are some alternatives
Large loop excision of Transformation zone. This is an excisional biopsy with See and Treat. This aims to completely excise the abnormal areas with!!! negative margins to reduce the likelihood of recurrence
Risk: Although 1 LLETZ procedure should not affect fertility, multiple can cause cervical incompetence => midtrimester pregnancy loss or preterm delivery. Treat with cervical cerclage
Alternatives: Cone biopsy, Cryotherapy, CO2 laser vaporization
After a LLETZ procedure it is important to advise the woman to return and seek medical help if she experiences heavy bleeding or has a temperature. It is also important to advise her to avoid heavy exercises, sexual intercourse, swimming etc for 48 hours. In the mean time, the histology report returned giving the CIN score. What is the score based off and what are the components?
What is the next step after this?
The histopathologist looks at the grade, determining the proportion of abnormal epithelium and microscopic features that would indicate a more malignant form. It will also define the type of neoplasia (squamous or Adenocarcinoma)
CIN I -> CIN2 -> CIN3 -> Cervical carcinoma
a) Grade: Lower 1/3 -> lower 2/3 -> Full thickness -> Breaches basement membrane
b) Microscopic features: Increasing N:C ratio, increased proportion of cells undergoing mitosis, hyperchromic nuclei, and decreasing differentiation
Oncology MDT
What is the etiology of Cervical cancer?
99.7% are due to HPV causing precursor lesions
What is the parametrium
Fat and connective tissue around uterus
State the FIGO staging of Cervical cancer (OSCE modified)
I - Confined to cervix
II - Invasion beyond uterus to vagina and later parametrium
III - Further invasion to pelvic side-wall obstructing ureters causing hydronephrosis and anuria (B) + LN metastasis (C)
IV - Extension beyond the pelvis to adjacent (bladder and rectum) and distant organs (lung and liver)
What are the risk factors for cervical cancer?
Those of HPV:
High sexual activity with multiple partners
unprotected sex (Barrier protection)
HIV/Transplant patients
IV drug users
Renal dialysis
+Smoking
+ COCP use
