Cervical cancer Flashcards
Types of cervical cancer
squamous carcinoma ~75%
adenocarcinomas
Cervical cancer oncogenesis
Viral transformation of surface epithelial cells by high risk HPV 16, 18, 31
2 viral gene products (E6, E7) interact with p53 and pRB –> affect control mechanism of cell cycle
Natural history of cervical cancer
Dysplasia - mild/moderate/severe
Carcinoma in situ
micro-invasive carcinoma
Risk factors of cervical cancer
HPV, smoking squamous cell requires sexual intercourse Early sex (
Spread of cervical cancer
local extension
lymphatics
SSx of cervical cancer
bleeding
discharge
Diagnosis of cervical cancer
Biopsy: suspicious lesions regardless of cytology
Colposcopy: magnifying instrument
Cone biopsy: suspicious or + cytology and no lesion found
Staging of cervical cancer
clinical
Tx cervical cancer - early
cryotherapy
laser therapy
electrosurgical loop excision
Tx cervical cancer, Stage
cone biopsy
hysterectomy + nodes
Tx cervical cancer, late >Ib2 (locally advanced)
radiation +/- chemo
Followup cervical cancer
adjuvant radiotherapy if pelvic nodes are involved
extension outside cervix
close margins
Squamocolumnar junction development until puberty
originally situated in region of external os
Before puberty: pH is alkaline; afterwards, breakdown of glycogen in vaginal/cervical squamous epithelium –> acidic pH
Puberty: endocervical epithelium extends distally into acid environment of vagina, forms ectropion
Transformational zone forms as squamous epithelium regrows over ectropion
penings of crypts may be obliterated in process and result in formation of mucus-filled Nabothian follicles
Transformation zone of the cervix
Zone of metaplastic squamous epithelium that extends from original squamocolumnar jxn to current squamocolumnar jxn –> new squamous epithelium in area previously columnar
Increasing age: squamocolumnar jxn moves superiorly as metaplastic squamous epithelium replaces endocervical glandular epithelium (jxn higher up in cervix)
Pap smear sampling
Do not use lubricant
If squamocolumnar jxn is visible: rotate spatula through 360, fixation not necessary
If not visible: spatula for exocervix. Cytobrush 180 degrees for endocervix; smear and fix
Pap smear cautions/clinical notes
Cytobrush not recommended in pregnant patients
If clinically suspicious specimen seen - biopsy immediately
reschedule if menstruation/infection present
Irregular bleeding may be a symptom of gynecological malignancy –> do a pelvic examination + appropriate investigations
Ideal patient conditions for screening
Patient has not douched vagina for 48 h before screening
Patient has avoided use of contraceptive creams/jellies for 48 h
Smears not recommended during menstruation
mid-cycle optimal
Patient should be informed that date of LMP is required
Cervical cancer screening recommendations - starting
Onset of sexual activity/soon after (21, or +3 after onset of sexual activity)
Smear q12 mo until 3 consecutive normal, then continue q24 mo
Cervical cancer screening recommendations - abnormal cytology
Mild dyskaryosis: repeat 6 mo. Colopscopy recomm if mild atypia persists for 2 y
Moderate/higher dyskaryosis: colposcopic exam recommended
Cervical cancer screening recommendations - older
> 69 y:
stop screening if >=3 normal smears in the last 10 y and no history of previous significant abnormality (moderate atypia or higher)
Cervical cancer screening recommendations - special populations
Pregnant women:
- if no history of previous Pap, do Pap
- otherwise follow guidelines of normal popn
HIV positive:
- repeat smear in 6 mo until 2 consecutive normal smears
- then continue q12 mo
Dysplasia
Histological finding
need biopsy for structure
Dyskaryosis
Cytological abnormality
result from Pap smear
Mild squamous dyskaryosis/mild endocervical glandular atypia management
Repeat smear q6mo
if abnormal cytology persists for 2 y, refer to colposcopy
If mild dysplasia (CIN1) confirmed at colposcopy, follow with repeat Pap in 6 mo
Low grade epithelial abnormalities from Pap
mild squamous dyskaryosis
mild endocervical glandular atypia
High grade epithelial abnormalities from Pap
moderate squamous dyskaryosis marked squamous dyskaryosis Suspicious for squamous cell carcinoma in situ malignant squamous cells moderate endocervical glandular atypia marked endocervical glandular atypia cells suspicious for endocervical carcinoma seen malignant glandular cells seen
High grade epithelial abnormality (Pap) management
Refer to colposcopy and directed biopsy
If moderate dysplasia/severe dysplasia/carcinoma in situ (CIN2-3) confirmed, tx by gynecologist
If microinvasion present, refer to gyne/gyne oncologist
If frank invasion present, refer to gynecologic oncologist
Cervical ca Stage I
confined to cervix
Cervical ca stage II
beyond uterus but not to the pelvic wall/lower 1/3 of vagina
Cervical ca stage III
extends to pelvic wall, and/or involves lower 1/3 of vagina and/or causes hydronephrosis or non-functioning kidney
Cervical ca stage IV
carcinoma has extended beyond true pelvis or has involved (biopsy proven) the mucosa of the bladder/rectum
LSIL
low grade squamous intraepithelial lesion
- possible cervical dysplasia
- usually associated with CIN-1 on biopsy
- likely caused by HPV infection
- watchful waiting
- can do colposcopy if HPV +ve, or repeat cytology in 6 mo
- low risk of invasive cancer
HSIL
high-grade squamous intraepithelial lesion
possible cervical dysplasia
associated with CIN2, 3, or carcinoma-in-situ
follow up with colposcopy and biopsy
tx usually LEEP/cryotherapy/laser ablation
2% associated with current invasive cancer
20% will proceed to invasive ca without treatment
CIN1
corresponds to LSIL cytology
mild dysplasia and abnormal cell growth (minimal)
confined to basal 1/3 of epithelium
corresponds with HPV infection - can be transient/cleared by immune activity
If not cleared, can progress to CIN-2
CIN-2
moderate dysplasia
spans more than 2/3 of epithelium or up to full thickness
can sometimes be called cervical carcinoma in-situ
can progressive to invasive cancer
HPV vaccine efficacy
bivalent/quadrivalent prevent 70% of cervical cancers
but difficult to get everyone to have 3 doses, so lower efficacy irl
Spontaneous clearing of HPV infection
majority cleared within 24 mo
