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Clin Med 3 - Exam 3 (Women's Health) > Cervical Cancer > Flashcards

Cervical Cancer Flashcards

1
Q

what are the 2 types of cells of the cervix?

A

glandular cells and squamous cells

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2
Q

what is cervical cancer caused by?

A

HPV

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3
Q

what is necessary for development of cervical neoplasia, but when alone is not sufficient to cause cervical cancer? what does this mean?

A

HPV
-means that the HPV has to be there, but the HPV alone is not sufficient -> there are other factors that contribute to the cervical abnormalities (co-factors)

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4
Q

what are the 2 major factors associated with development of cervical intraepithelial neoplasia (CIN) and cervical cancer?

A
  1. HPV types

2. Age and Persistence

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5
Q

what are the low-risk types of HPV?

A

6 and 11

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6
Q

what are the high-risk types of HPV?

A

16 and 18 (16 is more prevalent)

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7
Q

what’s the deal with age and persistence in association with HPV?

A

women < 30 y/o can clear HPV infection

as you get older, prevalence of HPV decreases, but the persistence of HPV infection in older women increases (can’t clear the infection)

don’t know how women clear HPV infection

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8
Q

what factors is the likelihood of HPV persistence related to? what do they mean?

A

older age, duration of infection, high oncogenic HPV subtypes

  • women >55 y/o have persistence of high-risk HPV infections vs women < 25 y/o
  • longer an HPV infection as been recognized, longer it takes to clear
  • high-risk HPV types persist longer than low-risk HPV types
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9
Q

what are the risk factors for HPV infection?

A

sexual transmission, cervical transformation zone (T-zone), HPV molecule mechanisms

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10
Q

what is the site of the cervix where carcinogenesis occurs by HPV?

A

the cervical transformation zone (T-zone)

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11
Q

what is the transformation zone (T-zone) of the cervix?

A

it is the border b/w the stratified squamous epithelium of the ectocervix and the columnar epithelium of the endocervix

also called the squamocolumnar junction (SCJ) - where squamous epithelium meets the columnar epithelium

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12
Q

what are the phases of HPV infection?

A

Latent infection (first phase), Active infection, Neoplastic transformation

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13
Q

what is the Latent infection phase of HPV infection?

A

without physical, cytologic, or histologic manifestations

-HPV is not active (not replicating)

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14
Q

what is the Active infection phase of HPV infection?

A

HPV undergoes replication, but NOT integration of the genome

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15
Q

what is the Neoplastic transformation phase of HPV infection?

A

The virus can persist in the cytoplasm

OR

Integrates into the host genome -> when integration occurs, this is neoplastic transformation

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16
Q

at what phase of HPV infection is there replication, but NO integration of HPV into the genome?

A

Active infection

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17
Q

at what phase of HPV infection is there integration of HPV into the genome?

A

Neoplastic transformation

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18
Q

what are the co-factors in pathogenesis of HPV causing cancer?

A

Immunosuppression
-HIV infection, immunosuppressive therapy

Cig Smoking
-HPV and Smoking have a synergistic effect

Herpes and Chlamydia

Oral contraceptives

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19
Q

2 ways for detecting HPV?

A

HPV DNA Testing and HPV RNA Testing

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20
Q

what does HPV RNA testing look for?

A

looks for expression of E6 and/or E7 RNA

-onco-proteins that suppress tumor suppressor genes
(E6 interferes with p53 and E7 interferes with retinoblastoma tumor suppressor gene)

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21
Q

if get infection with HPV low-risk type (6 and 11), what is the clinical consequence?

A

genital warts

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22
Q

if get infection with HPV high-risk type (16 and 18), what is the clinical consequence?

A

premalignant or malignant lesions

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23
Q

what is p16 for cervical cancer?

A

it is a surrogate marker for high-grade or low-grade HPV

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24
Q

if p16 staining is positive, what does that mean? if p16 staining is negative, what does that mean?

A

positive = high-grade, means it is active

negative = low-grade, means it is NOT active

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25
Q

what does CIN 1 mean?

A

LSIL -> low-grade lesions

-means the lower 1/3rd of the epithelium is chaotic in structure

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26
Q

what does CIN 2 mean?

A

HSIL -> high-grade lesions

-almost 2/3rds of the epithelium is chaotic

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27
Q

what does CIN 3 mean?

A

HSIL -> high-grade lesions and includes CIS (carcinoma in situ)

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28
Q

what is the difference b/w CIN 3 and CIS?

A

CIN 3 = more than 2/3rds of the epithelium is chaotic

CIS = carcinoma in situ = entire epithelium is chaotic

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29
Q

what does ASC-US and ASC-H mean?

A

ASC-US
-atypical squamous cells of undetermined significance

ASC-H
-atypical squamous cells: cannot exclude high-grade squamous intraepithelial lesion

Both mean you aren’t sure what is wrong with the cells -> so order HPV testing to see if pt has HPV infection or not

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30
Q

what are the 2 ACS screening tests?

A

Cervical cancer screening co-testing

Reflex HPV testing (aka Triage)

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31
Q

what is Cervical cancer screening co-testing?

A

Testing with both cervical cytology (Pap test) and high-risk HPV infection

-Means that at the time the pt comes to the clinic to get her pap, you also do a HPV test at the same time

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32
Q

what is Reflex HPV testing (aka Triage)?

A

The collection of a specimen for HPV testing when the cytology sample is collected, but performing the HPV test only if the cytology results are ASC-US

-Pt has no previous HPV infection hx, get pap and pap results are ASC-US or ASC-H -> if these are the results, then do HPV testing on the same sample

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33
Q

what does CIN mean?

A

Cervical intraepithelial neoplasia (CIN):

-premalignant condition of the uterine cervix

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34
Q

how is cervical cancer the most preventable cancer?

A

b/c have cervical screening and HPV vaccines

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35
Q

invasive cervical cancer risk factors?

A
  • Early onset of sexual activity
  • Multiple sexual partners
  • A high-risk sexual partner
  • History of sexually transmitted infections
  • History of vulvar or vaginal squamous intraepithelial neoplasia or cancer (HPV infection is also the etiology of most cases of these conditions)
  • Immunosuppression
36
Q

what are the 4 steps in the pathogenesis of cervical cancer?

A
  1. Oncogenic HPV (16 and 18) infection of the metaplastic epithelium at the cervical transformation
  2. Persistence of the HPV infection
  3. Progression of a clone of epithelial cells from persistent viral infection to pre-cancer
  4. Development of carcinoma and invasion through the basement membrane
37
Q

how does cervical cancer spread?

A

by direct extension (to adjacent organs) or by lymphatic or hematogenous dissemination

38
Q

what are the clinical manifestations of cervical cancer? what’s the most common?

A

irregular or heavy vaginal bleeding AND post-coital bleeding

M/C is post-coital bleeding

39
Q

cervical cancer diagnosis?

A

physical exam (pelvic exam), cervical cytology, cervical biopsy and colposcopy, cervical conization

40
Q

when should a pelvic exam be done for cervical cancer?

A

on any woman w/sx’s suggestive of cervical cancer (bleeding)

41
Q

what is the principle method for cervical cancer screening?

A

cervical cytology

42
Q

who should get a colposcopy with direct bx?

A

Women with a visible lesion (e.g. symptomatic, abnormal cervical cytology)

AND

Symptomatic women without a visible lesion and those who have only abnormal cervical cytology

43
Q

when is cervical ionization necessary?

A

if malignancy is suspected

44
Q

routine lab evaluations for cervical cancer?

A

CBC, liver and renal function tests, urinalysis

45
Q

what is the most common staging system for cervical cancer? what is it based upon?

A

FIGO

-based upon physical exam

46
Q

what are the major prognostic factors affecting survival among women for cervical cancer?

A

disease stage and lymph node status

47
Q

what is primary prevention for cervical cancer?

A

pap screening and HPV vaccine

48
Q

what is secondary prevention for cervical cancer?

A

aimed at the cervical cancer b/c the woman now has cervical cancer

use monitoring and tx to prevent progression to malignant disease

49
Q

what are the vaccines for HPV?

A

bivalent and quadrivalent and 9-valent

50
Q

at what age can HPV vaccines be administered to females?

A

age 9

51
Q

if younger than 15 y/o female, how many doses of HPV vaccine and when?

A

2 doses 6 months apart

52
Q

if 15 y/o and older female, how many doses of HPV vaccine and when?

A

3 doses in max of 2 years

53
Q

what are catch-up vaccines for HPV?

A

used in females age 13-26 y/o who haven’t been previously vaccinated or who have not completed their vaccine series

54
Q

when is HPV vaccine most effective?

A

in individuals the haven’t been infected with HPV

55
Q

what vaccines are for the prevention of anal cancer and its precursor lesions, and genital warts in females?

A

quadrivalent or 9-valent HPV vaccine

56
Q

what HPV vaccines are recommended for males? at what age can it be administered?

A

The routine use of quadrivalent OR

9-valent HPV vaccine in males aged 11 or 12 years

Can be administered starting at age 9

57
Q

HPV vaccine also recommended for what males besides age 9, 11, or 12?

A

males aged 13-21 y/o who haven’t been vaccinated previously or who have no complete the three-dose series

58
Q

9-valent HPV vaccine recommended for what females?

A

for females aged 11 to 12 for the prevention of cervical, vaginal, and vulvar cancer and the related precursor lesions caused by HPV

59
Q

can males older than 21 get the HPV vaccine?

A

males aged 22-26 can have “permissive use” of HPV vaccine

60
Q

pregnant women with ASC-US get colposcopy when?

A

Colposcopy may be deferred until 6 weeks post-partum

61
Q

pregnant women with ASC-H get colposcopy when?

A

Colposcopy should be performed and should not be deferred until the post-partum period

62
Q

cervical bx should be done in pregnant women only when?

A

only when a high-grade abnormality is suspected

63
Q

can endocervical curettage be done in pregnancy?

A

NO!!!

Endocervical curettage should not be done during pregnancy, but gentle sampling of the endocervical canal with a cytobrush may be performed

64
Q

why do a Pap smear?

A

regular screening with Pap smear reduces mortality from cervical cancer

65
Q

when do you start screening for cervical cancer

A

at 21 y/o

66
Q

when do you stop screening for cervical cancer?

A

women > 65 y/o

67
Q

cervical cancer/precancerous screening tools?

A

Pap smear (cytology) and HPV testing

68
Q

what part of the cervix gets tested with Pap smear? if don’t have cells from where then have to do what?

A

the Transformation zone (T-zone) - b/c it’s the most susceptible site of HPV infection

-if don’t have cells from endocervix, then pap needs to be repeated b/c not getting into the T-zone

69
Q

what is Traditional Pap smear - use what tool? for what part of the cervix?

A

use Ayres spatula

for ectocervix

70
Q

types of Pap smear?

A

Traditional, Endocervical Brush, Liquid Prep (Thin-Prep)

71
Q

in order to stop doing Pap smears for screening of cervical cancer at age 65, what are the criteria?

A

No previous HPV and 2 negative co-testing pap

OR

3 negative paps in the last 10 years

72
Q

if pt has any hx of CIN 2, how much longer do you screen for cervical cancer?

A

for 20 more years

73
Q

at what age is co-testing not recommended?

A

21-29 y/o

74
Q

recommended Pap smear screening for cervical cancer 21-29 y/o?

A

Pap test every 3 years

Primary HPV testing every 3 years for women age >/= 25 y/o

75
Q

recommended Pap smear screening for cervical cancer >/= 30 y/o?

A

Co-testing (pap tst and HPV testing) every 5 years (PREFERRED)

OR

Pap test every 3 years

76
Q

First step in evaluation for cervical cancer?

A

Pap smear, Reflex HPV, Co-testing

77
Q

Additional testing/tx options for cervical cancer?

A

Colposcopy

Cone biopsy

LEEP (loop electrosurgical excision procedure)

Cryosurgery

Endocervical curettage

78
Q

when is Endocervical curettage performed and what is it?

A

Performed when endometrial or cervical cancer is suspected or needs to be ruled out
-Usually done during colposcopy and does not require an anesthetic

Takes tissue samples -> HISTOLOGY

79
Q

Evaluation of ASC-US 25 y/o or older?

A

HPV triage (reflex testing)

  • HPV-Negative ASC-US -> co-testing in 3 years
  • HPV-Positive ASC-US -> Colposcopy
80
Q

Evaluation of ASC-US 21-24 y/o?

A

Repeat Pap in 12 months

  • Cytology is either negative, ASC-US or LSIL -> Repeat Pap in 12 months for 2 years
  • Cytology is ASC-H, HSIL, or AGC -> colposcopy
81
Q

Evaluation of ASC-H 25 y/o or older?

A

Colposcopy

No lesion or CIN 1 -> Co-testing in 12 and 24 months

  • Negative at both visits -> routine screening
  • HPV positive or cytology abnormalities -> Colposcopy
  • HSIL -> diagnostic excisional procedure

CIN 2, 3 -> Treatment -> LEEP

82
Q

Evaluation of ASC-H 21-24 y/o?

A

Cytology and colposcopy every 6 months for 12 months
-Both negative at 1 year -> co-testing after 1 year

  • Abnormality persists for 1 year -> repeat biopsy
  • Abnormality persists for 2 years -> treatment -> LEEP
83
Q

Evaluation of CIN 1 (LSIL) follow-up is required when?

A

Persistent CIN 1 for 2 years -> Follow up or treatment (LEEP)

Progresses to CIN 2 or 3 -> Treatment -> LEEP

84
Q

Evaluation of CIN 1 (LSIL) follow-up after treatment when?

A

Co-tsting in 12 and 24 months

85
Q

Evaluation of CIN 2, 3 (HSIL)?

A

Treatment is required -> LEEP

Follow-up after treatment:
Co-testing in 12 and 24 months
-If negative -> co-testing repeated in 3 years í if negative í resume normal screening
If abnormal cytology or positive HPV test -> colposcopy with endocervical curettage

Clin Med 3 - Exam 3 (Women's Health) (9 decks)

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