Cervical cancer Flashcards
List some DDx for intermenstrual and post-coital PV bleeding?
Vaginal
- vaginal atrophy, trauma/tear
- neoplasia: vaginal ca
- infective: STI, PID
- Bartholin cyst
Cervical
- neoplasia, cervical intraepithelial neoplasia, leiomyoma
- Nabothian cyst
- Infective: cervicitis
- cervical trauma
- cervical ectropion (protruding columnar portion of SCJ)
Uterine
- inflammatory: endometriosis
- neoplasia: uerine polyps, fibroids, cancer
- pregnancy: miscarriage/cervical incompetence, ectopic at cervix
- mechanical: uterine prolapse
Haematological- bleeding diathesis (e.g. platelet disorder, haemophilia, vWF)
Bleeding from non-gynae site
What does a colposcopy examine?
- examine vascularity
- 1% acetic acid wash (acetowhite indicates incerased cellular proteins -> neoplastic cells) -> white areas for punch biopsy
- iodine stain -> cells dye blue normally (due to glycogen in cells)
- > abnormal cells stay yellow (less glycogen due to high N:C ratio)
What is a papnicolaou smear test?
Aim: identify abnormal cell samples of cervical transformation zone (SCJ) where dysplasia and cancers arise
Method: cervical sample obtained by brush, placed in liquid based medium for HPV partial genotype screen
What does a positive pap smear result mean?
Tested for HPV w partial genotyping- positive indicates possibility of HPV infection
- Positive HPV 16, 18, 45 -> liquid based cytology (LBC) and colposcopy referral
- Positive other HPV types -> reflex LBC -> colposcopy
- Negative HPV -> repeat screening in 5 years
List some risk factors for cervical cancer?
Non-modifiable
o Gender
o Age (>40yo)
o FMHx
Modifiable o Smoking o OCP (>10years increased risk x4) o Immunosuppression o HPV (types 16 and 18 are high risk, 70%) o Early onset sexual activity (<21yo) o Multiple sexual partners o High-risk sexual partners o Prior STI history o Multiple pregnancies
Describe the cervix?
Cervix: the tapered end of the uterus that projects into the superior vagina
• Supravaginal segment (endocervix)- communicates w uterus via internal os
• Vaginal segment (ectocervix)- extends into vagina through external os
Describe the relations of the cervix?
• Anteriorly: bladder
- (Cervix below vesicouterine pouch -> cervical ca invades bladder directly)
• Posteriorly: posterior vaginal fornix, rectouterine pouch, rectum
• Laterally: vaginal fornices
• Inferiorly: vagina
Name the pelvic ligaments?
- Broad ligament
- Lateral cervical ligs (cardinal lig)
- Round lig of uterus
- Pubercervical lig
- Uterosacral sig
- Suspensory lig
- Ovarian lig
Describe the structure and function of the broad lig?
Broad ligament:
• Structure- double layer of peritoneum connecting uterus to pelvic wall and floor. Comprised of mesovarium, mesosalpins and mesometrium.
• Function- mesentery for ovaries fallopian tubes and uterus
Describe the structure and function of the lateral cervical ligaments?
Lateral cervical ligaments (cardinal lig):
• Structure - thickened CT at the base of broad lig, runs inferiorly to ureters and uterus
• Function- prevents lateral movement of cervix
Describe the structure and function of the round lig of the uterus?
Round ligament of the uterus:
• Structure - cord-like segment running from intramural part of fallopian tube to inguinal canal, attaching to labium majora
• Function- holds uterus forward in anteversion and anteflexion
Describe the structure and function of the pubocervical lig?
Pubocervical ligament
• Structure - runs from cervix to anterior pelvix wall, inserting into pubic symphysis
• Function- anchors cervix to anterior pelvic wall
Describe the structure and function of the uterosacral lig?
Uterosacral ligament:
• Structure- thickest cervical lig, extending from cervix posteriorly around rectum to attach to fascia over piriformis at sacrum
• Function- resists forward pull of round ligaments and anchors uterus posteriorly, keeping cervix anteflexed
Describe the structure and function of the suspensory lig?
Suspensory lig:
• Structure- peritoneal fold extending from ovary to pelvic wall
• Function- contains neovascular supply
Describe the structure and function of the ovarian lig?
Ovarian lig:
• Structure- fibrous lig running in the broad ligament of the uterus, connecting the ovary with the lateral aspect of the uterus
• Function- attaches ovary to uterus
Describe the arterial supply of the uterus and cervix?
Arterial supply: uterine artery
- Course: Internal iliac artery -> uterine artery -> travels in lateral cervical ligament (passes over ureter)
- Supplies: supravaginal part of cervix and vagina
Describe the venous drainage of the uterus and cervix?
Venous drainage: uterine veins
- Course: uterine veins -> enter broad lig -> form uterine venous plexus (on each side of cervix) -> internal iliac veins
Describe the lymphatic drainage of the uterus and cervix?
Lymphatic drainage:
- Fundus -> lumbar LNs -> external iliac LNs or superficial inguinal LNs
- Uterine body -> external iliac LNs -> para-aortic LNs
- Uterine cervix -> internal iliac LNs and sacral LNs (via uterosacral lig)
Describe the innervation of the uterus and cervix?
Innervation: uterovaginal plexus
- Course: inferior hypogastric plexus -> uterovaginal plexus
- Function: sympathetic, parasympathetic and visceral afferent fibers
How does cervical ca spread:
Direct invasion (rarely metastasises) -> uterine body, vagina, parametria, peritoneal cavity, bladder, rectum
Describe the pelvic floor?
Structure: levator ani msucles (include the ischiococcygeus, iliococcygeus and pubococcygeus)
- Covered above and below by the superior and inferior fascia of the pelvic diaphragm. Below the inferior fascia is the ischiorectal fossa.
- lateral wall muscles: piriformis and obturator internus
Functions:
- supports pelvic viscera
- increased abdo pressure for parturition, micturition and defecation
Describe the lateral wall muscles of the pelvic floor?
- Piriformis
- Structure: originates from anterior part of sacrum, gluteal region of spine and superior margin of greater sciatic notch -> exits pelvis through greater sciatic foramen and inserts on greater trochanter of femur
- Innervation: piriformis nerve (from sacral plexus, L5, S1 and S2)
- Function: external rotation of hip - Obturator internus:
- Structure: originates from ischiopubic ramus and obturator membrane -> inserts on medial aspect of greater trochanter
- Innervation: internus nerve (from sacral plexus, L5, S1, S2)
- Function: abduction and lateral rotation of extendd hip
