Cervical Cancer

Question 1

Incidence

Answer 1

• Two peaks
  
  • 25-29 years
  • >80 years

Question 2

Aetiology

Answer 2

• HPV
  
  • 100 subtypes - 16 and 18 are high risk
  • Releases proteins tha tbing to TSGs p53 and Rb preventing them from working
• Smoking
• Early first episode of SI
• COCP use
• Multiple sexual partners
• Immunosuppression

Question 3

Screening programme

Answer 3

• Prevents 8 out of 10 cancers developing
  
  • Has a premalignant pohase
• Screen 25-65-years-olds
  
  • 25-49 years is every 3 years
  • >50 years is every 5 years
• Smear using speculum - plastic ‘brush/ swept over the transformation zone, detects dyskaryosis, inappropriate if cervix is visibly abnormal
• Refer for colposcopy if smear abnormal or suspicious symptoms/examination findings

Question 4

HPV vaccination

Answer 4

• All 11-13 years olds
• 2 injections (3 if 1st after 15 years)
• Protects against HPV 16, 18 AND 6 and 11

Question 5

Pathology

Answer 5

• Fibromuscular origin
• Inner surface is lined with columnar epithelium
• Continuous with the squamous epithelium lining the outer part of the cervix
• Junction is the transformation zone (TZ)
• HPV interferes with the physiological metaplasia in the TZ (leads to dysplasia (CIN) and squamous cell carcinoma (SCC)

Question 6

Investiation and diagnosis

Answer 6

• Examination
  
  • Suprovlacicular
  • Abdominal
  • Speculum
  • Bimanual
  • PR
  • Colposcopy
• Biopsy
  
  • Punch
  • Large loop excision of TZ (LLETZ)
• Imaging
  
  • MRI
  • CT
  • PET-CT

Question 7

Cervical Intraepithelial Neoplasia (CIN)

Answer 7

• CIN 1 - low grade, given time to resolve
• CIN 2,3 - high grade and treatment offered
• Treatment
  
  • Destructive - cold coagulation, cryotherapy
  • Excisional - LLETZ, cold knife cone, laser excision
• Follow up smear at 6 months with hr HPC test

Question 8

Types of cervical cancer

Answer 8

• SCC (most common)
• Adenocarcinoma
• Adenosquamous carcinoma
• Endometriod
• Clear cell
• Serous
• Neuroendocrine

Question 9

Presentation

Answer 9

• Unscheduled vaginal bleeding
• Sero-sanguineous offensive vaginal discharge
• Obstructive renal failure
• Supraclavicular node
• Can be asymptomatic

Question 10

Staging

Answer 10

• FIGO
• Based on clinical examination
• FBC, U&Es, LFTs

Question 11

Management

Answer 11

• Surgery
  
  • Fertility sparing
  • Early stage disease
    
    • Less than 4cm
  • Simple vs radical
• Chemotherapy and radiotherapy

Question 12

Colposcopy

Answer 12

• Examination of CIN
• Adequate light and magnification
• Should visualise whole TZ
• Acetic acid applied
  
  • CIN appears aceto-white
  • Schiler’s iodine may confirm

Question 13

Management of CIN

Answer 13

• CIN I
  
  • Observed for spontaneous regression
  • Cryotherapy, laser or cold coagulation
• CIN II and III
  
  • Large loop excision of the TZ (LLETZ)
  • Mostly in clinic, under local anaesthesia
• Follow-up
  
  • Smear after 6 months