Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Gynae-Oncology > Cervical Cancer > Flashcards

Cervical Cancer Flashcards

1
Q

HPV 16 and HPV 18 account for ____ % cervical cancer cases

A

71%

FIGO, 2018

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the two major approaches for prevention of cervical cancer?

A

1) Prevention of invasive cancer by HPV vaccination

2) Screening for precancerous lesions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What percentage of sexually active women will acquire HPV infection at some stage in their life?

A

80%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the HPV vaccine?

A

Recombinant vaccine
Composed of virus-like particles (VLPs)
Not infectious since they do not contain viral DNA
VLPs induce an antibody response; when exposed to live HPV, the antibody response protects that individual from infection.
Not a therapeutic vaccine; it does not treat existing lesions.

WHO has reviewed safety data and concluded that there is no safety concern regarding HPV vaccine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How does cervical cancer spread

A

Direct extension: parametrium, vagina, uterus and adjacent organs i.e. bladder and rectum
Lymphatic channels: regional lymph nodes namely obturator, external iliac and internal iliac, and then to the common iliac and para-aortic nodes
Distant metastasis: lungs, liver, skeleton by haematogenous route is a late phenomenon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the best method of radiological assessment of primary cervical tumours greater than 10mm?

What is the advantage of imaging?

A

MRI Pelvis

Imaging has the advantage of the ability to identify additional prognostic factors, which can guide the choice of treatment modality.
The goal is to identify the most appropriate method and to avoid dual therapy with surgery and radiation as this has the potential to greatly augment morbidity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the standard treatment for locally advanced cervical cancer (Stage IIB - IVA)

A

Concurrent chemoradiation

IV administration of weekly cisplatin during the course of EBRT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Describe the distribution of peak incidence age of cervical cancer:

A

Bimodal distribution peaking 35-39 and 60-64 years of age.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the incidence of cervical cancer in NZ?

What is the mortality rate of cervical cancer in NZ?

A
  • Incidence of cervical cancer is 7 per 100,000 and was reduced by 40% due to screening.
  • Mortality rate of cervical cancer is 2 per 100,00 and was reduced by 60% due to screening
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

List the two most common high risk HPV subtypes.

What percentage of cervical cancers are they responsible for?

A

HPV subtypes 16 and 18.

Implicated in 70% of cervical cancers.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

List the risk factors for cervical cancer:

A
  • Young age of first sexual intercourse
  • Smoking
  • Multiple sexual partners
  • Ethnicity
  • Low SES
  • Chronic immunosuppression
  • Un-vaccinated (HPV vaccine)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the efficacy rate of the HPV vaccine?

A

95-100%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What HPV subtypes are covered by the 9-valent HPV vaccine (Gardasil 9)?

A

HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are HPV subtypes 6 and 11 responsible for?

A

90% of genital warts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Who should receive the HPV vaccine?

A
  • Females age 9 - 45
  • Males age 9 - 26
  • Women with previous HPV (protects against other subtypes they have not been infected with)
  • Women with previous CIN (not therapeutic; protects against other subtypes they have not been infected with)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Describe the NZ HPV vaccination programme including the vaccination schedule:

A
  • Gardasil 9 vaccine used.
  • School age females and males age 9 to 26 years old. Currently offered to Year 8 students at school.
  • Two doses at 0 and 5-13 months
  • If immunocompromised or older than 15 years, 3 doses recommended at 0, 2 and 6 months.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

List the side-effects of the HPV vaccine:

A
  • Localised discomfort
  • Redness and swelling at injection site
  • Heavy arm.
  • Mild fever
  • Nausea
  • Dizziness
  • Anaphylaxis (rare; 1-3 in 1 million)
  • Guillain-Barré syndrome and acute disseminated encephalomyelitis (1 in 100,000).
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Describe the pathophysiology of CIN and cervical cancer development:

A
  • At puberty, rising oestrogen levels cause the cervix to evert; the columnar tissue lining the cervical canal is everted to the surface of the cervix and is called an ectropion.
  • Squamous metaplasia is a normal physiological process caused by acid conditions in the vagina which causes columnar cells to transform into squamous cells. The area where this occurs is called the transformation zone.
  • If oncogenic HPV affects the transformation zone, CIN may form instead of normal squamous tissue.
  • HPV is epitheliotropic; once the epithelium is infected, the virus can either persist in the cytoplasm or integrate into the host genome. When HPV remains in an episomal nonintegrated state, the result is a low-grade lesion. When the virus becomes integrated into the human genome, high-grade lesions and cancer may develop
  • Interaction of viral E6 and E7 proteins with tumour suppression genes p53 and Rb.
  • Inhibition of p53: prevents cell cycle arrest and cellular apoptosis which normally occurs if damaged DNA present.
  • Inhibition of Rb: disrupts transcription factor E2F resulting in unregulated cellular proliferation.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the squamo-columnar junction of the cervix?

A

The area in which the squamous epithelium of the ectocervix meets the columnar epithelium of the endocervix.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Describe the natural history of CIN1 and HSIL

A
  • 60-90% of CIN1 revert to normal within 10-23 months

- 30% of HSIL progress to cervical cancer over 10 years if left untreated.

21
Q

Describe the grades of CIN:

A

CIN is characterised by lack of differentiation, disordered cellular maturation of squamous epithelium but not the basement membrane

  • CIN-1: lower one-third of epithelium affected.
  • CIN-2: lower two-thirds of epithelium affected.
  • CIN-3: full thickness of epithelium affected.
22
Q

Regarding cervical glandular intraepithelial neoplasia:

  • What is the incidence of CGIN?
  • Describe the treatment of CGIN:
A
  • Incidence 0.15% (rare)

Treatment:

  • Cone knife biopsy depth 25 mm to avoid missing skip lesions.
  • Consider hysterectomy if not desiring fertility or margins not clear due to inaccuracy of follow-up smears and colposcopy.
23
Q

What are the two most common types of invasive cervical cancer and their relative frequency?

A
  • Cervical squamous cell carcinoma 70-80%

- Cervical adenocarcinoma 20%. Develops from CGIN.

24
Q

Describe the presentation of advanced cervical cancer:

A
  • Abnormal, malodorous PV bleeding
  • Unintentional weight loss
  • Obstructive uropathy
  • Severe pain
  • Lymphoedema
  • Haematuria
  • Rectal bleeding
25
Q

Describe the colposcopic findings suggestive of cervical cancer:

A
  • Abnormal blood vessels: looped, branched or reticular. Punctate vessels.
  • Irregular surface contour with loss of surface epithelium and ulceration.
  • Yellow-orange colour instead of pink.
26
Q

In the work up for cervical cancer, what is the role of CT or PET scan?

A

Indicated in locally advanced disease i.e. stage IB2 to IVa.

Role is to assess pelvic and para-aortic lymph nodes for involvement.

27
Q

What are the complications of LLETZ and cone knife biopsy?

A
  • Preterm labour (depends of depth/amount of tissue removed and if repeat treatments needed)
  • Cervical stenosis.
28
Q

List the complications of a radical hysterectomy

A
  • Bleeding
  • Infection
  • Urinary dysfunction (partial denervation of detrusor muscle)
  • Vaginal shortening
  • Fistulas: ureterovaginal, vesicovaginal, rectovaginal
  • Bowel obstruction
  • Stricture or fibrosis of intestine and rectosigmoid colon
29
Q

Define cervical cancer stage IA1.

How should cervical cancer stage IA1 be managed?

A
  • Stage IA1: confined to cervix, deepest invasion ≤5 mm; seen only on microscopy. Stromal invasion ≤3 mm in depth and extension of ≤7 mm
  • Definitive treatment: class I hysterectomy (extra-fascial/simple)
  • Fertility sparing treatment: cone biopsy
30
Q

Define cervical cancer stage IA2.

How should cervical cancer stage IA2 be managed?

A
  • Stage IA2: confined to cervix, deepest invasion ≤5 mm; seen only on microscopy. stromal invasion >3 mm and not >5 mm in depth with extension not >7mm.
  • Definitive treatment: class II modified radical hysterectomy OR class I hysterectomy (extra-fascial/simple) PLUS pelvic node dissection (risk of pelvic node spread 5%).
  • Fertility sparing treatment: repeat knife cone biopsy with laparoscopic pelvic node dissection.
31
Q

Define cervical cancer stage IB1.

How should cervical cancer stage IB1 be managed?

A
  • Stage IB1: limited to cervix and uterus with >5 mm depth and ≤2 cm in greatest dimension

Definitive treatment: class II radical hysterectomy and pelvic lymphadenectomy OR chemoradiation.

Cure rates same but surgery preferred for young women to preserve ovaries.

Disadvantage of surgery is does not fully treat pelvic lymph nodes.

Fertility sparing treatment: radical trachelectomy (removal of cervix, parametrium and vaginal cuff) and laparoscopic pelvic node dissection.
- only if tumour <2 cm.

32
Q

Who is suitable for fertility sparing surgery?

A 
○ Desire to preserve fertility
○ Reproductive age <40 years old
○ Early stage disease stage IA1 to small stage IB1 (<2 cm)
○ Absence of recurrence risk factors
○ SCC or adenocarcinoma histology
- No evidence of lymph node metastasis.
33
Q

What are the acute complications / side effects of radiotherapy for cervical cancer?

A
  • Bowel: diarrhoea, abdo cramping, rectal discomfort, bleeding
  • Cystourethritis: dysuria, urinary frequency and nocturia
  • Perineal skin inflammation and desquamation
34
Q

What are the late complications (1-4 years later) / side effects of radiotherapy for cervical cancer?

A
  • Vaginal or rectal stenosis
  • Small bowel obstruction
  • Malabsorption
  • Radiation enteritis
  • Chronic cystitis
35
Q

What is the recommended management for locally advanced disease i.e. stages II to stage IVA?

A

Surgical AND chemoradiation.

Stage II: type III radical hysterectomy, pelvic and para-aortic lymphadenectomy
Stage III: primary chemoradiation
Stage IVA: primary exenteration (pelvic clearance) OR primary chemoradiation

Chemotherapy: cisplatin and fluorouracil.

Radiotherapy: EBRT or cervical brachytherapy.

36
Q

What is the recommended management for cervical cancer stage IVB?

A

Palliative radiotherapy if bleeding is an issue.

37
Q

Why is adjuvant radiotherapy recommended in the presence of intermediate risk factors?

A

Because risk of recurrence and death is up to 30% following surgery only.

Radiotherapy improves progression-free survival and overall survival.

38
Q

What are intermediate risk factors (Sedlis’ criteria)?

A

DDL:

  • Dimension (>2cm)
  • Depth
  • LVSI
  • Presence of LVSI plus deep one-third cervical stromal invasion and tumor of any size.
  • Presence of LVSI plus middle one-third stromal invasion and tumor size ≥2 cm
  • Presence of LVSI plus superficial one-third stromal invasion and tumor size ≥5 cm
  • No LVSI but deep or middle one-third stromal invasion and tumor size ≥4 cm
39
Q

Why is adjuvant chemo-radiotherapy recommended in the presence of high risk factors?

A
  • Risk of recurrence up to 40% and death up to 50% following surgery alone in presence of high risk factors.
  • Chemo-radiation therapy improves progression-free survival and overall survival
40
Q

What are high risk factors (Peter’s criteria)?

A
  • Involved lymph nodes
  • Microscopic parametrial invasion
  • Positive surgical margins.
41
Q

When is primary radiotherapy for the treatment of cervical cancer indicated?

A
  • Poor functional status

- Medical comorbidites that make pt poor surgical candidate

42
Q

Describe pelvic lymph node dissection as part of cervical cancer treatment:

A

Removal of nodal tissue from:

  • Distal one-half of each common iliac artery
  • Anterior and medial aspect of the proximal half of the external iliac artery
  • Distal half of the obturator fat pad anterior to the obturator nerve.
43
Q

Describe para-aortic lymph node dissection as part of cervical cancer treatment:

A

Removal of nodal tissue from:

  • Distal vena cava from the level of the inferior mesenteric artery to the mid right common iliac artery
  • Between the aorta and left ureter from the inferior mesenteric artery to the left mid common iliac artery.
44
Q

List the complications associated with pelvic and para-aortic lymph node dissections:

A
  • Vascular damage
  • Ureteral injury
  • Infection
  • Fistula formation
  • Lymphocyst/lymphedema
  • Bowel obstruction
  • Thrombophlebitis.
45
Q

What is recommend follow-up after fertility sparing treatment of cervical cancer?

A

There is a lack of formal guidance on ideal follow-up.

FIGO recommends:

  • 3 monthly smear and colposcopy for first 3 years.
  • Then 6 montly smear and colposcopy for next 2 years
  • Yearly smear and colposcopy thereafter.
  • HPV vaccination if not had already.

What is NOT recommended:
- Routine hysterectomy after child-bearing completed.

46
Q

What is recommended follow-up after surgical management of stage IA1 cervical SCC?

A

TAH and cone biopsy treated the same.
Smear at 6 months by gynaecologist.
Smear at 1 year and 2 years with HPV testing by GP; once 2 consecutive negative HPV tests, return to routine screening.

47
Q

What is recommended follow-up after surgical management of cervical SCC stage IA2, IB1 and all IA adenocarcinoma?

A

3 monthly smear with gynaecologist for first year.
6 monthly smear with gynaecologist in 2nd year.
If had radiation therapy: 6 monthly smear with gynaecologist in 3rd year to monitor for toxicity and alternative with radiation oncologist.
Annual smears with GP for at least 10 years if not treated with radiation.

48
Q

Can the HPV vaccination be given in pregnancy?

A

Yes

No risk for infant or mother

49
Q

Can the HPV vaccination be given in pregnancy?

A

Vaccination not recommended, category B2

But monitoring of women who have inadvertently been vaccinated during pregnancy has NOT identified any risk for infant or mother

If a woman has started the vaccination programme and then becomes pregnancy, she can resume the vaccination programme after (the increased time between vaccinations doesn’t matter)

Gynae-Oncology (8 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions