cervical cancer

Question 1

risk factors for cervical cancer?

Answer 1

age 45 to 49 
other STIs including HIV
hrHPV 16,18
high parity/OCP
smoking (3x risk)
early first sexual experience
immunocompromised
not going for smears
low socio-economic class

Question 2

how does HPV 16 and 18 play a role in viral carcinogenesis?

Answer 2

HPV 16 produces oncogene E6 which inhibits p53 tumour suppressor gene
HPV 18 produces oncogene E7 which inhibits RB gene

Question 3

symptoms of cervical cancer?

Answer 3

profuse post-coital bleeding, post-menopausal bleeding, intermenstrual bleeding, pelvic pain, dyspareunia

Question 4

signs on cervical cancer on vaginal examinaiton?

Answer 4

friable tissue with contact bleeding
rough, irregular cervix
palpable mass

Question 5

where does cervical cancer met to haematologically to in late stage disease?

Answer 5

liver - jaundice
lungs - haemoptysis, sob
bone - bone pain, pathological fractures, hypercalcaemia

Question 6

where is the endocervix located?

Answer 6

between external and internal os

Question 7

which type of epithelium lines the endocervix?

Answer 7

columnar (glandular) epithelium

Question 8

which type of epithelium lines the ectocervix?

Answer 8

non-keratinised stratified squamous epithelium

Question 9

what is the transitions zone?

Answer 9

interphase between the internal and external os

squamo-columnar junction

Question 10

what occurs at the transition zone?

Answer 10

columnar cells (of the endocervix) undergo metaplasia & become squamous epithelium in response to the harsh acidic vaginal environment

Question 11

what effect does oestrogen and progesterone have on the cervical mucus plug?

Answer 11

oestrogen - causes thinning of the cervical mucus

progesterone - formation of mucus plug

Question 12

spot diagnosis: what benign condition causes a red ring on the cervix?

Answer 12

cervical ectropion (erosion)

Question 13

risk factors for cervical ectropion?

Answer 13

exposure to high levels of oestrogen (pregnancy, OCP, teenagers)

Question 14

what is a cervical ectropion?

Answer 14

benign condition where columnar (glandular) epithelium of the endocervix spread to the external os giving a ‘red ring appearance’
can cause excessive discharge or bleeding

Question 15

lymphatic spread occurs (early/late) in cervical cancer?

Answer 15

lymphatic spread occurs EARLY to the pelvis, para-aortic lymph nodes

Question 16

haematogenous spread occurs (early/late) in cervical cancer?

Answer 16

haematogenous spread occurs LATE to the liver, lungs & bone

Question 17

investigation for cervical cancer?

Answer 17

urgent colposcopy and biopsy
TVUSS in post-menopausal women to rule out endometrial cancer
triple testing to rule out STIs

Question 18

describe grade I to IV of cervical cancer

Answer 18

Grande I - well differentiated
Grade II - mod. differentiated
Grade III - poorly differentiated
Grade IV - anaplastic (BAD)

Question 19

summary of Figo stages 0 to 4

Answer 19

0 -CIN
1 - limited to cervix
2 - spread to adjacent organs
3 - spread to pelvic wall
4 - distant mets

Question 20

which type of virus is HPV?

Answer 20

a DNA virus

Question 21

which age group has the highest prevalence of HPV

Answer 21

<25 year olds

Question 22

time frame for hrHPV to become CIN? and CIN to become cervical cancer?

Answer 22

hrHPV - CIN (6 months - 3 years)

CIN - cervical cancer (5 - 20 years)

Question 23

what is CIN?

Answer 23

cervical intraepithelial neoplasia
non-invasive precursor of cervical SCC
dysplasia of squamous cells at the transition zone
asymptomatic

Question 24

who is invited for cervical screening?

Answer 24

women age 25-65

age 25-49 (3 yearly smears)
age 50-65 (5 yearly)

Question 25

koilocytosis on histology indicated HPV infection - what are the features?

Answer 25

enlarged nucleus
dark nucleus (haemachromasia)
irregular membrane
perinuclear halo

Question 26

some histological features of cervical intraepithelial neoplasia ?

Answer 26

delayed maturation (immature basal cells occupying most of the epithelium; large nucleus, little cytoplasm)
excessive mitotic activity (mitotic figures)
nuclear abnormalities (enlarged, dark)

Question 27

how is cervical intraepithelial neoplasia classified?

Answer 27

CIN I,II, III based on severity of…
1) delayed maturation
2 nuclear abnormalities
3) excessive mitotic activity

Question 28

describe CIN 1

Answer 28

mild dyskaryosis
CIN in lower 1/3rd of the epithelium
mitotic figures limited to lower 1/3rd of epithelium
high chance of regression

Question 29

CIN II

Answer 29

moderate dyskaryosis

CIN in 2/3rds of epithelium

Question 30

CIN III

Answer 30

severy dyskaryosis affecting full thickness of the epithelium
carcinoma in situ

Question 31

what are the two types of cervical cancer?

Answer 31

squamous cell carcinoma (80%)

adenocarcinoma (10%)

Question 32

precursors of cervical SCC and cervical adenocarcinoma?

Answer 32

CIN - ectocervix precursor to SCC

CGIN - endocervix precursor to adenocarcinoma

Question 33

what is CGIN?

Answer 33

cervical glandular intra-epithelial neoplasia

Question 34

what is cervicitis?

Answer 34

Inflammation of the cervix characterised by a purulent endocervical exudate
contact bleeding
often seen in age 15-24

Question 35

causes of cervicitis?

Answer 35

chlamydia/gonorrhoea
HSV
IUD
allergy

Question 36

what is LLETZ?

Answer 36

large loop excision of transformation zone

Question 37

purpose of a LLETZ?

Answer 37

aims to remove the full circumference of the TZ

diathermy procedure under local anaesthetic

Question 38

LLETZ complications?

Answer 38

pyometria
cervical infection
cervical stenosis
follow up smears are difficult