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Y5 O+G > Cervical cancer and CIN > Flashcards

Cervical cancer and CIN Flashcards

1
Q

Define Cervical intraepithelial neoplasia (CIN)

A

Pre-cancerous dysplastic lesion of the transformation zone
Usually atypical cells within the squamous epithelium - dyskaryotic with larger nuclei and frequent mitoses

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2
Q

What are the risk factors for CIN and cervical cancer

A

HPV infection
Early pregnancy
Smoking
Immunocompromise e.g. HIV, steroid use
Long-term and combined contraceptive use
Not attending smear screening
Young age at first intercourse
Age 45-59

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3
Q

What are the types of CIN

A

CIN 1: Lower 1/3rd of the epithelium
CIN 2: 2/3rd of the epithelium
CIN 3: Affects the full thickness of the epithelium (Risk of stage Ia1 FIGO) - carcinoma in situ
(malignancy = cells invade the basement membrane)

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4
Q

What investigations are done for CIN

A

Cervical smear for histology:
- Increased nuclear to cytoplasmic ratio
- Abnormal nuclear shape - poikilocytosis
- Increased nuclear size
- Increased nuclear density - koilocytosis
- Reduced cytoplasm

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5
Q

What is the management for CIN 1

A

Conservative (watch and wait)
Annual cervical smears

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6
Q

What is the management for CIN 2/3

A

Cryosurgery (using nitrous oxide to freeze and kill abnormal cells)
- Conization (removal of the affected cells)
- Cold-knife conization (scalpel)
- Laser
- Heated electrical loop (LLETZ or Loop electrosurgical excision procedure/LEEP)
- Needle excision of the transition zone/NETZ
Cone biopsy
Hysterectomy

+ follow up 6 months later for smear and HPV test

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7
Q

What should be done at follow up after treatment for CIN

A

Smear and HPV test
Smear -ve, HPV absent: discharge
Abnormal smear OR HPV present: re-colposcopy

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8
Q

What are the benefits and risks of treating CIN

A

Removes abnormal cervical cells
Reduces risk of future cervical cancer

Early
- Infection, bleeding, pain, treatment failure
Late
- Premature birth in future pregnancy
- Repeat treatment

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9
Q

What is the prognosis for CIN

A

Untreated, 1/3 of women with CIN/II/III will develop cervical cancer over the next 10 years
CIN I commonly regresses spontaneously

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10
Q

Which strains of HPV are most associated with cervical cancer

A

HPV 16, 18 (+33)

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11
Q

Explain why the peak age of incidence for Cervical cancer is 45-59

A

Peak HPV infection incidence is in the late teens and early 20s, but in 90% of patients in this age group, the infection resolves within 2 years (with clearance typically occurring 6 months after infection)
Once infection resolves, the risk of cervical cancer returns to baseline.

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12
Q

What is the histology of cervical cancer

A

Most commonly squamous cell cancer (90%) (can be adenocarcinoma) at the transformation zone (where columnar cells and squamous cells meat and transition)

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13
Q

Describe how cervical cancer spreads

A
  1. Parametrium and vagina
  2. Pelvic side wall
  3. Lymphatic spread to pelvic nodes
  4. blood borne spread
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14
Q

What is occult cervical carcinoma

A

no symptoms, but diagnosis is made by biopsy of LLETZ

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15
Q

What are the symptoms of cervical cancer

A

Often asymptomatic

Abnormal vaginal bleeding
Post-coital bleeding
Pelvic or back pain
Dyspareunia
PV bleeding
Mucoid or purulent vaginal discharge
Metastases may cause bladder, renal, or bowel obstruction or bone pain

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16
Q

What are the differentials for cervical cancer

A

CIN
HPV infection
Pelvic infection
Nabothian cyst
Glandular hyperplasia
Endometriosis
Cervical polyp
Fibroid

17
Q

What are the signs of cervical cancer on examination

A

Bimanual
- Cervical mass felt on palpation
- Blood
Speculum
- Cervical mass visualised
- Cervical bleeding

18
Q

What investigations should be done for cervical cancer

A

Bedside: Cervical smear + HPV testing
Bloods: FBC, renal function, LFTs, U&Es (most fitness for surgery)
Other:
- Colposcopy (abnormal vascularity, white change with acetic acid, exophytic lesions)
- Biopsy
- MRI pelvis
- CXR (fitness for surgery)

19
Q

What is FIGO stage 1A and 1B for cervical cancer

A

1A = Confined to cervix, only visible by microscopy and less than 7 mm wide:
A1 = < 3 mm deep
A2 = 3-5 mm deep

1B = Confined to cervix, clinically visible or larger than 7 mm wide:
B1 = < 4 cm diameter
B2 = > 4 cm diameter

20
Q

What is FIGO stage 2 for cervical cancer

A

Extension of tumour beyond cervix but not to the pelvic wall
A = upper two thirds of vagina
B = parametrial involvement

21
Q

What is FIGO stage 3 for cervical cancer

A

Extension of tumour beyond the cervix and to the pelvic wall
A = lower third of vagina
B = pelvic side wall

NB: Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III

22
Q

What is FIGO stage 4 for cervical cancer

A

Extension of tumour beyond the pelvis or involvement of bladder or rectum
A = involvement of bladder or rectum
B = involvement of distant sites outside the pelvis

23
Q

What is the management for cervical cancer stage 1A

A

Fertility desired: cone biopsy (cold knife, LLETZ, laser)

Fertility not desired: simple hysterectomy ± lymphadenectomy

24
Q

What is the management for cervical cancer stage 1B

A

Fertility desired: Radical trachelectomy + lymphadenectomy (tumour size <2cm)

Fertility not desired: simple hysterectomy ± lymphadenectomy ± chemoradiation

25
Q

What is the management for cervical cancer stage 2

A

Radical hysterectomy + lymphadenectomy
± post-operative chemoradiation
± nephrostomy for hydronephrosis

26
Q

What is the management for cervical cancer stage 3

A

Combination chemotherapy + bevacizumab (+ paclitaxel)
± local treatment to metastases
± nephrostomy for hydronephrosis

27
Q

What is the management for cervical cancer stage 4

A

Chemoradiation
Palliative chemotherapy for stage IVB

28
Q

What does a radical hysterectomy and radical trachelectomy involve

A

Radical hysterectomy (wertheim’s) = pelvic node clearance, hysterectomy, and removal of the parametrium and upper 1/3 of the vagina

Radical trachelectomy = Removal of 80% of the cervix and upper vagina

29
Q

What are the complications of radiotherapy for cervical cancer

A

Short-term:
* Diarrhoea
* Vaginal bleeding
* Radiation burns
* Pain on micturition
* Tiredness/weakness
Long-term:
* Ovarian failure
* Fibrosis of bowel/skin/bladder/vagina
* Lymphoedema

30
Q

What are the complications of surgery for cervical cancer

A
  • Bleeding
  • Damage to local structures e.g. ureter, bladder
  • Voiding problems
  • Accumulation of lymph
  • Infection Anaesthetic risk
31
Q

What is the prognosis for cervical cancer

A

Death is usually from uraemia due to ureteric obstruction
Overall 5-year survival = 65%

Y5 O+G (70 decks)

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