Cervical Cancer and Ectropian

Question 1

What are the risk factors for cervical cancer?

Answer 1

• HPV exposure – no barrier contraception
• Young at first age of intercourse and multiple sexual partners
• Smoking
• Long term use of COCP
• High parity
• Immunosuppression/HIV
• Non-compliance with cervical smear
• Partner with penile cancer

Question 2

How can cervical cancer be prevented?

Answer 2

• HPV vaccine

* Cervical screening compliance

Question 3

How does cervical cancer usually present?

Answer 3

• Post coital bleeding
• Post menopausal bleeding
• Intermenstrual bleeding
• Blood stained vaginal discharge
• Dyspareunia
• Pelvic pain
• Weight loss
• Late disease: fistulae renal failure, nerve root pain and lower limb oedema

Question 4

How should suspected cervical cancer be examined and investigated?

Answer 4

Speculum examination - irregular mass, that bleeds on contact
Bimanual examination - cervix rough and hard with loss of fornices
Colposcopy and punch biopsy (LLETZ procedure NOT indicated)
GI examination
STIs

CT Chest, abdomen and pelvis
Note cervical smear are not used to detect cervical cancers

Question 5

How is cervical cancer staged?

Answer 5

1 Confined to cervix
2 Beyond cervix but not pelvic side wall or lower 1/3 of vagina
3 Pelvic spread and reached sidewall of lower 1/3 of vagina
4 Distant spread

Question 6

What type of cancer is cervical cancer histologically, which lymph nodes does it spread to and where does it metastasise to?

Answer 6

80% are squamous cell carcinomas, 20% - adenocarcinomas (also caused by high risk HPVs). May be exophytic (stick out) or infiltrative (not easily seen). Lymph nodes – para-cervical, pelvic, para-aortic. Metastasisese to the lungs, liver, bone and bowel.

Question 7

What is CIN?

Answer 7

Dysplasia of squamous cells within the cervical epithelium, induced by infection with high risk HPVs.

Question 8

What causes CIN?

Answer 8

Pathogenesis: Almost all cases related to high risk HPVs16 – 60% of cases, HPV 18 – 10% of cases. They infect immature metaplastic squamous cells in transformation zone and produce viral proteins E6 & E7 which interfere with activity of tumour suppressor proteins. Most women infected at some time.

Question 9

How do the 3 different types of CIN usually progress?

Answer 9

CIN I – most regresses spontaneously. CIN 2 3-5% progress to cancer, CIN 3 20-30% progress

Question 10

How are the different stages of CIN managed?

Answer 10

Low grade cervical intraepithelial neoplasia (CIN1) are likely to regress. If they are HPV positive, then should be offered 6 monthly colposcopy with the option of LLETZ if persistent.

Those with a high-grade colposcopy (>CIN1) will likely have a LLETZ (large loop excision of the transformation zone) procedure done on the same day to remove the visible area of the transformation zone of the cervix which will be sent as a biopsy to histology.

Question 11

What are the complications of LLETZ

Answer 11

Haemorrhage
Infection
Vaso-vagal reaction 
Anxiety 
Cervical stenosis 
Cervical incompetence and premature delivery (hence should not be done in pregnant women)

Question 12

How should cervical cancer be managed?

Answer 12

Micro invasive carcinomas Stage Ia1 – local excision or total abdominal hysterectomy
Clinical lesions 1b-2a – Radical hysterectomy or chemotherapy
Clinical lesions 2a and higher – chemoradiotherapy

Question 13

What are the common side effects of radiotherapy used in the treatment of cervical cancer

Answer 13

• Vaginal dryness
• Vaginal stenosis
• Radiation cystitis
• Loss of ovarian function

Question 14

What is cervical ectropian?

Answer 14

Definition – eversion of the endocervix exposing the columnar epithelium where normally only non-keratinized epithelium would be seen. Actually, occurs due to metaplasia of the squamous epithelium.

Question 15

What are the risk factors for cervical ectropian?

Answer 15

This usually occurs as a response to oestrogen so:
•	COCP
•	Pregnancy
•	Adolescences
•	Menstruating age

Question 16

What does cervical ectropian present as?

Answer 16

Asymptomatic and incidental finding
Red ring around the os on spec exam
Increased vaginal discharge (more glandular columnar cells)
Intermenstrual bleeding or post coital bleeding due to fine blood vessels

Question 17

How should suspected cervical ectropian be investigated?

Answer 17

Must rule out CIN, cervical cancer, pregnancy or infection/cervicitis

Pregnancy test
Triple swabs – individual test for gonorrhoea and chlamydia and then a high vaginal swab for fungal and bacterial infections
Cervical smear

Question 18

How should cervical ectropian be managed?

Answer 18

Benign condition but if the symptoms are persistent then ablation of the columnar epithelium

Question 19

What does cervical cancer screening detect?

Answer 19

Cervical cancer screening does not detect cancer – it detects premalignant changes. Note Cervical adenocarcinomas are not detected by this method.

Question 20

Who is offered cervical cancer screening?

Answer 20

Smear test offered to all women between ages of 25 and 64.
• 25-49 every 3 years
• 50-64 every 5 years

The smear is current liquid based and is analysed by cytology

Question 21

What happens if a woman’s screening is supposed to occur during pregnancy?

Answer 21

Cervical screening in pregnancy is delayed until 3 months after delivery unless they have missed the screening programme or had previous abnormal smears. If the women has never been sexually active they may wish to opt out as their risk if very low.

Question 22

What management is required for a borderline or mild/dyskaryosis result?

Answer 22

The original sample is tested for HPV

• if negative the patient goes back to routine recall
• if positive the patient is referred for colposcopy

Question 23

What management is required for a moderate dyskaryosis result?

Answer 23

Consistent with CIN II. Refer for urgent colposcopy (within 2 weeks)

Question 24

What management is required for a severe dyskaryosis result?

Answer 24

Consistent with CIN III. Refer for urgent colposcopy (within 2 weeks)

Question 25

What management is required for a suspected invasive cancer result?

Answer 25

Refer for urgent colposcopy (within 2 weeks)

Question 26

What management is required for an inadequate result?

Answer 26

Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy

Question 27

What is colpscopy?

Answer 27

Use of a colposcope – low magnification binocular microscope. Cervix is painted in acetic acid which is preferentially taken up by Neoplastic cells and then iodine which isn’t. Punch biopsy is performed on any aceto-white areas.

Question 28

After treatment for CIN1, 2 or 3 what kind of follow up should be offered?

Answer 28

Women who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for ‘test of cure’ repeat smear in the community. If ok, then they can return to the normal screening programme. Abnormal smear or HPV positive requires reassessment at colposcopy.

Question 29

What is CGIN and how is it managed differently?

Answer 29

CGIN – Cervical glandular intraepithelial neoplasia – this can co-exist with CIN or be a lone finding and is also associated with HPV virus. This is difficult to manage as the endocervical epithelium extends into the cervical canal and so can’t be properly visualised. This is managed with a Cylindrical LLETZ or cone biopsy. If family is complete can offer a hysterectomy.

Question 30

Who receives HPV vaccination?

Answer 30

Previously this was only done for the oncogenic forms 16 and 18. Now the vaccine includes the two strains that cause genital warts – 6 and 11. This vaccination programme started in 2008 and was originally just for girls. From September 2019 this vaccine will be offered to both girls and boys aged 12 and 13 (school year 8). A second dose is given between 6 and 24 months later.

Question 31

What is the new cervical screening system in the UK?

Answer 31

HPV first system - sample is tested for high-risk strains of HPV first and only undergoes cytological examination if this is positive.

Question 32

In the new cervical screening system what happens if the HPV test is negative?

Answer 32

Return to normal recall, unless:

1) On the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community.
2) On the untreated CIN1 pathway
3) Being followed up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
4) Being followed up for borderline changes in endocervical cells

Question 33

In the new cervical screening system what happens if the HPV test is positive?

Answer 33

Samples are examined cytologically, if the cytology is abnormal → colposcopy
this includes the following results:
1) Borderline changes in squamous or endocervical cells.
2) Low, high (moderate) and high (severe) grade dyskaryosis.
3) Invasive squamous cell carcinoma.
4) Glandular neoplasia

If the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months. If the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later. If hrHPV -ve at 24 months → return to normal recall, if hrHPV +ve at 24 months → colposcopy

Question 34

In the new cervical screening system what happens if the sample is inadequate?

Answer 34

repeat sample within 3 months, if two consecutive inadequate samples then go for colposcopy.