Cervical Cancer and Screening

Question 1

What are the 5 types of pathology in the cervix?

Answer 1

Developmental abnormalities
Inflammation/infection
Benign cervical polyps
Pre-malignant conditions
Malignancy

Question 2

List 3 examples of cervical pre-malignancies.

Answer 2

Borderline nuclear abnormality (BNA)
Cervical intraepithelial neoplasia (CIN)
Cervical glandular intraepithelial neoplasia (cGIN)

Question 3

List 4 examples of malignant tumours in the cervix.

Answer 3

Squamous cell carcinoma
Adenocarcinoma
Clear cell carcinoma
Adenosquamous carcinoma

Question 4

What is the normal histology of the cervix? (3)

Which 3 investigations can be done to look at it?

Answer 4

Upper cervix: columnar
Lower cervix: squamous
Transitional zone: squamocolumnar junction

INVESTIGATIONS:
Cervical smear
Colposcopy
Cervical biopsy

Question 5

What method can be used to detect HPV infection on colposcopy?

Answer 5

Spray acetic acid onto cervix

White colour change indicates HPV infection

Question 6

What are the features of a NORMAL cervical smear? (4)

Answer 6

Squamous cells with a nucleus (stain pink)
Intermediate cells (squamous cells clumped together; stain blue)
Endocervical cells (honeycomb appearance of nuclei)
Sperm cells

Question 7

On a cervical smear, outline features found in:

a) Herpes simplex infection (1)
b) Candida albicans infection (2)
c) Actinomyces infection (1)
d) Bacterial vaginosis (1)

Answer 7

HERPES SIMPLEX:
-Massive aggregation of large endocervical cells

CANDIDA ALBICANS:

• Fungal hyphi (long lines)
• Fungal spores (blobs)

ACTINOMYCES:
-Branching bacteria

BACTERIAL VAGINOSIS:
-Abnormally large endocervical cells

Question 8

What is bacterial vaginosis?

Answer 8

Disruption of the balance of the vaginal microflora; most commonly due to decreased numbers of lactobacilli (which normally produce lactic acid)

Question 9

What features are seen in borderline nuclear abnormality (BNA) on a cervical smear? (4)

Answer 9

Borderline nuclear change
Koilocytosis (abnormal vacuolated cells with clear cytoplasm or perinuclear halos)
Nuclear enlargement
Nuclear pyknosis

Question 10

List 2 causes of borderline nuclear abnormality on cervical smears.

Answer 10

HPV infection

CIN1

Question 11

Describe the staging of cervical intraepithelial neoplasia. (3)

Describe the features of each.

Answer 11

CIN1 - low grade
-Mild dyskaryosis

CIN2 - high grade
-Moderate dyskaryosis

CIN3 - high grade
-Severe squamous dyskaryosis

Question 12

How is cervical intraepithelial neoplasia treated? (1)

Briefly describe this procedure.

Answer 12

Large loop excision of transformation zone (LLETZ)

1. Diathermy wire used to remove ring of tissue around the cervix
2. Cervix then heals and re-epithelializes with normal cells

Question 13

Describe the features of cervical glandular intraepithelial neoplasia (CGIN). (2)

Answer 13

Rosettes - round clusters of endocervical cells; may form a lumen

Pseudo-stratification - endocervical cells form layers

Question 14

Describe the clinical features of cervical malignancy. (6)

Answer 14

Post coital bleeding
Intermenstrual bleeding
Irregular vaginal bleeding
Post-menopausal bleeding
Pain
Asymptomatic

Question 15

List 2 complications of cervical malignancy.

Answer 15

Infertility
Renal failure (due to blockage of urethras, causing hydronephrosis and renal failure)

Question 16

List 6 risk factors for cervical malignancy.

Answer 16

HPV infection
Young age at first intercourse
Increased number of sexual partners
Smoking
Method of contraception
Immunosuppression

Question 17

How is cervical cancer treated? (5)

Answer 17

LLETZ
Cone biopsy
Simple/radical hysterectomy
Radiotherapy
Chemotherapy

Question 18

What is the most common type of cervical cancer?

What does it originate from?

How is it graded? (3)

Answer 18

Squamous cell carcinoma

Origin: CIN

Grading:
G1 - well differentiated
G2 - moderately differentiated
G3 - poorly differentiated

Question 19

What type of cancer arises from CGIN (cervical glandular intraepithelial neoplasia)?

Answer 19

Cervical adenocarcinoma

Question 20

Describe the cervical screening programme. Consider:

a) Who is it for?
b) How often are women recalled?
c) Effectiveness?

Answer 20

Who? Women 20-60 yo

Recall? At least every 5 years (3 years in practice)

Effectiveness? 250 cases of cervical cancer prevented per year

Question 21

Cervical smears are used to detect CIN. What are the 5 possible results a smear could show?

What action should be taken after each?

Answer 21

Negative smear
-Routine recall in 3 years

Borderline nuclear abnormality

• Repeat smear after 6 months
• If BNA persists, repeat after six months 3 times
• Refer to colposcopy if BNA persists

Mild/moderate/severe dyskaryosis

• Refer to colposcopy
• Take biopsy

Question 22

If you do a cervical smear and it shows features suggesting invasion, what would you do?

Answer 22

Urgent referral to specialist

Question 23

How would you differentiate between CIN1-3 based on the amount of mitoses present?

Answer 23

CIN1 - abnormal amount of mitoses in basal layer of epithelium

CIN2 - mitoses in the basal 2/3 of the epithelium

CIN3 - mitoses all the way through the epithelium (right up to surface)

Question 24

How would you differentiate between mild/moderate/severe dyskaryosis? (3)

Answer 24

MILD:
Only affects proliferation layer

MODERATE:
Affects 75% of epithelium

SEVERE:
Affects whole epithelium

Question 25

What are the features of dyskaryosis on microscopy? (2)

Answer 25

Presence of mitotic figures

Large nucleus