Cervical Cancer (intraepithelial neoplasia to malignant)

Question 1

Define Cervical intraepithelial neoplasia (CIN)

Answer 1

Presence of atypical cells within the squamous epithelium

Atypical cells are;

• Dyskaryotic
• Large nuclei & frequent mitosis

Question 2

Outline the Natural Hx & pathophysiology of CIN & Cervical Cancer

Answer 2

1. Collumnar epithelium
2. [+low vaginal pH] ⇒ Squamous metaplasia [in transformation zone]
   
   1. ⇒ Normal squamous epithelium
   2. [+viral agents; HPV 16 & 18] ⇒ **Dysplasia CIN 1 **(incorporation of viral DNA into cell DNA)
      
      1. ⇒​Spontaneously regress
      2. ⇒ CIN 2
         
         1. ⇒ CIN 3
         2. ⇒ (Invades BM) Invasive Cervical Cancer

Question 3

Define the histological grades of CIN

Answer 3

1. Mild dysplasia - atypical cells found only in lower 1/3​​​
   
   • ​​Commonly regresses spontaneously
2. Mod dysplasia - atypical cells found in lower 2/3
3. Severe dysplasia - atypical cells found through full thickness of epithelium AKA CARCINOMA IN SITU

• **​Malignant: **Breaks through BM
  
  • 1/3 of CIN2/3 will develop malignancy over next 10yrs

Question 4

Outline the pathology of cervical cancer

Answer 4

Squamous cell carcinoma (90%)

Adenocarcinomas from collumnar epithelium (10%)

Question 5

Outline the epidemiology of CIN

Answer 5

• 90% of CIN 3 are in <45yr olds
• Incidence peak: 25-29

Question 6

Outline the epidemiology of cervical Cancer

Answer 6

8/100k (falling due to screening)

30s & 80yrs

Question 7

Outline the Aetiology of CIN & Cervical Cancer

Answer 7

• Human papilloma virus (HPV) STD
  
  • No. of sexual contacts [CIN not present in virgins]
  • Types 16, 18, 31 & 33 closely associated with CIN [13 types are high risk]
  • Vaccination prior to first sexual contact
    
    • UK 2008: HPV 16 & 18 [75% of CIN]
• Oral contraceptive & smoking: slightly associated
• Immunocompromised (HIV): inc risk & quicker progression
• CIN ⇒ Cervical Cancer

Question 8

Outline the clinical features of CIN/ Cervical Cancer

Answer 8

• CIN asymptomatic
• Carcinoma
  
  • Asymptomatic
  • IMB/ PMB/ PCoital bleeding
  • Offensive vaginal discharge
  • Late: surrounding structures
• O/E
  
  • Normal
  • Ulcer/ mass

Question 9

How is CIN and Cervical cancer investigated and diagnosed

Answer 9

• Smears
  
  • 25+ every 3yrs ⇒ 49yrs every 5yrs ⇒ 64yrs
  • Brush rotated around external circle of os → preservative fluid → centrifuged → liquid-based cytology (LBC)
  • Results shows cellular changes (not histological)
    
    • Dyskariosis ⇒ Often graded ‘CIN 3’ so to suggest biopsy would likely find CIN 3 histologically

SMEAR RESULTS

• Mild-mod DYSKARYOSIS
  
  • ​Sample tests for HPV
  • High risk HPV type ⇒ Colposcopy
• Severe Dyskaryosis
  
  • ​⇒ Colposcopy

Symptomatic/ examination findings ⇒ Colposcopy

Colposcopy

• 5% acetic acid shows characteristic CIN features
• Biopsy → Histology [showing CIN grade]

Spread

• PV/ PR exam
• Cystoscopy for bladder involvement
• MRI for size/ spread/ LN

Question 10

What happens if Mild to Moderate Dyskaryosis is found on a smear

Answer 10

• Mild-mod DYSKARYOSIS
  
  • ​Sample tests for HPV
  • High risk HPV type ⇒ Colposcopy
• Colposcopy
  
  • 5% acetic acid shows characteristic CIN features
  • Biopsy → Histology [showing CIN grade]

Question 11

What happens if Severe Dyskaryosis is found on smears?

Answer 11

• Straigh to Colposcopy
  
  • 5% acetic acid shows characteristic CIN features
  • Biopsy → Histology [showing CIN grade]

Question 12

What are the psychological aspects of cervical smearing

Answer 12

Handle sensitively

Many assume cancer

Explain ‘early warning cells’

CIN3: without treatment has a 30% chance of developing cancer in 8-15yrs & treatment is simple & successfull

Question 13

What happens if a symptomatic pt/ examination findings may indicate cervical lesion?

Answer 13

Symptomatic/ examination findings ⇒ Colposcopy

Colposcopy

• 5% acetic acid shows characteristic CIN features
• Biopsy → Histology [showing CIN grade]

Spread

• PV/ PR exam
• Cystoscopy for bladder involvement
• MRI for size/ spread/ LN

Question 14

Outline the staging of Cervical Carcinoma

Answer 14

Federation of Gynaecology & Obstetrics (FIGO) staging

1. Confined to Cervix
   
   • ai <3mm in depth/ <7mm laterally
2. ⇒ Vagina & parametrium
3. ⇒ Lower vagina/ pelvic wall/ causing ureteric obstruction
4. ⇒ Bladder/ rectal mucosa/ beyond

Question 15

Outline the treatment of CIN & prevention of Cervical Carcinoma

Answer 15

CIN2/3

• Large Loop Excision of Transformation Zone [LLETZ]
  
  • Transformation zone excised with cutting diathermy under local
  • Allows diagnosis + treatment at the same time

Question 16

Outline the treatmet of Cervical Cancer

Answer 16

• Stage 1. a) i)
  
  • Cone biopsy (as LN spread 0.5%)
    
    • or Hysterectomy (no need to remove LNs)
• 1a(ii) - 1b(i)
  
  • ​Radical trachelectomy [preserve fertility] + Laparoscopic lymphadenectomy [confirm -LN]
• 1a(ii) to 2a
  
  • -LN = ​Surgery
    
    • Wertheim’s Radical abdominal hysterectomy
    • Platinum Chemo-radiotherapy
  • +LN = Platinum Chemo-radiotherapy
• Stages 2b, 3 & 4
  
  • Chemo-radiotherapy (platinum agents)
• Recurrent tumours
  
  • Chemo-radiotherapy if not used before
  • Pelvic exenteration [vagina/ bladder/ rectum)