Cervical Disease Flashcards
Around 50% of cases of cervical cancer occur in women under the age of 45 years
true
cervical cancer in the UK are highest in people aged
25-29 years
Types of cervical cancer
squamous cell cancer (80%)
adenocarcinoma (20%)
Features of cervical cancer
may be detected during routine cervical cancer screening
abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
vaginal discharge
Which virus is commonest for cervical cancer?
Human papillomavirus (HPV), particularly serotypes 16,18 & 33
Rx factors cervical cancer?
smoking human immunodeficiency virus early first intercourse, many sexual partners high parity lower socioeconomic status combined oral contraceptive pill*
Mechanism of HPV causing cervical cancer
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
The UK has a well established cervical cancer screening program which is estimated to prevent 1,000-4,000 deaths per year.
true
The main aim of cervical screening
detect pre-malignant changes rather than to detect cancer
cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening
true
Who is screened and how often? A smear test is offered to all women between the ages of
25-64 years
Cervical cancer screening 25-49 years:
3-yearly screening
Cervical cancer screening 50-64 years:
5-yearly screening
cervical screening cannot be offered to women over 64
true
cervical screening in pregnancy
usually delayed until 3 months post-partum unless missed screening o
women who have never been sexually active have very low risk of developing cervical cancer therefore they may wish to opt-out of screening
True
Cervical screening - How is performed?
There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid.
It is said that the best time to take a cervical smear is around mid-cycle. Whilst there is limited evidence to support this it is still the current advice given out by the NHS.
Advantages of LBC includes
reduced rate of inadequate smears
increased sensitivity and specificity
management is based solely on the degree of dyskaryosis
false
The introduction of HPV testing allowed patients with mild dyskaryosis to be further risk-stratified
HPV is such a strong risk factor patients who were HPV negative could be treated as having normal results.
true
The NHS has now moved to an HPV first system what does this mean
sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
Management of results - negative hrHPV
return to normal recall, unless:
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
the untreated CIN1 pathway
follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
follow-up for borderline changes in endocervical cells
Management of results - positive hrHPV
samples are examined cytologically
different mx based on cytology abnormal/normal
Management of results - positive hrHPV if the cytology is abnormal
this includes the following results: borderline changes in squamous or endocervical cells. low-grade dyskaryosis. high-grade dyskaryosis (moderate). high-grade dyskaryosis (severe). invasive squamous cell carcinoma. glandular neoplasia
if the cytology is abnormal → colposcopy
Management of results - positive hrHPV if the cytology is normal
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
Management of results - positive hrHPV
If the sample is ‘inadequate’
repeat the sample within 3 months
if two consecutive inadequate samples then → colposcopy
The follow-up of patients who’ve previously had CIN is complicated but as a first step,
individuals who’ve 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.
The management of cervical cancer is determined by the
FIGO staging and the wishes of the patient to maintain fertility.
FIGO Stage IA
Confined to cervix, only visible by microscopy and less than 7 mm wide:
A1 = < 3 mm deep
A2 = 3-5 mm deep
FIGO Stage IB
Confined to cervix, clinically visible or larger than 7 mm wide:
B1 = < 4 cm diameter
B2 = > 4 cm diameter
FIGO Stage II
Extension of tumour beyond cervix but not to the pelvic wall
A = upper two thirds of vagina
B = parametrial involvement
FIGO Stage III
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
FIGO Stage IV
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
Management of stage IA tumours
Gold standard of treatment is hysterectomy +/- lymph node clearance - nodal clearance for A2 tumours
For patients wanting to maintain fertilit:
A cone biopsy with negative margins can be performed
Close follow-up of these patients is advised - For A2 tumours, node evaluation must be performed
Radical trachelectomy is also an option for A2
Management of stage IB tumours
For B1 tumours: radiotherapy with concurrent chemotherapy is advised
Radiotherapy may either be bachytherapy or external beam radiotherapy
Cisplatin is the commonly used chemotherapeutic agent
For B2 tumours: radical hysterectomy with pelvic lymph node dissection
Management of stage II and III tumours
Radiation with concurrent chemotherapy
If hydronephrosis, nephrostomy should be considered
Management of stage IV tumours
Radiation and/or chemotherapy is the treatment of choice
Palliative chemotherapy may be best option for stage IVB
Management of recurrent disease
Primary surgical treatment: offer chemoradiation or radiotherapy
Primary radiation treatment: offer surgical therapy
The prognosis of cervical cancer is dependant on the FIGO staging:
I 1yr 99% 5yr96%
II 1yr85% 5yr54%
III 1yr74% 5yr38%
IV 1yr35% 5yr5%
Cervical cancer - Complications of surgery
Standard complications (e.g. bleeding, damage to local structures, infection, anaesthetic risk)
Cone biopsies and radical trachelectomy may increase risk of preterm birth in future pregnancies
Radical hysterectomy may result in a ureteral fistula
Cervical cancer - Complications of radiotherapy
Short-term: diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness
Long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
What is a Cervical Ectropion
Elevated oestrogen levels result in larger area of columnar epithelium being present on the ectocervix
What is in the transformation zone?
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal.
What can elevate oestrogen levels
ovulatory phase, pregnancy, combined oral contraceptive pill use
Features of cervical etropion?
vaginal discharge
post-coital bleeding
Mx cervical ectropion
Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
