Cervical Disorders Flashcards
The Transformation Zone and Metaplasia
Endocervical canal = columnar epithelium
Ectocervix = squamous epithelium (continuous with vagina)
Two meet at squamocolumnar junction
In puberty and pregnancy partial eversion of cervix occurs
Lower pH in vagina –> causes columnar to switch to squamous (metaplasia)
These metaplastic cells are more vulnerable to insult and dysplastic change
Cervical Ectropion
Columnar epithelium of endocervix protrudes through internal os
Visible as redness on surface, looks indistinguishable from cervical cancer
Normal in young patients and those taking COCP
Can cause discharge (exposed columnar more prone to infection) or PCB
Ix:
Smear and colposcopy
Tx: cryotherapy
Acute and Chronic Cervicitis
Acute cervicitis: associated with sexually transmitted infection
Ulceration and infection can also occur in severe prolapse
Chronic cervicitis
Often with ectropion with infection
Common cause of dishcrage and inflammatory smear
Tx: cryotherapy +/- antibiotics
Cevrical Polyps
Asymptomatic or PMB/PCB
Common >40yrs, usually <1cm
Evulsed
Nabothian Follicle
Cyst
Squamous cell formation from metaplasia of columnar cells
Columnar cell secretions are trapped –> retention cyst
Appear as white or opaque swelling on ectocervix
Tx: required if symptomatic
Premalignant Condition of the Cervix
CIN: cervical intraepithelial neoplasia
Presence of atypical cells within the squamous epithelia: dyskaryotic with frequent mitoses
CIN: I-III (mild, moderate and severe dysplasia)
Thickness of epithelium
CIN I usually regresses spontaneously
If left, 1/3 of women with CIN III will develop Cervical cancer in 10 years
Risk Factors
HPV 16, 18, 31 and 33
Smoking
Immunocomprimised
Cervical Cancer
Bimodal peak incidence: 30s and 80s
90% squamous cell carcinoma
10% adenocarcinoma (worse prognosis)
Same risk factors as CIN
HPV present in all
Immunosupression accelerates progression
NOT FAMILIAL
Clinical Features
Can be occult: diagnosis made at coloscopy
PCB
Offensive discharge
IMB or PMB
Later stages: Uraemia, Haematuria, Rectal bleeding, Pain
Examination
Ulcer or mass may be visible/palpable
Ix
Tumour biopsy
Stage disease: vaginal and rectal examination
Cytoscopy for bladder involvement
MRI to detect size, spread and LN involvement
Assess fitness: FBC, renal function, CXR
Tx
Microinvasive disease: Stage 1a
Cone biopsy sufficient as risk of LN spread is 0.5%
Simple hysterectomy preferred in older women
Stage 1 and 2a
Choice between surgery and chemotherapy
If LN involvement –> chemotherapy is better
Surgical
LN dissected
Radical abdo hysterectomy performed
Wertheim’s hysterectomy: LN clearance, hysterectomy, removal of parametrium and upper 1/3 of vagina
Radical trachelectomy - less invasive for women wanting to preserve fertility
Lymphadenectomy
If nodes + –> chemotherapy instead of srugery
If nodes neg –> trachelectomy (80% of cervix and upper vagina)
Cervical suture placed to prevent PTD
Incomplete margins –> radio chemotherapy
Stage 2b or worse, or positive LNs
Radiotherapy and chemotherapy (platinum agents)
Pallative radiotherapy used for bone pain or haemorrhage
Recurrent Tumours
Radio chemotherapy if not previously used
Pelvic exenteration
Preop MRI and PET scan
Uraemia due to ureteric obstruction can be a cause of death
Cervical Smears
Screening from age 25
Every 3 years 35-49
Every 5 years 50-64
Women under 25 often have cervical changes but risk of cancer is low –> commencing screening at 25 reduces unnecessary colposcipies
Method
Liquid based cytology and microscopy
HPV testing at same time
Result
Mild/borderline test –> HPV result
HPV neg –> re-screen as normal
HPV pos –> colposcopy
Anything above mild –> colposcopy
Occasionally if abnormal columnar cells seen: cervical glandular intraepithelial neoplasia CGIN
Adenocarcinoma of cervix or endometrium needs to be excluded
Colposcopy or endocervical curettage (hysteroscopy if not clear cause)
Problems with smears and screening:
Most women with cervical cancer have never had a smear
Significant false negative rate
Distinctions between grades of dyskariosis and CIN are blurred
CIN can regress
Colposcopy
Cervix inspected via speculum using microscopy with 10-20 fold magnification
Stained with acetic acid and iodine
Grades of CIN have characteristic appearance when stained with 5% acetic acid
Biopsy taken
Diagnosis confirmed histologically
Tx:
CIN II or III: cutting diathermy under local anaesthetic (LLETZ or DLE)
LLETZ; diagnosis and treatment at same time
OR
can biopsy small area and wait for results prior to LLETZ
Complications of LLETZ: haemorrhage, and preterm labour
