Cervical Disorders Flashcards
What are the risk factors for cervical cancer? [7]
Age (peaks at 45-55yrs) Early age of 1st intercourse, older age of partner Multiple partners, STIs Prolonged OCP use Immunodeficiency, persistant infection Smoking *** HPV types 16 and 18
What types of cancer are caused by HPV 16 & 18? [4]
In order of most prevalent to least: Cervical and anal cancers Penile and vaginal cancers Oropharyngeal cancers Mouth cancers
HPV infection causes abnormal growth of squamous cells aka Squamous Intraepithelial Lesion (SIL).
SIL vs CIN [2]
Both terms are used to describe changes in the cervix. However, they are used in different situations.
SIL detectable on smear (screening) and can be low/high grade
CIN - report of biopsy and histological examination of abnormal cells in cervix
How do we grade CIN? [1]
Outcome of low-grade SIL
Outcomes of CIN1 [3]
High grade SIL (HSIL) is associated with what grade of CIN at biopsy?
CIN 1-3 based on proportion of affected cervix
Outcome of low-grade SIL -cleared within 6-12m
Outcomes of CIN1
- May regress
- Remain unchanged
- Progress to CIN2, CIN3 or cervical ca
High grade SIL (HSIL) is associated with CIN2/3 at biopsy
How do we prevent HPV infections? [3]
A secondary school immunisation programme for girls and boys. Quadrivalent vaccine containing 16/18/6/11
Now a 2 dose regime.
What is the aim of cervical screening? [4]
- Detect cervical dyskaryosis
- Reduce risk of cervical cancer
- Detect CIN (pre-cancerous disease)
- Prevent cervical cancer
Describe the process of cervical screening, from smear to results
Smear taker enters request onto Scottish Cervical Call Recall System (SCCRS)
Lab tests puts results on SCCRS database
GP and women receive results
1) If normal come back in 3yrs
2) If abnormal SCCRS creates a colposcopy referral
How often do you get a cervical smear? [2]
3yrly from age 25-50, then 5yrly after that 50-64
What method do we use to test for cervical abnormality? [2]
Liquid based Cytology (LBC)
We take smears from the “transformation zone”, i.e. where the endocervical glandular epithelium becomes squamous cells
Why do we call them PAP smears?
Cos a thin layer of cells is smeared onto a slide using the Papnicolaeou method
The lab looks for nuclear abnormalities in the cells called “Dyskariosis”, what are these abnormalities? [4]
- Increased nuclear size, nuclear: cytoplasmic ratio
- Varied shape, size & outline of nuclei (normal: uniform)
- Coarse irregular chromatin
- Nucleoli
What are the possible results from a PAP smear? [4]
What are the next steps for each result and how soon should they be completed?
- Normal so come back in 3yrs
- Borderline Nuclear Abnormalities (BNA) aka low grade dyskariosis - repeat in 6w
- Unsatisfactory: repeat in 3 months
- High grade dyskaryosis - colposcopy within 2w
How is acetic acid and iodine used in colposcopy to obtain biopsies? [5]
Acetic acid helps to visualize transition zone
Iodine - stains starch on normal cells so non-stained are abnormal allowing us to…
- Identify lesions
- Select biopsies (punch)
- Define area to treat
Which results warrant treatment [1]
How can we treat a case of CIN? [3]
CIN2/3 require treatment
LLETZ (Loop diathermy)
Cold Coagulation
Laser Ablation
How do we follow up after treating CIN? [1]
If both negative?
If either is positive?
LBC and HPV test at 6 months
If both -ve your good to go back to 3yrly smears
IF either is +ve refer to colposcopy
Define Cervical Cancer? [2]
A squamous carcinoma involving malignant changes in the squamous cells in the transformation zone of cervix
How might cervical cancer present? [3]
Abnormal vaginal bleeding including *PCB, IMB or PMB
Offensive discharge (dead tumour)
~ pain - late stage
How do we stage cervical cancer? [3]
How do we diagnose it in the first place?
EUA esp rectal exam
PET-CT
MRI
Based on clinical findings and biopsy
How can cervical cancer be treated?
Radical hysterectomy [4]
3 methods if beyond stage 2a or unfit for radical surgery
Stage IV [1]
Radical hysterectomy:
- Remove cancer with border of healthy tissue, explore for mets
- Remove uterus, cervix and upper vagina. Remove parametria and pelvic nodes
- Conserve ovaries
If beyond stage 2a or unfit for radical surgery:
External Beam RT
Chemo - 5 cycles cisplatin
Caesium insertion (24hrs)
Stage IV: palliative RT for bleeding control
HPV 6 & 11 are responsible for causing what problems?
Genital warts
What can be demonstrated at a site of HPV infection [5]
Infected basal layer
Koilocytosis - cells with wrinkled nucleus and perinuclear halo, multinucleation
CIN grading [3]
CIN1 - undifferentiated cells only occupy lowest 1/3 of epithelium and surface cells can mature to big flat cells
CIN2 -undifferentiated cells occupy 2/3 of epithelium thickness, only top layers show maturation to medium size cells
CIN3 - Neoplastic cells or undifferentiated cells fill full thickness of epithelium, no normal differentiated cells seen
How does persistent HPV infection cause cervical cancer? [3]
How does E6 and E7 proteins affect host genome?
Viral DNA integrates into host cell genome
Overexpression of viral E6 and E7 proteins causing
Dysregulation of host cell cycle
E6 - inhibits cell death
E7 - prevents cell cycle arrest
Symptoms of advanced disease [6]
Signs [5]
Symptoms: Advanced disease - Heavy vaginal bleeding - Ureteric obstruction - Weight loss - Bowel disturbance - Vesicovaginal fistula - Pain
Signs: Irregular, punched out lesion Exophytic - cauliflower, fungating Bleeds on contact with speculum Roughened and hard cervix on bimanual Loss of fornices (advanced)
FIGO staging [4]
I: confined to cervix (A: microscopic (1: <3mm, 2:<5mm), B: macroscopic (1: <4cm diameter, 2:>4cm diameter))
II: spread to upper 2/3 vagina (A) or parametria (B)
III: spread to lower 1/3 vagina (A) or pelvic wall (B)
IV: spread to bladder or rectum (A) or distant organs (B)
Cervical ectropion or erosion
Ax [3]
Pathogenesis [2]
Ix [3]
Ax: puberty, COCP, pregnancy
Px: increased in oestrogen [1] leads to extension of endocervical epithelium over paler ectocervix [1]
Ix: pregnancy test, triple swab, smear test
Cervical ectropion or erosion Symptoms [4] Signs [1] Mx [2] When to do nothing [3]
Sy: post-coital bleeding, intermenstrual bleeding, mucus discharge, infection
Si: red ring around external os on speculum
Mx: Switch to non-hormonal contraceptive if on COCP. Cautery w/ diathermy if pt wishes
Do nothing if asymptomatic, pubertal or pregnant
Management of CIN1 [2]
6m colposcopy if HPV positive
LLETZ if doesn’t regress
LLETZ complications [6]
Cx: haemorrhage, infection, vaso-vagal symptoms, cervical stenosis, cervical incompetence, premature delivery
