Cervical Disorders Flashcards
Explain the anatomy of the cervix, in relation to cellular composition
Endocervix (canal)
- Lined by columnar (glandular) cells
Ectocervix (continuous with vagina)
- Lined by squamous epithelium
Squamocolumnar junction (region of transformation zone) - Where the two types of cells meet
Describe how the transformation zone is formed, and the significance of this area
- During puberty and pregnancy, partial eversion of the cervix occurs
- This exposes the columnar cells to the low pH of the vagina –> metaplasia to squamous epithelium
- This area of new cells is the transformation zone
- This is where cells are most vulnerable to neoplastic change
Define ectropion and outline in which women it is usually found in
When columnar epithelium of the endocervix is visible as a red area around the os on the surface of the cervix, this is due to eversion
3Ps
- Commonly found in pregnant women, those taking the pill and during puberty
Outline the clinical presentation of ectropion
- Can be asymptomatic
- Post-coital bleeding (most common cause of PCB)
- Vaginal discharge
Describe the investigations and management of cervical ectropion
Investigations:
- Smear
- Possible colposcopy depending on smear results
- Cervical and upper vaginal swabs to test for STIs
Management (if causing functional problems)
- Switch from oestrogen based contraception
- Cervical ablation (cryocautery)
Define, outline the risk factors, clinical presentation and management for cervical polyps
Benign tumours arising from the endocervical epithelium
Symptoms:
- Asymptomatic, PCB, IMB
Managment:
- Removed with avulsion
Define and outline the treatment for cervical nabothian follicles
Occur when squamous epithelium forms over the columnar epithelium of the transformation zone. The underlying columnar secretions are trapped, forming cysts which appear as white or opaque swellings
Management: nil (unless very large and symptomatic)
Define CIN (cervical intraepithelial neoplasia)
Presence of atypical cells within the squamous epithelium. These atypical cells are dyskaryotic:
- Exhibiting larger nuclei
- Frequent mitoses
This makes CIN a histological diagnosis
Explain the 3 different grades of CIN
• CIN I (mild dysplasia): Atypical cells are found only
in the lower third of the epithelium.
• CIN II (moderate dysplasia): Atypical cells are found
in the lower two-thirds of the epithelium.
• CIN III (severe dysplasia): Atypical cells occupy
the full thickness of the epithelium. (No invasion of basement membrane, if this occurs there is malignancy)
Explain how HPV increases the risk of developing CIN
- Incorporation of viral DNA into host cell DNA, in the TZ
- Viral proteins inactive tumour suppressor genes
- -> more mutations –> dysplasia –> carcinoma
- Virus also induce changes to hide infected cell from immune system
Outline the different screening procedures for cervical pre-malignant & malignant conditions
- Cervical smear (cytology)
- Colposcopy (+ biopsy)
Which strains of HPV does the childhood vaccine protect against?
6, 11, 16 & 18
- 16 & 18 responsible for most cases of cervical cancer
- 6 & 11 can cause genital warts
- Given to 12 to 13yr olds (Year 8)
At what ages and how frequently are smears taken in the cervical cancer screening programme
- 25-49 every 3 years
- 50-64 every 5 years
Explain what can be seen on cervical smear samples
- Identifies cellular NOT histological abnormalities
- Can detect and grade dyskaryosis (borderline, low, high grade)
- This suggests the presence of CIN
- Can detect cervical glandular intraepithelial neoplasia: CGIN (abnormal columnar cells)
- Also tests for HPV
Outline the clinical presentation of CIN
- Generally asymptomatic
* Speculum – cervix often unremarkable
Outline the next steps in investigation for the following smear results:
normal, borderline OR low grade dyskaryosis, high grade dyskaryosis, CGIN
Normal: return to routine cervical screening
Borderline or low grade dyskaryosis:
- If HPV -ve: return to routine recall
- If HPV +ve: colposcopy
High grade dyskaryosis: colposcopy
CGIN: colposcopy (if no abnormality, then hysteroscopy)
- Want to exclude adenocarcinoma of the cervix or endometrium
Give some risk factors for developing CIN
Multiple sexual partners, early age of first intercourse, smoking, low socioeconomic status, HIV
Give the management for CIN
CIN II/III:
- LLETZ (large loop excision of transformation zone)
- Resulting specimen is further tested histologically
What are some complications of LLETZ?
- Postoperative haemorrhage (uncommon)
- Risk of subsequent preterm delivery
Outline the pathology of cervical cancers
- 90% squamous cell carcinoma
- 10% adenocarcinoma
CIN is the pre-invasive stage for SCC
Give some risk factors for cervical cancer
- CIN
- Rest same as RF for CIN: smoking, early first intercourse,
multiple sexual partners, lower, socioeconomic status, HIV
NOT hereditary
Describe the clinical presentation of cervical cancer on history and examination
History:
- PCB, IMB
- Offensive vaginal discharge
- Often missed smears
- Later stages of disease: uraemia, haematuria, rectal bleeding, pain (ureter, bladder, rectum and nerve involvement)
Examination
- Palpable or visible cervical ulcer/mass
- Abdominal mass (pelvic spread)
Outline some investigations for cervical cancer
- Tissue dx – colposcopy and biopsy
- Bloods – FBC (anaemia), U&E (obstruction), LFT (mets), clotting (if abnormal LFT), GS (surgical prep)
- Imaging – CXR, CT (radiological staging), MRI (increased accuracy, can assess) lymph nodes
- Other – cystoscopy
Describe the FIGO staging of cervical cancer (stages 1,2,3,4)
Stage 1: confined to cervix
1a: only seen under microscope, 1b: clinically visible
- 1a(i): max horizontal dimension = 7mm and depth of invasion = <3mm
- 1a(ii): max horizontal dimension = 7mm, depth of invasion = 3-5mm
- 1b(i): lesions greater than 1a(ii), no greater than 4cm in size in greatest dimension
- 1b(ii): clinically visible, greatest dimension >4cm
Stage 2: invasion into vagina (upper 2/3rds only), but not pelvic side wall
- 2a: involves vagina
- 2b: involves parametrium
Stage 3: invasion of lower vagina and/or pelvic wall
- 3a: lower 1/3rd of vagina
- 3b: pelvic wall: hydronephrosis due to ureteric obstruction
Stage 4: involves bladder, rectal mucosa or extends beyond the true pelvis (distant spread)
Outline the management for cervical cancer
Surgical:
1a(i)
- Cone biopsy
- Or simple hysterectomy (older women)
1a(ii)
- Simple hysterectomy with pelvic lymphadenopathy
1b
- May be suitable for trachelectomy (radical excision of
cervix) to conserve fertility
1b or 2a
- Radical hysterectomy and pelvic lymphadenopathy
Chemoradiation
- Can be used for 1a(ii) - 2a, if LN are involved, as alternative to surgery
2b and worse, or positive LN:
- Radiotherapy and chemotherapy (platinum) alone
Recurrence:
- Consider radiation if not already given, or pelvic exenteration (removal of uterus, cervix, bladder and/or rectum)
Outline the difference between: simple hysterectomy, radical hysterectomy, trachelectomy
Simple hysterectomy
- Uterus and cervix removed
Radical hysterectomy
- Hysterectomy: uterus, ovaries
- Pelvic node clearance
- Removal of parameterium and upper 1/3rd of vagina
Trachelectomy
- Laparoscopic lymphadenectomy first
- If nodes +ve: use chemo-radiotherapy, if nodes -ve, then progress to trachelectomy
- -> Removal of 80% of cervix and the upper vagina
Outline the prognosis for cervical cancer, in the following stages: I,II,II,IV
Five year survival:
Stage I, II, II, IV → 90-95%, 65%, 35%, 10-30%
