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Year 3 - Reproduction > Cervical screening, cancer and HPV > Flashcards

Cervical screening, cancer and HPV Flashcards

1
Q

Which virus is commonly associated with cervical cancer?

A

HPV = Human papillomavirus

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2
Q

What is the peak prevalence of HPV in terms of age?

A

15-25 years old

  • Prevalence declines with age however.
  • Overall prevalence is 10%
  • Lifetime exposure is up to 75% from serological studies
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3
Q

Within men which types of cancers can be caused by HPV?

A

> Penis = 40% cases are caused by HPV
Anus = 90% of cases are caused by HPV
Mouth = 3% cases are caused by HPV
Oropharynx = 12% cases caused by HPV

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4
Q

Within women which types of cancers can be caused by HPV?

A 
> Cervix = 99% of cases caused by HPV
> Vulva/Vagina = 40% cases are caused by HPV
> Anus = 90% of cases are caused by HPV
> Mouth = 3% cases are caused by HPV
> Oropharynx = 12% cases caused by HPV
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5
Q

Where can abnormal growth of squamous cells be detected on smear?

A

The transformation zone, changes are called squamous intraepithelial lesions and can be graded low or high depending on how much of the cervical epithelium is affected and how abnormal the cells appear

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6
Q

Abnormal cells in the cervix detected by biopsy and histological examination are classified as what?

A

Cervical intraepithelial neoplasia (CIN). Graded 1 to 3 according to the proportion of cervix affected.

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7
Q

What is considered CIN I? How is this managed?

A

When <1/3rd of the thickness of the epithelium is involved

Mild dyskaryosis

1) Perform HPV testing (Cervical cytology)
2) If positive colposcopy within 8 weeks
3) If negative, repeat screen in 3-5 years

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8
Q

What is considered CIN II? How is this managed?

A

When <2/3rd of the thickness of the epithelium is involved

Moderate dyskaryosis

Urgent colposcopy within 2 weeks

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9
Q

What is considered CIN III? How is this managed?

A

Almost entire epithelium is involved, this is rarely reversible

Severe dyskatyosis

Urgent colposcopy with punch biopsy within 2 weeks

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10
Q

If after cervical screening there is changes what is the next step?

A

HPV serology

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11
Q

If there is a positive HPV serology what is the next step?

A

Colposcopy

  • if low grade (CIN I) within 8 weeks
  • if high grade CIN II within 2. weeks, CIN III requires bunch biopsy
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12
Q

What percentage of patients with CIN 1 will regress in patients aged 15-34 yrs old?

A

> 65%

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13
Q

What percentage of patients with CIN 1 will regress in patients aged >35 yrs old?

A

40%

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14
Q

Which forms of HPV commonly cause cervical cancer?

A

High risk:
> 16, 18, 31 and 33.
> With 16 and 18 causing 70% of cervical cancers in Europe

Low risk:
> 6 and 11

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15
Q

At CIN 2/3 at biopsy what percentage of patients will go onto develop cervical carcinoma?

A

40%

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16
Q

What is the prevention protocol now?

A

UK HPV Immunisation Programme:

1st Sept 2008
> Girls born after 1 September 1990 = Bivalent vaccine HPV16/18

Sept 2012
> Quadrivalent vaccine HPV 16/18/6/11

Sept 2014
> 2 dose regime

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17
Q

What is LBC?

A

Liquid based cytology

Hybridisation of PCR is usually used which allows identification of high risk types of HPV (16, 18, 31 and 33)

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18
Q

Which type of epithelium is present within the endocervix?

A

Columnar epithelium

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19
Q

Which type of epithelium is present within the ectocervix?

A

Squamous epithelium

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20
Q

How many samples show mild dyskaryosis (CIN I)?

A

Of satisfactory smears, around 6% will show mild dyskaryosis or borderline nuclear abnormalitiy (BNA) due to HPV features or very minor abnormalities

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21
Q

How many samples show moderate dyskaryosis (CIN II) or sever dyskaryosis (CIN II)?

A

1.5%

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22
Q

What forms the transition zone?

A

It is where the columnar epithelium of the endocervix meets the squamous epithelium of the ectocervix

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23
Q

What is an abnormal cytology of the cervix called? Nuclear features?

A

Dyskaryosis

Nuclear features:
> Increased size and nuclear:cytoplasmic ratio
> Variation in size, shape and outline
> Coarse irregular chromatin
nucleoli
24
Q

What are the nuclear features in dyskaryosis?

A 
Nuclear features:
> increased size and nuclear:cytoplasmic ratio
> Variation in size, shape and outline
> Coarse irregular chromatin
nucleoli
25
Q

Koilocytes on cytology?

A

KOILOCYTES - reflect HPV infection

26
Q

Advantages of HPV test?

A

Sensitive to allow easy confirmation of HPV

27
Q

Advantages of HPV test?

A

Specific, allowing identification go cellular changes and low grade (CIN I) or high grade (CIN II/III) dyskaryosis

28
Q

So if the patients HPV test was negative for high risk HPV (hrHPV) what would be the next step in management?

A

Routine recall in 5 years

29
Q

So if the patients HPV test was positive for high risk HPV (hrHPV) what would be the next step in management?

A

Perform cytology:
> If normal; repeat tests in 1 year
> If Dyskaryosis refer to colposcopy (If low grade within 8 weeks If high grade within 2 weeks, CIN III requires punch biopsy)

30
Q

What is used to help within visualisation of the lesion within colposcopy?

A

Acetic acid =/- Iodine

31
Q

What is CIN?

A

Cervical intraepithelial neoplasia

32
Q

How does HPV cause cancer?

A

Two pathways:
1) E6 = Down regulation of p53, this inhibits cell death and allows progression of G1 to S phase

2) E7 = Down regulates Rb, this inhibits cell cycle arrest and allows E2F to progress the cell cycle into S1

33
Q

HPV histology?

A

Koilocytosis:
Cells with wrinkled nucleus and perinuclear halo

Multinucleation

34
Q

Low Risk types

6, 11, 42, 44 (et al), cause what?

A

Genital warts and Low grade CIN

Often transient and resolve

35
Q

High Risk types

16, 18, 31, 45 (et al) , cause what?

A

Persistent infection increases risk of developing high grade CIN and (more rarely) cancer

36
Q

How does HPV cause high grade CIN?

A

Persistent infection
> Viral DNA integrates into host cell genome
> overexpression of viral E6 and E7 proteins
> deregulation of host cell cycle

Two pathways:
1) E6 = Down regulation of p53, this inhibits cell death and allows progression of G1 to S phase

2) E7 = Down regulates Rb, this inhibits cell cycle arrest and allows E2F to progress the cell cycle into S1

37
Q

How is CIN II and III treated?

A

> LLETZ
Thermal Coagulation
Laser ablation

Then follow ups, LBC at 6months:

1) To rule of residual disease
2) To rule out recurrent disease
3) To detect occasional cancer
4) To reassure the women

38
Q

After treatment of CIN II and III what is the next steps?

A

Follow-up LBC at 6 months for cytology and high risk HPV

1) Both negative – return to recall
2) Either positive – return to colposcopy

39
Q

Incidence and death of cervical cancer in the UK?

A

> 2500 cases per year in UK
1200 deaths
10th components cancer in women in Scotland

40
Q

Peak age for cervical cancer?

A

45-55 years old

41
Q

Risk factors for cervical cancer?

A 
> Peak age 45-55 years
> HPV related (16 &amp; 18)
> Multiple partners
> Early age at first intercourse
> Older age of partner
> Cigarette smoking
> Immunodeficiency 
> Use of oral contraceptive
42
Q

What are the symptoms of cervical cancer?

A 
> Abnormal vaginal bleeding
> Post coital bleeding
> Intermenstrual bleeding/PMB
> Discharge
> (Pain)
43
Q

How is cervical cancer diagnosed?

A

> Clinical
Screen detected (Pap smear, LBC, HPC serology)
Biopsy

Remember screening aims to detect pre-cancerous disease NOT cancer

44
Q

Histology of cervical cancer?

A

Tumour cells from epithelium invade into underlying stroma

Majority squamous carcinoma (80%)

Adenocarcinoma (endocervical) rising in relative incidence (15%)

45
Q

Stage 1A of cervical cancer?

A

Stage IA: Invasive cancer identified only microscopically.

IA1 ≤ 3 mm depth and ≤7 mm diameter (=microinvasive)

IA2: ≤ 5 mm x7 mm

46
Q

Stage 1B of cervical cancer?

A

Stage IB: clinical tumours confined to the cervix

47
Q

Stage 2 of cervical cancer?

A

Local invasion into upper 2/3rds of the vagina

48
Q

Stage 3 of cervical cancer?

A

Local invasion into lower vagina, pelvis

49
Q

Stage 4 of cervical cancer?

A

Local invasion into bladder, rectum

50
Q

How does cervical cancer metastases and where to?

A

Lymphatic – pelvic nodes

Blood – liver, lungs, bone

51
Q

What is the leading cause of death caused by cervical cancer?

A

Local invasion through the anterior uterine wall into the bladder blocking the ureters.

This leads to urinary retention and increased rates of hydronephrosis with post renal failure which can cause death.

52
Q

Tools/Tests use to stage cervical cancer?

A

1) EUA (Especially rectal) = Examination under anaesthesia
2) PET-CT
3) MRI

53
Q

How is stage 1a cervical cancer treated?

A

Stage 1a: Type 3 Excision of the cervical TZ or hysterectomy

54
Q

How is stage 1b-2a cervical cancer treated?

A

Stage 1b - 11a:
Radical hysterectomy or
chemo-radiotherapy

55
Q

How is stage 2b-4 cervical cancer treated?

A

Chemo-Radiotherapy

56
Q

What is taken away during radical hysterectomy?

A

Removal of:

1) Uterus, cervix, upper vagina
2) Parametria
3) Pelvic nodes
4) Ovaries conserved

The pelvic and para-aortic nodes will be explored and possibly removed

57
Q

Non-surgical treatment of cervical cancer options?

A

Radiotherapy- External Beam x 20 fractions

Chemotherapy- 5 cycles of cisplatin

Caesium Insertion (24 hours)

Year 3 - Reproduction (25 decks)

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