Cervical screening, colposcopy and cervical cancer

Question 1

Please outline what features you are looking for during colposcopy:

Answer 1

• Satisfactory/unsatisfactory colposcopy and why.
• SCJ visibility: completely, partially or not visible.
• Transformation zone type 1, 2 or 3.

Describe abnormal findings:

• Location of lesion: inside or outside TZ
• Location of lesion by clock position.
• Size of lesion by number of quadrants it covers.
• Acetowhite changes: thin/dense, geographic border (irreg/sharp)
• Lugol’s iodine: stained/non-stained
• Glands
• Blood vessel pattern: Mosaic (fine/coarse), punctation (fine/coarse)

Overall impression:

• Normal
• Condyloma/subclinical papillomavirus infection (SPI)
• LSIL
• HSIL
• ACIS
• SCC
• Adenocarcinoma
• Other

Question 2

Counsel someone about the HPV vaccine Gardasil 9

Answer 2

• Protects against 9 subtypes of HPV including the commonest causes of cervical cancer and genital warts.
• Provides 90% protection against cervical cancers.
• Most effective if given before sexual activity/contact with HPV but benefit for women who have had sex already.
• Does not contain virus; contains recombinant proteins from the outer shell of the virus. You cannot get HPV from the vaccine itself.
• The vaccine teaches the immune system to recognise the virus so that when exposed to the real thing, antibodies will protect them from infection.
• If <15 years old: 2 x doses 6 months apart.
• If >15 years old: 3 doses at 0, 2 and 6 months.
• Side-effects: local site reaction, mild fever, nausea, dizziness, Guillain-Barre, anaphylaxis.

Question 3

Explain to a patient why colposcopy is needed and what to expect

Answer 3

• Indication: Cervical screening has found abnormal cells in your cervix. Cells can often go away on their own but there is a risk they could also turn into cervical cancer if not treated.
• Procedure: takes around 15-20 mins.
  
  • Undress from the waist down and lie down in a chair with padded supports for your legs.
  • A device called a speculum is inserted into your vagina and opened so we can see the cervix.
  • A microscope with a light called a colposcope is used to look carefully at your cervix.
  • We apply liquids to the cervix to highlight any abnormal areas.
  • We biopsy any abnormal areas; we take a very small sample and it can briefly feel uncomfortable for a second while we take it.
  • You will have some abnormal brown discharge or a little bit of bleeding after the procedure.

Question 4

List the FIGO staging of cervical cancer

Answer 4

• Stage I: only on cervix
  
  • Stage IA1: microinvasion ≤5mm.
• Stage II: invasion beyond uterus but not lower ⅓ vagina or pelvis.
• Stage III: spread to pelvic wall, lower ⅓ vagina, ureteric obstruction, pelvic or para-aortic nodes.
• Stage IV: spread to bladder, bowel or outside of pelvis.

Question 5

Outline investigations and work-up for suspected cervical cancer

Answer 5

• Colposcopy and biopsy/ECC and/or EUA and biopsy/ECC
  
  • Hysteroscopy, cystoscopy and proctoscopy.
• Imaging: pelvic USS, CT AP or PET CT, IV pyelogram, MRI, CXR, skeletal XR
• Bloods: FBC, U&Es, LFTs

Question 6

Explain how you would perform an EUA for suspected cervical cancer

Answer 6

• Lithotomy position
• Speculum, bimanual and rectovaginal exam: parametrial, vaginal and rectal invasion.
• Cervical: colposcopy, biopsies and ECC
• Hysteroscopy
• +/- cystoscopy and proctoscopy.
• Palpate groin and supraclavicular lymph nodes and right upper quadrant for distant metastases.

Question 7

Outline risks associated with fertility sparing surgery for cervical cancer

Answer 7

• Cone biopsy: bleeding, preterm birth, cervical stenosis.
• Simple trachelectomy: bleeding, preterm birth, cervical stenosis, abnormal PVB and discharge, vault scarring/dyspareunia
• Vaginal radical trachelectomy: in addition to the above.
  
  • Parametrium: urinary dysfunction, vaginal shortening, ureterovaginal fistula.
• Abdominal trachelectomy: in addition to above.
  
  • Bilateral uterine arteries sacrificed: endometrial atrophy, lower birth rate, IUGR

Question 8

Outline the management of cervical cancer in pregnancy:

Answer 8

• CIN 2-3: defer until postnatal but monitor with colposcopy every trimester.
• Indication for treatment during pregnancy: invasive cancer with LN metastases; progression of disease during pregnancy; patient choice to terminate the pregnancy.
• Stage IA1: cone biopsy ‘coin biopsy’ 12-20 weeks +/- prophylactic cerclage.
• Stage IA2-IB1 (<2 cm): cone biopsy or simple trachelectomy + laparoscopic pelvic lymphadenectomy < 20 weeks.
• Stage IB1 (>2 cm): neoadjuvant chemotherapy +/- pelvic lymphadenectomy; then CS and radical hysterectomy after delivery.
  
  • Risk: PTL, PPROM, IUGR.
• If >20 weeks, can’t have pelvic lymphadenectomy so use NACT until fetal maturity (35-36 weeks).

Question 9

Outline management of AIS

Answer 9

• Simple hysterectomy
• Fertility sparing: cone biopsy + ECC + D&C

Follow-up post-hysterectomy:

• Annual vault hrHPV testing for 3 years; if all negative then hrHPV test every 3 years for at least 25 years.
• For vault cytology and vaginal colposcopy if hrHPV positive.

Follow-up after cone biopsy:

• Cotesting hrHPV and cytology with ECC every 6 months for 3 years.