cervical, vulvar, vaginal cancer

Question 1

HPV role in cancer

Answer 1

• produces proteins that overcome RB and p53 genes

- interplay /w smoking, immunodeficiency

Question 2

cervical cancer screening

Answer 2

start at 21 if sexually active

repeat q3 years if normal

stop at 70 if 3 neg in past 10 years

if no cervix, no screening (unless hx of cerv neoplasia)

if visible lesion, no pap, straight to colposcopic biopsy

Question 3

cytology reports and management

Answer 3

atyp squamous cells - undetermined sign (ASCUS)
= repeat at 6 + 12mo, if normal resume N screen, abnormal = colpo. If over 30 can do HPV test instead

ASC - cannot rule out HSIL
= colposcopy

Low grade squamous intraepithelial lesion (LSIL)
= repeat at 6 + 12m, if abnormal colpo, otherwise cont

HSIL = colpo
atypical glandular cells = colpo
adenocarcinoma in situ = colpo

squamous cell carcinoma or adenocarcinoma = urgent colpo

unsatisfactory - repeat in 3mo
benign endometrial cells - endo bx if post-menopausal

Question 4

colposcopy procedure

Answer 4

• acetic acid to highlight dysplasia, biopsy

- after biopsy can treat

Question 5

treatment options for dysplasia

Answer 5

• ablative (no specimen, for LSIL, must have visualize entire lesion + not look invasive): laser, cryo, electrocoagulation
• excisional (+ve endocervical currettage, glandular, microinvasive cancer, or unsure): Loop-Electrosurgical-Excision-Procedure (or cone biopsy)

also hysterectomy if minimal cervical length, other pathology – must r/o cancer

Question 6

prevention levels

Answer 6

primary - vaccine, abstinence, condoms, smoking, HIV

second - PAPs

tertiary - detect + treat cancer to prevent morbidity

Question 7

HPV vaccine popluation

Answer 7

females and males over age 9

all get in school in gr 7

Question 8

symptoms of cervical cancer

Answer 8

• none
• vag bleed
• malodourous discharge, weight loss, pelvic pain, sciatica, urine obstruction, GI (late symptoms)

Question 9

cervical cancer staging

Answer 9

clinical FIGO stage

- spec, biman, rectal, CXR, cystoscopy, proctoscopy, IV pyelogram (not CT + MRI for stage)

Question 10

treatment for cervical cancer

Answer 10

• early stage invasive (cervix only) = rad surg (keeps ovaries) or chemorad
• late early stage (>4cm) or advanced (out of cervix) = chemoradiation

Question 11

surgeries for cervical cancer

Answer 11

rad hysterectomy (remove more cervix + some vag + parametria)
\+ pelvic +/- paraaortic lymph nodes
- may keep ovaries

small invasive cancer + want fertility: radical trachelectomy (leaves uterus) - 60% fertile

if microinvasive (<3mm invasion) can do simple hyst or cone biopsy

after chemorad if recurrs: pelvic exenteration (if no other mets)

Question 12

radiation therapy for cerv cancer

Answer 12

• early cancers + not surg candidate, or advanced cancers (or adjuvent based on post-op pathology)
• external beam + brachytherapy

Question 13

chemo for cervical cancer

Answer 13

/w radiation as radiosensitizer

cistplatin

or palliative

Question 14

vulvular intra-epithelial neoplasia dx + managment

Answer 14

• macular or papular, keratotic, often rough surface
• white, grey or brown
• mostly in immunosuppressed elderly women, +/- HPV
• dx on punch biopsy (2-4mm, monsels if bleed)
• tx: wide excision, sulfcial skinning vulvectomy, or CO laser vaporization (most, but don’t do if suspicious of invasive)

Question 15

vulvodynia + vulvar vestibulities tx

Answer 15

dynia:
moisture, cold, amitriptyline, gabapentin, xylocaine, biofeedback

vestibulitis:
remove yeast, BCP, moisture, diet changes, baiofeedback, CBT, resection if reproducible

Question 16

extramammary paget’s disease appearance + tx

Answer 16

• associated /w adenocarcinoma
• white lesion on vulva, eczematoid appearance, on hair portion, weeping
• pruritis, sore
• sometimes secondary primary neoplasm (cervix, colon, bladder, galbladder, breast)
• tx: resection, may need to repeat

Question 17

vulvar cancer dx + staging

Answer 17

• older
• mass, pruritis +/- groin mass
• raised, ulcerated, fleshy or warty
• most commonly squamous
• assess genitals + lymph nodes
• dx: biopsy, staging /w FIGO

Question 18

vulvar cancer tx

Answer 18

• surgical excision
• if extensive, pre-op chemorad to shrink
• primary chemorad if unresctable
• inguinal femoral lymphadenectomy if >1mm invasion (ipsilat only), or sentinel node procedure
• post-op chemorad based on pathology (eg positive nodes)

Question 19

vagina cancer dx + tx

Answer 19

• visible lesions: biopsy
• VAIN = dysplasia
• symptoms = bleed, discharge, nothing
• caused by HPV
• tx biopsy on colpo, then destructive means or excision
• usually secondary (anal, vulva, endometrium, cervix.. look there)
• exception = DES exposure