Cervix

Question 1

What is the anatomy of the cervix?

Answer 1

• Cervix is a tubular structure, continuous with the uterus, 2-3cm long- predominantly elastic connective
• Attached posteriorly to the sacrum by the uterosacral ligaments and laterally to the pelvic side wall by the cardinal ligaments
• Lateral to the cervix is the parametrium containing connective tissue, uterine vessels and the ureters

Question 2

What is the transformation zone of the cervix?

Answer 2

• There are two areas of the cervix, the two cell types meet at the squamocolumnar junction
o Endocervix- lined with glandular epithelium
o Ectocervix- lined by squamous epithelium
• During puberty and pregnancy, partial eversion of the cervix occurs- lower pH of the vagina causes the columnar epithelium to undergo metaplasia to squamous epithelium and produces a transformation zone at the junction
• Cells undergoing metaplasia are vulnerable to agents that induce neoplastic change- it is from this area that cervical carcinoma commonly originates

Question 3

What is the blood supply and lymph drainage of the cervix?

Answer 3

• Blood supply is from the upper vaginal branches and the uterine artery
• Lymph drainage is to obturatory and internal & external iliac nodes then to the common iliac and para- aortic nodes
• Cervical carcinoma characteristically spreads in the lymph- locally by direct invasion into the uterus, vagina, bladder and rectum

Question 4

What is cervical ectropion (erosion)?

Answer 4

the columnar epithelium of the endocervix are visible as a red area around the external os- due to eversion and is a normal finding in younger women, particularly those who are pregnant or taking the pill Normally asymptomatic, but can cause vaginal discharge/ postcoital bleeding
treated with cryotherapy, but only after a smear/colposcopy excludes a carcinoma
NB – exposed epithelia are prone to infection

Question 5

What is acute cervicitis?

Answer 5

Rare, but often results from STIs
ulceration and infection are occasionally found in severe degress of prolapse when the cervix protrudes or is held back with a pessary

Question 6

What is chronic cervicitis?

Answer 6

chronic inflammation or infection, often of an ectropion
common cause of vaginal discharge
may cause ‘inflammatory smears’- cyrotherapy is used +/- antibiotics depending on bacterial culture

Question 7

What are cervical polyps?

Answer 7

benign tumours of the endocervical epithelium
most common >40yrs and normal <1cm
may be asymptomatic, but can cause intermenstrual or postcoital bleeding
small polyps can be avulsed without anaesthetic and histologically, but bleeding abnormalities must still be investigated

Question 8

What are nabothian follicles?

Answer 8

where squamous epithelium has been formed by metaplasia over endocervical cells
the columnar cells secretions are trapped and form retention cysts
appears as white or opaque swelling on the ectocervix- treatment is not required unless symptomatic

Question 9

What is cervical intraepithelial neoplasia? (CIN)(cervical dysplasia)

Answer 9

the presence of atypical cells with the squamous epithelium

these atypical cells are dyskaryotic, so exhibit larger nuclei with frequent mitoses

Question 10

How is CIN graded?

Answer 10

o CIN I (mild dysplasia)-atypical cells are found only in the lower third of the epithelium
o CIN II (moderate dysplasia)- atypical cells are found in the lower two-thirds of the epithelium
o CIN III (severe dysplasia)- atypical cells occur in the full thickness of the epithelium
(carcinoma in situ- the cells are similar to appearance to those in malignant lesion, but there is no invasion- malignancy ensues if these abnormal cells invade through the basement membrane

Question 11

What is the prognosis for CIN?

Answer 11

• In untreated, 1 in 3 women with CIN II/III will develop cervical cancer in the next 10yrs- CIN I has the least malignant potential and commonly regresses spontaneously, but can progress to CIN II/III
• 90% of women with CIN III are <45yrs, peak incidence in those aged 25-29yrs

Question 12

What is the aetiology of CIN?

Answer 12

• Human papilloma virus (type 16, 18, 31 & 33)- most important factor is the number of sexual contacts, particularly in early age, vaccination against individual viruses reduces the incidence of precancerous cervical lesions and therefore the potential for cervical cancer, but should be administered before 1st sexual contact as it is only prophylactic
• Oral contraceptive useage and smoking- associated with a slightly increased risk of CIN
• Immunocompromised patients (eg. HIV), also at an increased risk and of early progression to malignancy

Question 13

What is the pathology of CIN?

Answer 13

• Columnar epithelium undergoes metaplasia to squamous epithelium in the transformation zone- exposure to HPV results in incorporation of viral DNA into cell DNA, viral proteins inactivate key tumour suppressor gene products and pushes the cell into a cell cycle, over time other mutations accumulate and can lead to carcinoma
• Viruses can also cause changes to hide the infected cell from the immune system, failure of the immune system to detect and destroy these cells can result in malignancy eg. cell changes or immunosuppression

Question 14

When are cervical smears performed?

Answer 14

Performed on all women from 25yrs, or after 1st intercourse if later, then repeated every 3yrs until 49y/o, between 50-64yrs smears are performed every 5yrs
• Abnormal smears identifies women likely to have CIN and therefore at risk of subsequent development on invasive cancer
• Women <25yrs often have abnormal cervical changes

Question 15

How is CIN diagnosed?

Answer 15

Smears: abnormalities are called dyskaryosis
• Dyskaryosis is graded mild, moderate and severe- suggests the presence of CIN, with grading partly reflected the severity of CIN
• Colposcopy is used to investigate abnormal smear- hysteroscopy is used if the cause of the abnormal cells is still unclear
• Occassionally, abnormal columnar cells are visible (cervical glandular intraepithelial neoplasia (CGIN)-adenocarcinoma of the cervix and endometrium should then be excluded using colposcopy and endocervical curettage or cone biopsy

Question 16

What is colposcopy?

Answer 16

• If a cervical smear is severely or persistently abnormal, a colposcopy is performed to detect the presence and grade of CIN
• The cervix is inspected via a speculum using a operating microscopy with magnification 10 to 20-fold
• Grades of CIN have characteristic appearance when stained with 5% acetic acid, although the diagnosis is only confirmed histologically and therefore a biopsy is required

Question 17

What is the management for CIN I or II?

Answer 17

large loop excision of transformation zone (LLETZ), the transformation zone is excised with cutting diathermy under local anaesthetic- the specimen is examined histologically
• LLETX enable diagnosis and treatment to be achieved at the same time- complications (post-operative haemorrhage and increased risk of preterm delivery)
• Alternatively, small biopsy of the abnormal area can be taken colposcopically and confirmatory results awaited before performing LLETZ
• If CIN II is found then the woman has around a 30% chance of developing cancer over 8-15 years, but screening has reduced the number of cervical cancers in the UK by 75% over the last 20 years

Question 18

What is cervical carcinoma?

Answer 18

2 peaks of incidence at 30yrs and 80yrs
• 95% of cervical malignancies are squamous cell carcinoma, 10% are adenocarcinomas originating from the columnar epithelium (worse prognosis)
• CIN is the pre-invasive stage- causative factors are therefore the same, HPV is found in all cervical cancers, so vaccination is likely to prevent many cases in the future, immunosuppression also accelerates the process of invasion from CIN
• NB - there is no familial link for cervical cancer

Question 19

What are the clinical features of cervical carcinoma?

Answer 19

•	Signs & symptoms
o	Postcoital bleeding
o	Offensive vaginal discharge
o	Intermenstrual bleeding
o	Post-menopausal bleeding
o	Pain (late feature)
Later stages:
o	Uraemia
o	Haematuria
o	Rectal bleeding
o	Pain
•	An ulcer or mass may be visible or palpable on the cervix, but with early disease the cervix may appear normal to the naked eye

Question 20

How does cervical carcinoma spread?

Answer 20

spreads locally to the parametrium and vagina, then to the pelvic side wall
o Lymphatic spread to the pelvic nodes is an early feature
o Ovarian spread is rare with squamous carcinoma
o Blood-bourne spread occurs late

Question 21

What are the investigations for a cervical carcinoma?

Answer 21

Tumour is biopsied
• Stage the disease- vaginal and rectal examination used to assess size of lesion and parametrial or rectal invasion examination done under anaesthetic, unless small
cystoscopy detects bladder involvement
MRI detects tumour size, spread and lymph node involvement

Question 22

What is the treatment for stage 1a(i)?

Answer 22

treated with cone biopsy, as risk of LN spread is only 0.5% hysterectomy is preferred in older women

Question 23

What is the treatment for stage 1a(ii) to 2a?

Answer 23

o Radical abdominal hysterectomy: includes pelvic node clearance, hysterectomy and removal of parametrium and upper third of the vagina, ovaries only left in young women to prevent menopause
o Radical trachelectomy: less invasive procedure for conserving fertility, laparoscopic pelvic lymphadenectomy is first performed (+ve = chemo-radiotherapy)
involves removal of 80% of cervix and upper vagina, suitable for Stage 1a(ii)-1b(i) is tumour is <20mm
a cervical suture is inserted to help prevent preterm delivery, if margins are incomplete then chemo-radiotherapy is required

Question 24

What is the management for stage 2b or worse (+Ve LN)?

Answer 24

Should be treated with radiotherapy and chemotherapy (eg. platinum agents)
the use reduced recurrence and increases survival, palliative radiotherapy is used for bone pain or haemorrhage
• Recurrent tumours- treated with chemo-radiotherapy if not used previously
pelvic exenteration (removal of vagina, bladder and/or rectum) can be considered if the disease is central if it has been used and has 50% cure rate
pre-operative MRI & PET scan used to look for metastases
• Patients are reviewed at 3 and 6 months- then every 6 months for 5 years, recurrent disease is commonly central

Question 25

What are the poor prognostic indicators in cervical carcinoma?

Answer 25

o	LN involvement
o	Advanced clinical stage
o	Large primary tumour
o	Poorly differentiated tumour
o	Early recurrence
•	Death is commonly from uraemia due to ureteric obstruction