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Reproductive Medicine > Cervix - benign and malignant disease and screening > Flashcards

Cervix - benign and malignant disease and screening Flashcards

1
Q

What are the high risk types of HPV?

A

16, 18, 31, 45

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2
Q

How does HPV cause cervical cancer?

A
  • Infects basal layer and utilitses host for replication
  • Virus produces E6 + E7 protein product -> prevents cell cycle arrest and inhibits cell death
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3
Q

Where do columnar cells of the endocarvix undergo metaplasia?

A

Transformation zone (squamocolumnar junction)

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4
Q

What is post coital bleeding?

A

Vaginal bleeding occurring immediately after sexual intercourse – this has a 6% annual incidence in the UK

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5
Q

What is intermenstrual bleeding?

A

Vaginal bleeding (other than postcoital) occurring between periods

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6
Q

What are abnormal cells on histology of the cervix classed as?

A

Cervical intraepithelial neoplasia (CIN)

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7
Q

What are risk factors for CIN?

A
  • Early age at first intercourse
  • Multiple sexual partners
  • Prolonged oral contraceptive use
  • STD’s
  • Cigarette smoking
  • Immunodeficiency
  • Persistent high-risk HPV
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8
Q

What is cervical intraepithelial neoplasia?

A

Disorganised proliferation of abnormal cells in squamous epithelium

  • Lack of maturation
  • Variation in cellular size and shape
  • Nuclear enlargement
  • Irregularity
  • Hyperchromasia
  • Cellular disarray
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9
Q

What does CIN 1 indicate?

A

Mild dysplasia

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10
Q

What is the likelihood of CIN 1 progressing to cervical cancer?

A

Usually regress - 50-60% regress within 2 years

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11
Q

What does CIN 2 indicate?

A

Moderate dyskaryosis

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12
Q

What is the likelihood of CIN 2 progressing to cancer?

A

Regression is less likely - 3-5% develop cancer within 10 years

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13
Q

What does CIN 3 indicate?

A

Severe dyskaryosis - full thickness changes

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14
Q

What is the likelihood of CIN 3 progressing to cancer?

A

Regression unlikely - 20-40% develop cancer in 10 years

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15
Q

What screening programme is available to women to monitor for CIN and cervical cancer?

A

Cervical smear:

  • Aged 25-49 - screened every 3 years
  • Aged 50-64 - screened every 5 years

Uses liquid-based cytology to assess the cells of the cervix for premalignant or malignant change

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16
Q

If someone had normal cervical smear, how would you manage them?

A

Follow up in 3 years

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17
Q

How would you follow up someone with an unsatisfactory cervical smear?

A

Repeat smear in 3 months

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18
Q

How would you manage someone with suspected CIN1?

A

Conservative:

  • High risk HPV testing
    • If +ve refer for colposcopy within 6 weeks
    • If -ve - repeat in 3 years
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19
Q

How would you manage someone with CIN 2?

A
  • Refer for colposcopy +/- LLETZ within 2 weeks
  • 6 month follow up
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20
Q

How would you manage someone with CIN 3?

A
  • Refer for colposcopy +/- LLETZ within 2 weeks
  • 6 month follow up
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21
Q

What is involved in LLETZ (loop diathermy)?

A

https://www.youtube.com/watch?time_continue=26&v=rxs5Rg4hn9U

Cone of tissue is removed from cervix. Can be used to biopsy and treat CIN and early cervical cancer

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22
Q

What is involved in colposcopy?

A

Cervix is inspected and acetic acid is applied to its surface – abnormal cells have increased surface proteins, which are coagulated by the acid and turn white, producing “acetowhite” areas which can be biopsied for histological assessment

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23
Q

What are criteria for colposcopy referral?

A
  • High grade dyskariosis
  • 3 x unsatisfactory results
  • Persisting low grade dyskariosis
  • Clinically suspicious cervix
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24
Q

What are the main treatment options for CIN?

A
  • LLETZ
  • Cold coagulation
  • Laser ablation
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25
Q

If someone was treated for CIN 2/3 with LLETZ and was HPV -ve at 6 months, how would you follow them up?

A

3 yearly follow up

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26
Q

How often should HIV positive individuals have a cervical smear?

A

Every year

27
Q

What vaccinations are available for preventing HPV?

A
  • Cervarix (Bivalent) - 16/18
  • Quadravalent (Gardasil) - 16/18/6/11
28
Q

When are females given their HPV vaccine (based on vaccine schedule)?

A

12-13 years at 0, 1 and 6 months

29
Q

What are symptoms of cervical cancer?

A

May be completely asymptomatic:

  • Post coital bleeding
  • Intermenstrual bleeding
  • Menorrhagia
  • Increased/altered vaginal discharge
  • Postmenopausal bleeding
  • Symptoms of advanced disease - pelvic pain, leg pain/swelling, GI problems, lung problems
30
Q

What are signs of cervical cancer?

A

Usually normal except in advanced disease:

  • Pelvic mass
  • Craggy hepatomegaly
  • Speculum - bleeding, discharge or obvious ulceration
  • Bimanual - friable tissue, obliteration of fornices, roughened, hard, irregular cervix which may be fixed/immobile
31
Q

What are causes of post-coital bleeding?

A
  • Trauma
  • Ectropian
  • Cervicitis
  • Cervical/endometrial polyp
  • Cervical cancer
  • Vaginitis
  • Vaginal cancer
  • Vulval dermatitis
  • Vulval cancer
  • STIs - Gonorrhoea, Chlamydia
32
Q

What are causes of intermenstrual bleeding?

A
  • Physiological
  • Trauma
  • Ovarian tumour
  • Uterus - endometritis/PID, polyp, hyperplasia, fibroids, cancer
  • Cervix - cervicitis, polyp, cancer
  • Vagina - vaginitis, cancer
  • Vulva - dermatitis, dystrophy, cancer
  • Pregnancy - miscarriage, ectopic, molar pregnancy
  • Systemic - bleeding disorder, metastatic cancer
  • Iatrogenic - IUCD, HRT, POP, depoprovera
  • STIs - gonorrhoea, chlamydia
  • Bleeding from somewhere else - urethra, bladder, anus, rectum
33
Q

What investigations would you consider doing in an attempt to diagnose someone with suspected cervical cancer?

A
  • Bloods - pregnancy test
  • Imaging - TVUSS + endometrial sampling
  • Other - Swabs for STI, colposcopy + punch biopsy
34
Q

What investigations would you do to stage cervical cancer?

A
  • Bloods - FBC, U+E’s, LFTs
  • Imaging - CXR, CT abdo/pelvis, MRI pelvis, PET scan,
  • Other - cystoscopy, protoscopy/sigmoidoscopy, surgical staging
35
Q

What does surgical staging of cervical cancer involve?

A

Examination under anaesthesia:

  • LLETZ
  • Cystoscopy
  • Hyesteroscopy
  • Fractional currettage from endocervix and endometrium
36
Q

What staging system is used to stage cervical cancer?

A

FIGO staging system

37
Q

What is stage 0 cervical cancer?

A

CIN - carcinoma in situ

38
Q

What is stage I cervical cancer?

A

Cancer limited to the cervix

39
Q

What is stage II cervical cancer?

A

Extension to uterus/parametria/vagina

40
Q

What is stage III cervical cancer?

A

Extension to pelvic side wall and/or lower third of the vagina

41
Q

What is stage IV cervical cancer?

A

Cancer tha has extended to adjacent organs or beyond true pelvis

42
Q

How would you manage stage 0 cervical cancer?

A

Colposcopy + LLETZ

43
Q

How would you manage stage Ia1 cervical cancer?

A
  • LLETZ or cone biopsy - can be considered curative if excision margins are clear and preserve fertility
  • Offer hysterectomy if family is complete
44
Q

How would you manage stage Ia2 cervical cancer?

A

Simple hysterectomy and Bilateral lymph node dissection (BPND)

45
Q

How would you manag estage Ib1 cervical cancer?

A

Radical hysterectomy and BPND

46
Q

What is involved in simple hysterectomy?

A

Removal of uterus and cervix

47
Q

What is involved in a radical hysterectomy?

A

Removal of uterus, fallopian tubes, cervix, upper vagina and parametrium

48
Q

How would you manage someone with stage Ib2 and stage IIa cervical cancer?

A

Radical hysterectomy + BPND if no evidence of lymph node involvment

49
Q

How would you manage cervical cancer stage IIB and above?

A

These are inoperable (unless radical destructive surgery considered):

  • Combination chemoradiotherapy
50
Q

What types of radiotherapy are used to manage cervical cancer?

A
  • External beam irradiation
  • Intracavity brachytherapy
51
Q

What chemotherapeutic agents are used in cervical cancer?

A
  • Cisplatin
  • Topotecan
52
Q

What are complications of hysterectomy?

A
  • Bleeding
  • Infection
  • VTE
  • Ureteric fistula
  • Bladder dysfunction
  • Lymphoedema
53
Q

What are complications of radiotherapy in cervical cancer?

A
  • Acute bladder/bowel dysfunction with tenesmus, mucositis, bleeding, ulceration, strictures and fistula
  • Vaginal stenosis, shortening and dryness
54
Q

What is cervical ectropian?

A

Red ring around the os due to endocervical epithelium extending past its trritory over paler epithelium of the ectocervix

55
Q

What can cause cervical ectropian?

A

Normal phenomenon

  • Puberty
  • The pill
  • Pregnancy

Cervicitis

56
Q

Is cervical ectropian prone to bleeding?

A

Yes - columnar epithelium is much more fragile than squamous epithelium

57
Q

What is the following?

A

Cervical polyp - pedunculated benign tumours of endocervical epithelium which may cause increased mucus discharge or postcoital bleeding

58
Q

How would you manage someone with cervical polyps?

A
  • Pre-menopause - Simple avulsion
  • Peri/post menopause - TVS +/- hysteroscopy
59
Q

What are causes of cervicitis?

A
  • Chlamydia
  • Gonorrhoea
  • Herpes
  • Can mask neoplasia
60
Q

What is the following?

A

Cervicitis - may be follicular or mucopurulent, presenting with discharge

61
Q

What areas of the cervix does cervical screening aim to sample?

A
  • Squamous part
  • Transition zone
  • Columnar part
62
Q

How is a cervical smear taken?

A

Brush inserted and rotated

63
Q

If a woman is nulliparous/has never had sex, what type of cervical cancer are they at risk of?

A

Adenocarcinoma of the cervix - due to lack of exposure to HPV

64
Q

What are the wilson criteria for developing a screening programme?

A
  • Important – the condition should be an important one
  • Acceptable treatment for the disease
  • Treatment and diagnostic facilities should be available
  • Recognisable at an early stage of symptoms
  • Opinions/policy on who to treat as patients must be agreed
  • Guaranteed safety e.g. low radiation exposure
  • Examination must be acceptable by the patient
  • Natural history of the disease must be known
  • Inexpensive test
  • Continuous screening i.e. not a one-off

Reproductive Medicine (43 decks)

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