Cervix - benign and malignant disease and screening Flashcards
What are the high risk types of HPV?
16, 18, 31, 45
How does HPV cause cervical cancer?
- Infects basal layer and utilitses host for replication
- Virus produces E6 + E7 protein product -> prevents cell cycle arrest and inhibits cell death
Where do columnar cells of the endocarvix undergo metaplasia?
Transformation zone (squamocolumnar junction)
What is post coital bleeding?
Vaginal bleeding occurring immediately after sexual intercourse – this has a 6% annual incidence in the UK
What is intermenstrual bleeding?
Vaginal bleeding (other than postcoital) occurring between periods
What are abnormal cells on histology of the cervix classed as?
Cervical intraepithelial neoplasia (CIN)
What are risk factors for CIN?
- Early age at first intercourse
- Multiple sexual partners
- Prolonged oral contraceptive use
- STD’s
- Cigarette smoking
- Immunodeficiency
- Persistent high-risk HPV
What is cervical intraepithelial neoplasia?
Disorganised proliferation of abnormal cells in squamous epithelium
- Lack of maturation
- Variation in cellular size and shape
- Nuclear enlargement
- Irregularity
- Hyperchromasia
- Cellular disarray
What does CIN 1 indicate?
Mild dysplasia
What is the likelihood of CIN 1 progressing to cervical cancer?
Usually regress - 50-60% regress within 2 years
What does CIN 2 indicate?
Moderate dyskaryosis
What is the likelihood of CIN 2 progressing to cancer?
Regression is less likely - 3-5% develop cancer within 10 years
What does CIN 3 indicate?
Severe dyskaryosis - full thickness changes
What is the likelihood of CIN 3 progressing to cancer?
Regression unlikely - 20-40% develop cancer in 10 years
What screening programme is available to women to monitor for CIN and cervical cancer?
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
If someone had normal cervical smear, how would you manage them?
Follow up in 3 years
How would you follow up someone with an unsatisfactory cervical smear?
Repeat smear in 3 months
How would you manage someone with suspected CIN1?
Conservative:
-
High risk HPV testing
- If +ve refer for colposcopy within 6 weeks
- If -ve - repeat in 3 years
How would you manage someone with CIN 2?
- Refer for colposcopy +/- LLETZ within 2 weeks
- 6 month follow up
How would you manage someone with CIN 3?
- Refer for colposcopy +/- LLETZ within 2 weeks
- 6 month follow up
What is involved in LLETZ (loop diathermy)?
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
What is involved in colposcopy?
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
What are criteria for colposcopy referral?
- High grade dyskariosis
- 3 x unsatisfactory results
- Persisting low grade dyskariosis
- Clinically suspicious cervix
What are the main treatment options for CIN?
- LLETZ
- Cold coagulation
- Laser ablation
If someone was treated for CIN 2/3 with LLETZ and was HPV -ve at 6 months, how would you follow them up?
3 yearly follow up
How often should HIV positive individuals have a cervical smear?
Every year
What vaccinations are available for preventing HPV?
- Cervarix (Bivalent) - 16/18
- Quadravalent (Gardasil) - 16/18/6/11
When are females given their HPV vaccine (based on vaccine schedule)?
12-13 years at 0, 1 and 6 months
What are symptoms of cervical cancer?
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
What are signs of cervical cancer?
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
What are causes of post-coital bleeding?
- Trauma
- Ectropian
- Cervicitis
- Cervical/endometrial polyp
- Cervical cancer
- Vaginitis
- Vaginal cancer
- Vulval dermatitis
- Vulval cancer
- STIs - Gonorrhoea, Chlamydia
What are causes of intermenstrual bleeding?
- 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
What investigations would you consider doing in an attempt to diagnose someone with suspected cervical cancer?
- Bloods - pregnancy test
- Imaging - TVUSS + endometrial sampling
- Other - Swabs for STI, colposcopy + punch biopsy
What investigations would you do to stage cervical cancer?
- Bloods - FBC, U+E’s, LFTs
- Imaging - CXR, CT abdo/pelvis, MRI pelvis, PET scan,
- Other - cystoscopy, protoscopy/sigmoidoscopy, surgical staging
What does surgical staging of cervical cancer involve?
Examination under anaesthesia:
- LLETZ
- Cystoscopy
- Hyesteroscopy
- Fractional currettage from endocervix and endometrium
What staging system is used to stage cervical cancer?
FIGO staging system
What is stage 0 cervical cancer?
CIN - carcinoma in situ
What is stage I cervical cancer?
Cancer limited to the cervix
What is stage II cervical cancer?
Extension to uterus/parametria/vagina
What is stage III cervical cancer?
Extension to pelvic side wall and/or lower third of the vagina
What is stage IV cervical cancer?
Cancer tha has extended to adjacent organs or beyond true pelvis
How would you manage stage 0 cervical cancer?
Colposcopy + LLETZ
How would you manage stage Ia1 cervical cancer?
- LLETZ or cone biopsy - can be considered curative if excision margins are clear and preserve fertility
- Offer hysterectomy if family is complete
How would you manage stage Ia2 cervical cancer?
Simple hysterectomy and Bilateral lymph node dissection (BPND)
How would you manag estage Ib1 cervical cancer?
Radical hysterectomy and BPND
What is involved in simple hysterectomy?
Removal of uterus and cervix
What is involved in a radical hysterectomy?
Removal of uterus, fallopian tubes, cervix, upper vagina and parametrium
How would you manage someone with stage Ib2 and stage IIa cervical cancer?
Radical hysterectomy + BPND if no evidence of lymph node involvment
How would you manage cervical cancer stage IIB and above?
These are inoperable (unless radical destructive surgery considered):
- Combination chemoradiotherapy
What types of radiotherapy are used to manage cervical cancer?
- External beam irradiation
- Intracavity brachytherapy
What chemotherapeutic agents are used in cervical cancer?
- Cisplatin
- Topotecan
What are complications of hysterectomy?
- Bleeding
- Infection
- VTE
- Ureteric fistula
- Bladder dysfunction
- Lymphoedema
What are complications of radiotherapy in cervical cancer?
- Acute bladder/bowel dysfunction with tenesmus, mucositis, bleeding, ulceration, strictures and fistula
- Vaginal stenosis, shortening and dryness
What is cervical ectropian?
Red ring around the os due to endocervical epithelium extending past its trritory over paler epithelium of the ectocervix
What can cause cervical ectropian?
Normal phenomenon
- Puberty
- The pill
- Pregnancy
Cervicitis
Is cervical ectropian prone to bleeding?
Yes - columnar epithelium is much more fragile than squamous epithelium
What is the following?
Cervical polyp - pedunculated benign tumours of endocervical epithelium which may cause increased mucus discharge or postcoital bleeding
How would you manage someone with cervical polyps?
- Pre-menopause - Simple avulsion
- Peri/post menopause - TVS +/- hysteroscopy
What are causes of cervicitis?
- Chlamydia
- Gonorrhoea
- Herpes
- Can mask neoplasia
What is the following?
Cervicitis - may be follicular or mucopurulent, presenting with discharge
What areas of the cervix does cervical screening aim to sample?
- Squamous part
- Transition zone
- Columnar part
How is a cervical smear taken?
Brush inserted and rotated
If a woman is nulliparous/has never had sex, what type of cervical cancer are they at risk of?
Adenocarcinoma of the cervix - due to lack of exposure to HPV
What are the wilson criteria for developing a screening programme?
- 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
