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Gwen - Reproductive Medicine (Obs, Gyn, Breast) > 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, 33

(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) - means that the disease is confined to the epithelium, it is a cancer when there is a breach of epithelial basement membrane

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7
Q

What are risk factors for CIN?

A
  • Cigarette smoking
  • HIV
  • Sex
    • Early age at first intercourse
    • Multiple sexual partners
    • High parity
    • STIs
  • Prolonged oral contraceptive use > 5 years
  • Weak immune system eg HIV, post transplant
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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 (basal 1/3rd of epithelium)

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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

(basal 2/3rds of epithelium)

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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

(>2/3rds epithelium)

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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

Peak age of cervical cancer

A

25-45 years

(80% of cases in developing world)

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17
Q

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

A

Follow up in 3 years

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18
Q

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

A

Repeat smear in 3 months

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19
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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20
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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21
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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22
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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23
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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24
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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25
Q

What are the main treatment options for CIN?

A
  • LLETZ
  • Cold coagulation
  • Laser ablation
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26
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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27
Q

How often should HIV positive individuals have a cervical smear?

A

Every year

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28
Q

What vaccinations are available for preventing HPV?

A
  • Cervarix (Bivalent) - 16/18
  • Quadravalent (Gardasil) - 16/18/6/11
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29
Q

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

A

12-13 years at 0, 1 and 6 months

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30
Q

What are symptoms of cervical cancer?

A

May be completely asymptomatic (hence testing):

  • Abnormal PV bleeding
    • Post coital bleeding
    • Intermenstrual bleeding
    • Menorrhagia
    • Postmenopausal bleeding
  • Discharge
    • Increased/altered vaginal discharge
    • Offensive
  • Symptoms of advanced disease - pelvic pain, leg pain/swelling, GI problems, lung problems
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31
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 “BOGGY UTERUS”

May have leg oedema from lymphatic obstruction

32
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
33
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
34
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

Premanopausal women with abnormal bleeding should be tested for chlamydia

Note that cervical smears detect pre-cancer, not cancer when asymptomatic

35
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
36
Q

What does surgical staging of cervical cancer involve?

A

Examination under anaesthesia:

  • LLETZ
  • Cystoscopy
  • Hyesteroscopy
  • Fractional currettage from endocervix and endometrium
37
Q

What staging system is used to stage cervical cancer?

A

FIGO staging system

38
Q

What is stage 0 cervical cancer?

A

CIN - carcinoma in situ

39
Q

What is stage I cervical cancer?

A

Cancer limited to the cervix

40
Q

What is stage II cervical cancer?

A

Extension to uterus/parametria/vagina

41
Q

What is stage III cervical cancer?

A

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

42
Q

What is stage IV cervical cancer?

A

Cancer tha has extended to adjacent organs or beyond true pelvis

43
Q

How would you manage stage 0 cervical cancer?

A

Colposcopy + LLETZ

44
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
45
Q

How would you manage stage Ia2 cervical cancer?

A

Simple hysterectomy and Bilateral lymph node dissection (BPND)

46
Q

How would you manage stage Ib1 cervical cancer?

A

Radical hysterectomy and BPND

47
Q

What is involved in simple hysterectomy?

A

Removal of uterus and cervix

48
Q

What is involved in a radical hysterectomy?

A

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

49
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

50
Q

How would you manage cervical cancer stage IIB and above?

A

These are inoperable (unless radical destructive surgery considered):

  • Combination chemoradiotherapy
51
Q

What types of radiotherapy are used to manage cervical cancer?

A
  • External beam irradiation
  • Intracavity brachytherapy
52
Q

What chemotherapeutic agents are used in cervical cancer?

A
  • Cisplatin
  • Topotecan
53
Q

What are complications of hysterectomy?

A
  • Bleeding
  • Infection
  • VTE
  • Ureteric fistula
  • Bladder dysfunction
  • Lymphoedema
54
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
55
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

56
Q

What treatments are used if screening shows no cervical cancer but shows biological changes

A
  • Large loop excision of the transformation zone (LLETZ)
  • Cone biopsy
  • Laser therapy
57
Q

What fertility sparing surgery can be done?

A

Trachelectomy - only in early stage disease (Ia2 and Ib) if LN proven to be neg following lymphadenopathy

Vaginal procedure and involves removal of cervix and para-cervical tissue, to the elvel of internal os

Permanent cerical suture inserted to prevent pre-term labour and will require delviery by C-section

58
Q

What can cause cervical ectropian?

A

Normal phenomenon

  • Puberty
  • The pill
  • Pregnancy

Cervicitis

59
Q

Is cervical ectropian prone to bleeding?

A

Yes - columnar epithelium is much more fragile than squamous epithelium

60
Q

What is the following?

A

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

61
Q

How would you manage someone with cervical polyps?

A
  • Pre-menopause - Simple avulsion
  • Peri/post menopause - TVS +/- hysteroscopy
62
Q

What are causes of cervicitis?

A
  • Chlamydia
  • Gonorrhoea
  • Herpes
  • Can mask neoplasia
63
Q

What is the following?

A

Cervicitis - may be follicular or mucopurulent, presenting with discharge

64
Q

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

A
  • Squamous part
  • Transition zone
  • Columnar part
65
Q

How is a cervical smear taken?

A

Brush inserted and rotated

66
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

67
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
68
Q

How often are women screened?

A

Between 25-49 every 3 years

Between 50-64 every 5 years

69
Q

Action taken if borderlink dyskanosis

A

Original sample tested for HPV. If neg patient does back to reoutine re-call. If pos they are referred for colposcopy.

70
Q

Action taken if moderate dyskariosis

A

Consistent with CIN 2. Refer for urgen colposcopy

71
Q

Action taken if severe dyskariosis or suspected invasive cancer

A

refer urgently

72
Q

Action taken in sample inadequate

A

Repeat - if 3 inadequate samples assessment by colposcopy

73
Q

What do cells with dyskariosis look like

A

Altered nuclear features - size, sahpe and outline, nucleoli

74
Q

Whats the difference between low or high grade dyskinesia?

A

Reflects decree of underlying CIN eg high grade=1.4%, low grade=0.8%

75
Q

Criteria for colposcopy referral

A

3 consequtive inadequate smear samples

3 borderline smears

Mild/moderate/severe dyskaryosis (depends on size of nucleus)

Suspected invasive disease

76
Q

What is the transzitional zone

A

Columnar epithelium lines the endocervix, squamous epithelium lines the exocervix. The junction betweent the 2 is the squamo-olumnar epithelium.

At puberty and pregnancy the endocerviacl epithelium is pushed out and glandular lining cells are transferred into squamous cells. It is an unstable zone where many pre-cancerous lesions arise.

Gwen - Reproductive Medicine (Obs, Gyn, Breast) (49 decks)

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