Cervix - benign and malignant disease and screening Flashcards
What are the high risk types of HPV?
16, 18, 33
(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) - means that the disease is confined to the epithelium, it is a cancer when there is a breach of epithelial basement membrane
What are risk factors for CIN?
- 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
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 (basal 1/3rd of epithelium)
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
(basal 2/3rds of epithelium)
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
(>2/3rds epithelium)
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
Peak age of cervical cancer
25-45 years
(80% of cases in developing world)
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 (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