Cervix & cervical screening, Vulval cancer Flashcards
What percentage of cervical cancers are caused by HPV?
> 99%
Does cervical cancer have a good cure rate?
Good cure rate if detected early BUT major cause of death in in women in low income countries
Despite cervical screening & despite HPV immunisation some women will still develop cancer either because they are not vaccinated or the have cancer which is attributed to non vax high risk HPV types or because they have a cancer that is not related to HPV such as neuroendocrine tumours
What is the peak age for cervical cancer?
Peak age 45-55 years
What types of HPV are related to cervical cancer?
HPV related (16 & 18)
What predisposes people to cervical cancer?
Multiple sexual partners
Early age at first intercourse
Older age of partner
Cigarette smoking
Young age of onset of sexual activity likely relates to the immaturity of the cervix & the TZ is more susceptible to HPV infections
Older partner is more likely to have acquired HPV infection & persistent infection themselves
Smoking-effects cell mediated immunity & nicotine is detected within cervical mucous
For whom is cervical smear test for?
Asymptomatic population
What are the symptoms of cervical cancer?
Abnormal vaginal bleeding
Post coital bleeding
Intermenstrual bleeding/PMB
Discharge
(Pain)
Sometimes women describe bleeding as discharge as is brown and has got a smell to it – but could be that they have a very offensive discharge if they have a large necrotic tumour
When is pain associated with cervical cancer?
Pain is associated with very advanced cancer that has spread to sidewalls of pelvis so have neuropathic pain or else got obstruction of the ureters and so getting back pain from hydronephrosis
How is cervical cancer diagnosed?
Clinical
Screen detected
BIOPSY needed for diagnosis as it is a pathological diagnosis
Remember screening aims to detect pre-cancerous disease NOT cancer
Screen detected=as a result of attending screening programme
Screening is for the detection of precancerous asymptomatic changes
What are the histological types of cervical cancer?
Tumour cells from epithelium invade into underlying stroma
Majority squamous carcinoma (80%)
Adenocarcinoma (endocervical) rising in relative incidence
Adenocarcinomas-developing in endocervical glandular epithelium
Can see combo of squamous adenocarcinomas
Where does cervical cancer spread to?
Metastases:
Lymphatic – pelvic nodes- Spreads out laterally within pelvis to the parametrium to pelvic LNs
Blood – liver, lungs, bone
How is cervical cancer staged?
PET-CT
MRI
How is cervical cancer staged?
PET-CT
MRI
What are the treatment options for cervical cancer?
Excision of the cervical TZ or hysterectomy
Radical hysterectomy
Chemo-radiotherapy
Cervical cancer is very radiosensitive
How is radical hysterectomy done?
Exploration of pelvic and para-aortic space
Removal of:
Uterus, cervix, upper vagina
Parametria
Pelvic nodes
Ovaries conserved-in premenopausal women
What are the therapy option ways to treat cervical cancer?
Radiotherapy- External Beam
Chemotherapy- once weekly during radiotherapy
Brachytherapy - Caesium Insertion (24 hours)- to boost the treatment to the site of the tumour in the cervix
What is screening for in cervical cancer?
Screening detects pre-invasive changes which are asymptomatic
What is the single most important cause of cervical cancer?
HPV
Cervical cancer causes abnormal vaginal bleeding. There is effective cure for early stage disease, what are they?
Surgery or combined chemoradiation
12% of human cancers are caused by viruses. Which viruses are implicated?
HBV
HIV
EBV
HPV
HPV is a very stable virus, what does this mean?
Very stable virus so does not mutate or change
How common is a HPV infection?
Peak prevalence 15-25yrs
prevalence declines with age
~30% prevalence in young women
lifetime risk of exposure 80% from serological studies
How is HPV infection in the cervix transmitted?
Transmitted by close intimate contact usually by penetrative sex
How can HPV infection & cervical disease be prevented?
Prevention by preventing HPV infection and by detecting precancerous changes and treating them to avoid progression
What does vaccinating against HPV 6 & 11 prevent against?
Genital warts
Most HPV infections are cleared by what?
The immune system
HPV very rarely causes cancer
Who is vaccinated for HPV in the UK?
In UK, 12 year olds are immunised against HPV16/18 to reduce the risk of cervical cancer
What is used for cervical smears?
LBC=Liquid based cytology
Sample transformation zone
When are people invited for a smear test?
CHI identifies she is female and age 25
First registered on SCCRS when become age 25
What is the presentation of vulva cancer?
Age 74 (27-97)
75% diagnosed over age 60
Presentation:
pain
itch
bleeding
lump/ulcer
(Older women with pain/ulcer/lump)
(Younger women with VIN)
What are the risk factors for vulva cancer?
Intraepithelial neoplasia or cancer at other lower genital tract site
Lichen sclerosus
Smoking
Immunosuppression
What is lichen sclerosis (risk factor for vulva cancer)?
Chronic dermatoses which is believed to be autoimmune in origin & it is not related to HPV
How is the staging of vulva cancer done?
Staging surgical-pathological
Size of lesion
Lymph node involvement
- inguinal & upper femoral
- pelvic
What is the difference between HPV and non HPV related vulva cancer?
HPV:
Usual type VIN
Younger women
Multifocal
Multizonal
Immunosuppression
Past history of intra-epithelial neoplasia
Non-HPV:
Differentiated VIN
Older women
Lichen Sclerosus
Often presents as cancer at first diagnosis
What staging is used for vulva cancer?
Like other gynaecological cancers use FIGO staging
Stage 3= risk of affecting the inguinal lymph nodes
Histopath for vulva cancer: what are the possible diagnosis?
Punch biopsy or excisional biopsy
Small piece of tissue which we process and look at under the microscope
Possible diagnosis?
Inflammatory, including lichen sclerosus
Dysplasia- VIN
Malignant- squamous cell carcinoma
What is vulvar intraepithelial neoplasia?
Abnormal proliferation of squamous epithelium; can progress to carcinoma
Usual type (aka classical / warty)
- Associated with HPV infection
Differentiated type
- In older women, not HPV related
- always high grade
Describe vulva cancer - squamous cell carcinoma?
Malignant tumour of squamous cells
Ability to invade adjacent tissues and spread to distant sites (metastasis)
On a biopsy very important to measure depth of invasion
Grade on how differentiated it is
Depth of invasion affects the staging and the management of the patient
How can vulva cancer be treated?
Surgery
- individualised surgery
- Local excision
- Unilateral or bilateral node dissection
Radiotherapy/Chemotherapy-may be sole treatment or may be used to downstage the disease and reduce it before surgery for any residual disease
Also plan whether to remove LNs or not – depends on location of lesion & size – may use sentinel node involvement
With what morbidity is groin node dissection associated with?
Inguinal and upper femoral nodes
Separate node incisions
Staging and remove nodal disease
Associated with significant morbidity
Wound infection
Lymphocysts
Nerve damage
When is the peak prevalence of HPV infection?
Peak prevalence 15-25yrs
Prevalence declines with age
Does smoking put you at higher risk of cervical cancer?
YES
Cigarette smoking alters cell mediated immunity – nicotine secreted in cervical mucous
Who is invited for a smear test and screened for cervical cancer and how is this done?
Person with a cervix aged 25-64 years
5 yearly smears
Liquid Based Cytology (LBC)
Test for high risk HPV
If hrHPV positive; triage with cytology
Why do we test for HPV in cervical screening?
HPV testing is more sensitive than cytology for high grade abnormalities
As more HPV-immunised women enter the screened population, cervical disease will decrease and will be more difficult to detect by cytology. HPV will be more effective test for the future.
If the HPV test is negative, the woman’s chance of developing cervical cancer in the next 5 years is very small, allowing a 5 year screening interval for all women regardless of age.
When is a cervical cytology sample done?
Only if high risk HPV +ve
- Microscopic assessment of cells scraped from the transformation zone
- Look for abnormal cells (dyskaryosis)
- Indicate that woman may have underlying cervical intraepithelial neoplasia - CIN
Graded low or high grade dyskaryosis reflects what?
Reflects degree of underlying CIN
Low grade (+ borderline)
High grade
Borderline = not definite dyskaryosis but there are changes so cant report as negative
What do Koilocytes reflect?
HPV infection
(Cells with a perinuclear halo)
What happens if negative for hrHPV compared to if positive?
Negative for hrHPV – routine recall 5 years
Positive for hrHPV:
- Cytology normal; repeat test 1 year
- Dyskaryosis: refer to colposcopy
What should be done if cervix looks abnormal?
Refer to gynae for urgent assessment – not managed through screening programme
How is a colposcopy done?
Magnification and light to see cervix
Exclude obvious malignancy
Use of acetic acid +/- Iodene:
- Identify limits of lesion
- Select biopsy site
- Define area to treat
What are the options for management?
Punch biopsy to make a diagnosis
Return for Treatment if CIN2/3
“See and treat” at first visit
- See and treat if have hrHPV +ve, high grade CIN & colposcopy features suggesting high grade
What are the low risk types of HPV?
E.g. 6 & 11
- Genital warts & low grade CIN
- Often transient & resolve
What are the high risk types of HPV?
E.g. 16 & 17
- Persistent infection increases risk of developing
- High grade CIN & more rarely cancer
CIN is invisible to the naked eye: what are the grades of CIN?
CIN 1: low grade dysplasia–will regress
CIN 2: moderate dysplasia – may regress
CIN 3: severe dysplasia – unlikely to regress
Precursor of invasive cancer
(CIN 1 – consider to be a HPV infection & CIN 2 in young women or those who haven’t completed their families-manage conservatively)
How is CIN 2/3 treated?
Excise TZ of cervix
- LLETZ = Large loop excision of the transformation zone
Ablate TZ of cervix
- Thermal Ablation
- Laser ablation
What follow up is done after treatment of CIN?
To confirm that treatment was effective = Residual disease with in 2 years
To prevent invasive cancer
- Recurrent disease 5% after 3-5 years
- Detect occasional cancer
To reassure the woman that her treatment has worked
Follow-up LBC at 6 months for cytology and high risk HPV
- Both negative – return to 3? year recall
- Either positive – return to colposcopy
What is the aim of cervical screening?
Reduce the risk of cervical cancer
How is protection against cervical cancer maximised?
HPV vaccination + cervical screening to maximise protection
Even if immunised, anyone with a cervix still needs to be offered cervical screening
