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Gyn Onc > Cervix Tid bits > Flashcards

Cervix Tid bits Flashcards

1
Q

What is the mean age at diagnosis of ACIS

A

35 - 37

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2
Q

What is the overall incidence of AIS (US)

A

6.6: 100 000

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3
Q

What is the average interval between clinically detectable AIS and ealry invasive Ca

A

“At least 5 years” - SGO guideline 2020

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4
Q

What percentage of women with AIS have a coexisting squamous lesion

A

~55%

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5
Q

What % of AIS is astd with HPV 18

A

36 - 48%

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6
Q

How often are atypical glandular cells of cytology astd with AIS or Adenocarcinoma

A

3-4% with AIS

2% with adenocarcinoma

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7
Q

What proporation of AIS on biopsy will have invasive adenocarcinoma on final histo

A

15%

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8
Q

What length of specimen is preferred for Ix of AIS / AGC

A

10mm for those wanting fertility 10 - 20 for those no longer wanting fertility.

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9
Q

With a -ve margin on AIS what is the liklihood of recurrent disease?

A

2.6%

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10
Q

WIth a +ve margin on AIS what is the risk of recurrence?

A

19%

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11
Q

With a -ve margin the risk of residual AIS on a second specimen is?

A

20%

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12
Q

In AIS - with -ve margins on cone the risk of Adenocarcinoma is?

A

2%

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13
Q

In AIS, previous excision with +ve margins the risk of residual disease is?

A

53%

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14
Q

In AIS with previous excision and +ve margis what is the likelihood of Adenocarcinoma in excisional specimen?

A

6%

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15
Q

In retrospective studies is there a differnce in survival benefit for Rad Hyst vs Simply hyst for microinvasive adenocarcinoma?

A

No

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16
Q

In observational studies what is the risk of LN metastases in microinvasive adenocarcinoma

A

1 - 3%

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17
Q

What is the risk of ovarian metastases in invasive adenocarcinoma? What are the RF for ovarian mets?

A

2-5%

RF: Increasing stage of diease. Increased stomal invasion

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18
Q

What is the SGO recommendation for post excision screening of AIS

A

co-testing (Pap plus HPV tests) with endocervical sampling (endocervical curettage or endocervical brushing) every 6 months for 3 years, then annual co-testing with or without endocervical sampling for at least 2 years or until hysterectomy at the completion of childbearing.

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19
Q

In women with a Hx of AIS who have at least two consecutive negative co-test results after treatment, the 5-year risk of CIN 2 or worse is

A

1.5%.

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20
Q

According to the SGO guideline when should a cervical excisional procedure be undertaken during pregnancy and what alternative surveillance is recommended

A

diagnostic excisional procedure or repeat biopsy is recommended only if cancer is suspected based on cytology, colposcopy, or histology

Surveillance: Colposcopy omitting endocervical sampling is recommended each trimester, with an excisional procedure performed postpartum.

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21
Q

For PAP smears: What is the false -ve rate

A

20 - 30%

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22
Q

for PAP smears: What % had a +ve finding?

A

Less than 5% of smears had a +ve finding

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23
Q

for PAP smears: What % found a high grade lesion?

A

<1% of the smears were high grade.

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24
Q

According to Seven 1992 what is the rate of LN mets in lesions with a depth of invaion of < 1mm

A

0 %

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25
Q

According to Seven 1992 what is the rate of LN mets in lesions with a depth of invasion of < 3mm ?

A

0.3 % ( 2 out of 743)

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26
Q

According to Seven 1992 what is the rate of LN mets in lesions with a depth of invasion of 3.1 - 5mm

A

7.4% ( 18 / 243)

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27
Q

According to Seven (1992) what is the rate of LN mets in lesions with a depth of invasion of < 5.1mm ?

A

2.2 % ( 28 / 1257)

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28
Q

According to Seven (1992) what is the rate of invasive cancer recurrence in lesions with a depth of invasion of < 3.0mm ?

A

0.2% (1 / 513)

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29
Q

According to Seven (1992) what is the rate of invasive cancer recurrence in lesions with a depth of invasion of 3.1 - 5mm

A

5.4% ( 9/166)

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30
Q

According to Seven (1992) what is the rate of invasive cancer recurrence in lesions with a depth of invasion of < 5.1mm

A

3.6% ( 10 / 677)

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31
Q

What is the sensitivity for parametrial invaison for clinical examination compared to MRI?

A

CLinical examination 40%

MRI 84%

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32
Q

What is the specificity for parametrial invasions of clinical examination and MRI?

A

Clinical examination 93%

MRI 92%

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33
Q

Name 2 uncommon histological types of Cervix Ca?

A

Small cell (Neuroendocrine tumours)
Melanoma
Adenoid cystic tumours

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34
Q

the GOG score aiming to quantify the risk of recurrent cervix cancer in the pelvis is based on?

A
  • outer 1/3 myometrial invasion
  • LVSI
    Large clinical tumour diameter
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35
Q

What 4 considerations are the treatment of advanced or recurrent cervix cancer depend on?

A
  1. previous treatment
  2. site or extent of disease
  3. disease free interval
  4. patient performance status
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36
Q

With pelvic recurrence post radical surgery, chemo rad may cure what % of patients?

A

40 - 50%

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37
Q

What % of cervix Ca are small cell?

A

~2%

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38
Q

ESGO 2018 Guideline - Low risk Cervix Ca group for Type B1 (or A) Rad Hyst includes

A

Low risk <2cm in size, no LVSI, inner 1/3 MMI

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39
Q

ESGO 2018 Guideline - Intermediat risk Cervix Ca group for Type B2 (C) Rad Hyst includes

A

Intermediate risk:
Either:
- >/= 2cm in size, NO LVSI, any stromal invasion
- <2cm in size, LVSI +ve, Any stromal invasion

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40
Q

ESGO 2018 Guideline - High risk Cervix Ca group for Type C1 (or C2) Rad Hyst includes

A

High risk

: > 2cm in size, PVSI +ve and any MMI

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41
Q

Describe a type Querleu-Morrow Type A Rad Hyst in terms of

  1. Paracervix or lateral parametrium
  2. Ventral parametrium
  3. Dorsal Parametrium
A

Paracervix: Halfway between the cervix and the ureter (medial to the ureter - ureter identified but not mobilised)
Ventral Parametrium - minimal excision
Dorsal parametrium - minimal excision

42
Q

Describe a type Querleu-Morrow Type B1 Rad Hyst in terms of

  1. Paracervix or lateral parametrium
  2. Ventral parametrium
  3. Dorsal Parametrium
A

Paracervix: At the ureter (at the level of the ureter bed, ureter is mobilised from the cervix and lateral parametrium)
Ventral parametrium: Partical excision of the vescico uterine ligament
Dorsal parametrium: Partial resetcion to the rectouterine / recot vaginal ligament and uterocasral fold

43
Q

Describe a type Querleu-Morrow Type B2 Rad Hyst in terms of

  1. Paracervix or lateral parametrium
  2. Ventral parametrium
  3. Dorsal Parametrium
A

Paracervix:At the ureter (at the level of the ureteralbed, ureter is mobilized from the
cervix and lateral parametrium) PLUS paracervical
lymphadenectomy without resection
of vascular/nerve structures

Ventral Parametrium: Partial excision of the
vesicouterine ligament

Dorsal parametrium: Partial resection of the
rectouterine-rectovaginal
ligament and uterosacral fold

44
Q

Elliot et al., (+Carter) published Australian data regarding risk of LVSI and LN mets in Stage IA Ca in 2000 (1995 version < 5mm inv and < 7mm lateral)
What as the risk of LVSI with invasion < 1mm

A

8.5%

45
Q

Elliot et al., (+Carter) published Australian data regarding risk of LVSI and LN mets in Stage IA Ca in 2000 (1995 version < 5mm inv and < 7mm lateral)
What as the risk of LVSI with invasion 1.1 - 2.0 mm

A

19%

46
Q

Elliot et al., (+Carter) published Australian data regarding risk of LVSI and LN mets in Stage IA Ca in 2000 (1995 version < 5mm inv and < 7mm lateral)
What as the risk of LVSI with invasion 2.1 - 3 mm

A

29 %

47
Q

Elliot et al., (+Carter) published Australian data regarding risk of LVSI and LN mets in Stage IA Ca in 2000 (1995 version < 5mm inv and < 7mm lateral)
What as the risk of LVSI with invasion > 3mm

A

53%

48
Q

Elliot et al., (+Carter) published Australian data regarding risk of LVSI and LN mets in Stage IA Ca in 2000 (1995 version < 5mm inv and < 7mm lateral)
What as the risk of LN +ve in tumours with <3mm of invasion

A

0.8 %

49
Q

Elliot et al., (+Carter) published Australian data regarding risk of LVSI and LN mets in Stage IA Ca in 2000 (1995 version < 5mm inv and < 7mm lateral)
What as the risk of LN +ve in tumours with 3.1 - 5mm f invasion?

A

3.4%

50
Q

Name 14… different variants of adenocarcinoma?

A
  1. adenocarcinoma of the usual or endocervical type (60-70%)
  2. Adenoma malignum (minimal deviation adeno - Peutz Jaegher)
  3. Villoglandular adenocarcinoma
  4. Serous
  5. Clear cell
  6. Endometrioid
  7. Mesonephric
  8. intestinal type
  9. Signet ring cell type
  10. Adenosquamous
  11. Adenoid basal
  12. Adenoid cystic
  13. Adenocarcinoma admixed with NEC
  14. undifferentiated carcinoma
51
Q

What is the median time to clearance of HPV infection

A

6 - 18 months

52
Q

What are the two key HPV proteins in carcinogenesis and to what do they bind?

A

E6 protein - bind to p53 - leads to deascred apoptosis, stops cell cycle arrest and DNA repair.
E7 - binds to retinoblastoma protein –> uncontrolled cell growth.

53
Q

Can you be reinfected by the same HPV viral type?

A

Maybe. The HPV type can resolve and reappear. Not clear if this is reinfection or reactivation of a low level persistent infection.

54
Q

How does a diagnosis of CIN1 predict the development of CIN 3 in the future

A

For any given type of carcinogenic HPV, diagnosing CIN 1 does not predict meaningfully higher risk of CIN3 than does negative biopsy.

55
Q

After persistent HPV 16 infection (i.e. 3-5yrs) what is the absolute risk fo a precancer Dx?

A

~ 40%

56
Q

What is the likelihood that a precancer will develop into a cancer and over what time.

A

Precise magnitude and timing of risk of invasion, if
precancers were left untreated, will remain unknown as it is unethical to run that study. Older studies in large precancers suggested there is a 20-30% risk of progression to Ca over 5-10 years.

57
Q

What do you tell women with HPV +ve but normal cytology

A

“HPV is extremely common, almost all infections go away within a year or two; many are gone within 6 months. Make sure you get retested and if the infection does not cear you will need to have a full examination and possibly treatment to prevent Ca”

58
Q

After radical trachelectomy with Lap PLND what is the likelihood of recurrence? What are the pregnancy rates? and pregnancy outcomes?

A

There is an approximately 4% recurrence rate.
In one study of 72 women, 31 women (43%) had a successful pregnancy. Among the remaining 38 patients, 33 did not attempt conception, 2 died of disease, 2 underwent hysterectomy, and one received adjuvant radiation therapy. In all, 7 women experienced infertility problems. Four became pregnant and 3 were unable to conceive.

59
Q

Can I not treat CIN 2, especially in young women?

A

likelihood of regression of CIN 2 in women <25 is high.
systematic review and meta-analysis in the BMJ 2018 (http://dx.doi.org/10.1136/bmj.k499 ) found that in women
< 30 at 2 yrs : 60% regressed, 23% persisted and 11% progressed to CIN 3. Amongst women of all ages there were 15 cases of invasive Ca ( 0.5% 15 of 3160) of which 13 were stage 1A1 and 2 more advanced.
In line with this the ASCCP - American Colp society - recommend that in women with CIN2 observation is preferred with 6 /12 LBC and Bx if concerns for higher grade. IF @ 6 and 12/12 both are lower grade the next can be 12 months later. If persistent at 2 years for treatment. The Canadian society guideline is basically the same. The Australian Guideline indicates that these women are at a higher rate of regression but does indicate that observation may be acceptable for up to 6 - 12 months for women who have not completed childbearing. (Chap 10 - Treatment of HSIL - “CIN 2’).
Histologicially strong and diffuse block positive p16 results support a categorization of precancer. Negative or non-block positive staining strongly favours an interpretation of low-grade disease or a non-HPV associated pathology. This can be used as a triaging tool for treatment.

60
Q

Cochrane review on excisional treatment and its effect on pregnancy indicated that the effect of excisional Bx on rate of PTB was?

A

In 6.5 million women of whom 65,000 were treated there was an increased risk of PTB at:
<37 weeks - (10.7% versus 5.4%, RR 1.75, 95% CI 1.57 to 1.96, 59 studies, 5,242,917 participants, very low quality),
32 to 34 weeks) (3.5% versus 1.4%, RR 2.25, 95% CI 1.79 to 2.82), 24 studies, 3,793,874 participants, very low quality),
< 28 to 30 weeks (1.0% versus 0.3%, (RR 2.23, 95% CI 1.55 to 3.22, 8 studies, 3,910,629 participants, very low quality), as compared to women who had no treatment.

All evidence of very low quality.

61
Q

Cochrane review on excisional treatment and its effect on pregnancy indicated that the effect of excisional Bx on rate of the overall rate of prematurity was?

A

In 6.5 million women of whom 65,000 were treated there was an increased risk of prematurity in women with an excisional treatment

excision versus no treatment: 11.2% versus 5.5%, RR 1.87, 95% CI 1.64 to 2.12, 53 studies, 4,599,416 participants) than
ablation versus no treatment: 7.7% versus 4.6%, RR 1.35, 95% CI 1.20 to 1.52, 14 studies, 602,370 participants) treatments
Also for women needing treatment after delivery vs not needing any 5.9% versus 5.6%, RR 1.24, 95% CI 1.14 to 1.34, 15 studies, 4,357,998 participants, very low quality).

All evidence of very low quality.

62
Q

In the ancient study on Cone biopsy in pregnancy. How many women had a pregnancy loss after cone?

A

175 women had delivered 20 (11.4) had foetuses that did not survive. Cones were done in 1st trimester (33), 2nd trimester (42) and 3rd trimester (105)

63
Q

According to the metanalysis by Cheng et al., 2019. What is the likelihood of ovarian metastases in stage 1A Adenocarcinoma of the cervix?

A

0% stage IA,

64
Q

According to the metanalysis by Cheng et al., 2019. What is the likelihood of ovarian metastases in stage 1B Adenocarcinoma of the cervix?

A

2.8% in stage IB,

65
Q

According to the metanalysis by Cheng et al., 2019. What is the likelihood of ovarian metastases in stage IIA Adenocarcinoma of the cervix?

A

3.4% in stage IIA,

66
Q

According to the metanalysis by Cheng et al., 2019. What is the likelihood of ovarian metastases in stage IIB Adenocarcinoma of the cervix?

A

11.8% in stage IIB cervical adenocarcinoma.

67
Q

Name the 6 trials that examined RT +/- chemo

A

NCIC - Pearcet et al., -ve trial ? duration is important
Peters et al., SWOG8797 - Cis+5FU improved PFS and OS by >10%
GOG 85 - Whitney et al., Cis+5FU better than HU and RT
GOG120 - Rose et al., 3 groups all with diff chemo - CIs containing better
GOG 123 - Key et al., IB3 + Hyst with RT / CCRT with CT better
RTOG90-01 - diff RT but one with Cis-5FU. CT improved PFS and OS.

68
Q

A trachelectomy can be offered to women with what stage cervix Ca?

A

ESGO guideline indicates: Conization and simple trachelectomy are adequate
fertility-sparing procedures for stages T1a1 and T1a2,
lymph node–negative, LVSI-negative patients (grade B).
T1a1 = <3.0mm invasion
T1a2 = 3 - <5mm invasion.

69
Q

A radical trachelectomy can be offered to women for fertility sparing in which stage Ca?

A

Radical trachelectomy (type A) can be considered for
stages T1a1 (<3mm) and T1a2 (3-5mm) -ve LN with LVSI +ve
Radical trachelectomy (type B) for women with cervical cancer stage T1b1 (<4cm) equal to or less
than 2 cm of the largest diameter, LN -ve LVSI± (grade B).
Intraoperative cerclage should be
performed during simple or radical trachelectomy.

70
Q

Describe a simple trachelectomy

A

LND prior to trachelectomy recommended
Rim of vaginal mucose around cervix identifieid and Ant and post vagina opened and bladder and rectum mobilised off.
Later. al tissue mobillsed off similar to VH
ID uterine article pedicle and amputate cervix approx 1cm below isthmus. Frozen on margin - aim 8mm clear.
ECC. O suture prolene for cerclage vaginal reconstruction with os in centre. Don’t stent os.

71
Q

Describe a radical trachelecotmy

A

Divide round ligaments and open paravesical and paravaginal space. Undertake PLND. Reflect bladder and dissect ureter. Open tunnel and lateralised. Take uterine vessels as they pass over the ureter. Open rectovaginal septum to the pelvic floor. Divide uterosacrals and parametrium. open vagina. Take vaginal cuff for frozen. Remove cervix to ~1cm from internal os. Taken margin for frozen. Cerclage. Close vaginal around new external os.

72
Q

In a review of 125 Vaginal radical trachelectomy, the likelihood of 1st trimester loss in women who became pregnant was?

A

20%

73
Q

In a review of 125 Vaginal radical trachelectomy the likelihood of 2nd trimester loss in women who became pregnant was?

A

3%

74
Q

In a review of 125 Vaginal radical trachelectomy the likelihood of the pregnancy entering the third trimester was ?

A

73%

75
Q

In a review of 125 Vaginal radical trachelectomy, 73% of pregnancies continued into the third trimester. the rate of term delivery in that group was?

A

75%

76
Q

Disruption of the cervical ring on MRI is predictive of?

A

Strongly predictive of microscopic parametrial infiltration in patients with early invasive cervical cancer and the requirement for adjuvant RT or CCRT if primarily OT is undertaken.

Stage Ib1 disease or with stage Ib2-IIa1 disease with intact stromal ring should undergo primary radical surgery and those with Ib2-IIa1 disease with a disrupted stromal ring or with Ib3 disease could undergo
either definitive CCRT or NACT followed by radical
surgery. Esp younger women for QOL.

77
Q

Indications for a cone biopsy?

A
  1. T3 TZ on colposcopy
  2. Abnormal glandular cells on CST
  3. AIS on biopsy
  4. Discordance between CST and Bx
  5. Treatment for early-stage Ca (e.g. IA1,2)
78
Q

Meta-analysis of 19 retrospective studies in Adeno Ca (2020) - risk of ovarian mets in Stage IA:

A

0%

No difference in PFS or OS if ovariers preserved.

79
Q

Meta-analysis of 19 retrospective studies in Adeno Ca (2020) - risk of ovarian mets in Stage IB:

A

2.8%

NO difference in PFS and OS if ovaries preserved

80
Q

Meta-analysis of 19 retrospective studies in Adeno Ca (2020) - risk of ovarian mets in Stage IIA?

A

3.4%

No difference in PFS and OS if ovaries preserved

81
Q

Meta-analysis of 19 retrospective studies in Adeno Ca (2020) - risk of ovarian mets in Stage IIB:

A

11.8%

No difference in PFS and OS if ovaries preserved.

82
Q

After Dx with CIN1 what % will regress, persis and progress

A

57% will regress, 32% will persist and 12% will progress

83
Q

What % of CIN2 progres to CIN3 and invasion?

A

22% will progress to CIN3. 5% to Cancer

84
Q

What is the cumulative incidnce of invasive cancer in women wtih CIN3 over 30 years

A

31% will go on to develop cancer over 30 years.

85
Q

Does age influes the rate of persistence of CIN ? and how does that change over time?

A

Yes, the rate of clearance decreases over time. For every 5 years of increased are the odds of regression decrease by about 20%

86
Q

NCCN Guideline 1.2024.
What is the preimary treatment (Fertility sparing) for Stage IA1 LVSI -ve

A

Cone with -ve margins (+ ECC).
If cone +ve margins - repat of more ve trachelecomty.

87
Q

NCCN Guideline 1.2024.
What is the primary treatment (Fertility sparing) for Stage IA2 - IB1 with
LVSI -ve
Cone with -ve margin
SCC or Adenoc
DO < 10mm
Negative imaging

A

Cone biopsy (+ECC) with negative margins and Pelvic LND or Sentinel LN mapping is adequate Rx

88
Q

NCCN Guideline 1.2024.
What is the primary treatment (Fertility sparing) for Stage IA1 - IA2 WITH LVSI +ve

A

LND or SLN procedure needs to be done.
Cone biospy (+ECC) with -ve margins or Trachelecotmy (they say radical)

89
Q

NCCN Guideline 1.2024.
What is the preimary treatment (Fertility sparing) for Stage IB1 with one or more of:
+ve LVSI
Cone with +Ve margin
Grade 3 SCC or adnoc
DOI > 10mm

A

Radical trachelecotmy
+ Pelvic +/- Para aortic LND (consider sentinel LN).

90
Q

NCCN Guideline 1.2024.
What is the preimary treatment (NON - Fertility sparing) for Stage IA1 - No LVSI
After a cone biopsy with
1. -ve margins and medically inoperable
2. -ve margins and medically operable
3. +ve margins and medially inoperable
4. +ve margins and medically operable

A
  1. -ve margins and medically inoperable
    * Observe
  2. -ve margins and medically operable
    * Extrafascial hysteretomy
  3. +ve margins and medially inoperable
    * Brachytherapy +/- EBRT
  4. +ve margins and medically operable
    * Consider repeat cone to confirm stage
    * or Extrafascial hysterectomy if +ve for dysplasia or Modified rad hyst if margins +ve for carcinoma
    * Consider SLN mapping.
91
Q

NCCN Guideline 1.2024.
What is the preimary treatment (NON - Fertility sparing) for Stage IA1 - IB1 with:
* No LVSI
* Cone with -ve margins
* SCC or Adeno
* Ca <2cm
* DOI < 10mm
* No metastatic disease

A

Can have an Extrafascial hysterctomy + Pelvic LND or SLN mapping.

92
Q

NCCN Guideline 1.2024.
What is the primary treatment (NON - Fertility sparing) for
Stage IA1 - IA2 with LVSI

A

MOdified Rad Hyst + pelvic LND consider SLN mapping or
Pelvic EBRT and Brachytherapy.

93
Q

NCCN Guideline 1.2024.
What is the primary treatment (NON - Fertility sparing) for
Stage BA not meedting conservative surgery criteria, IB2 and IIA1

A

Rad Hyst + LND +/- PaLND and consider SLN
OR
Pelvic EBRT + Brachy and platinum.

94
Q

NCCN Guideline 1.2024.
What is the primary treatment (NON - Fertility sparing) for
Stage IB3 and stage IIA2

A

Pelvic EBRT + platinum + Brachy
or
Rad Hyst + PLND +/- PaLND
or
Pelvic EBRT + platinum + brachy then completion hysterectomy (Cat 3 - ‘there is major NCCN disagreement that the intervention is appropriate’)

95
Q

NCCN Guideline 1.2024
In the presence of a local/regional recurrence and no previous RT or Failure outside of the previous field what are the treatment options.

A
  1. Consider surgical resection if feasible
  2. If not or after resection - Inidvidualased EBRT + PLainutm +/- Brachytehrapy
96
Q
A
97
Q

NCCN Guideline 1.2024
In a SMALL CELL Neuroendocrine carcinoma of the cervis that after imaging is <4cm and confined to the cervis. What are the options for management?

A
  1. Rad Hyst + Nodes +/- PaLN with Adjnvant cisplatin /etoposide or CCRT
  2. Chemoradiation + brachytherapy with consideriotn of additional sstemic treatment after RT.
98
Q

NCCN Guideline 1.2024
In a SMALL CELL Neuroendocrine carcinoma of the cervis that after imaging is >4cm and confined to the cervis. What are the options for management?

A
  1. CCRT + Brachytherapy and consider post treatment systemic treatment.
  2. NACT with Cisplatin + Etoposide followed by Rad hyst or CCRT and Brachy. If Rad Hyst - consider EBRT after.
99
Q

NCCN Guideline 1.2024
In an advanced SMALL CELL Neuroendocrine carcinoma of the cervix - i.e. IB3 - IVA Rx

A
  1. CCRT + Brachy followed by cisplatin and etoposide
  2. OR
  3. NACT with cisplatin / etoposide followed by Chemoradiation + brachytheropy
100
Q
A

Gyn Onc (23 decks)

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