CIN/cervical cancer

Question 1

What is colposcopy?

Answer 1

Examination of cervix by binocular microscope
Transformation zone is identified and painted with acetic acid
Punch biopsy can be taken to gain histological diagnosis
If there is strong uptake of acetic acid, perform definitive treatment without waiting for biopsy result
CIN also associated with vascular abnormality

Does not detect adenocarcinoma

Question 2

What is large loop excision of the transformation zone

Answer 2

LLETZ is performed in colposcopy clinic under local using loop diathermy
Used for > CIN I

Question 3

What is follow up for LLETZ?

Answer 3

Smear at 6 months with high risk HPV testing
If negative, return to 3 yearly smears
Abnormal smear result and/or positive high risk HPV test requires repeat assessment and colposcopy

Question 4

What is CGIN?

Answer 4

Cervical glandular intraepithelial neoplasia
Can co-exist with CIN or be sole finding
Associated with high risk HPV
Endocervical epithelium extends into cervical canal and is not completely visible at colposcopy

Question 5

When are people offered HPV vaccine

Answer 5

Grils at 12 years old
against 6 and 11 - anogenital wards
and 16 and 18 high risk HPV
Do not prevent all cancers

Question 6

Who does cervical cancer occur in?

Answer 6

30-39 year olds, and over 70s

Question 7

What are types of cervical cause?

Answer 7

Squamous cell carcinoma 80%

Adenocarcinoma 20%

Question 8

What are features of cervical cancer?

Answer 8

Cervical smear showing ?invation
Incidental finding on treatment of CIN
Post-coital and/or post-menopausal bleeding
Vaginal discharge - watery

Advanced disease:
easy bleeding
Ureteric obstruction
Weight loss
Bowel disturbance
Vesiovaginal fistula
Pain

Question 9

What is found on examination of the cervix?

Answer 9

Colposcopy shows irregular cervical surface
Abnomral vessels and dense uptake of acetic acid

On bimanual examination, cervix feels roughened and hard and if disease is advanced, there is loss of the fornices and the cervix is fixed

Speculum shows irregular mass that bleeds on contact

Question 10

What investigations for cervical cancer?

Answer 10

FBC U&E LFT
Punch biopsy for histology
LLETZ - is CI as it will bleed heavily
CT abdo, pelvis for staging
MRU pelvis for staging

Question 11

What are stages of cervical cause?

Answer 11

I - tumour confined to cervix
Ia - microscopic
Ib - macroscopic

II - extended locally to upper 2/3 of vaigna
IIb - to parametric

III - spread to lower 1/3 of vagina
IIIb - pelvic wall

IV - spread to bladder or rectum
IVb - distant organs

Question 12

What is management for stage Ia?

Answer 12

<3mm depth - local excision (fertility sparing) or hysterectomy
<5mm depth - lymphadenectomy and if node negative Wertheim’s hysterectomy

Question 13

What is management for stage Ib

Answer 13

Macroscopic

<4cm diameter - lymphadenectomy and if node negative - Wertheim’s hysterectomy

> 4cm diameter Chemoradiotherapy
If negative lymph nodes, consider Wertheim’s hysterectomy

Question 14

Mx for stage II cervical cancer?

Answer 14

Combination chemoradiotherapy

Question 15

Mx for stage IV?

Answer 15

Chemoradiotherapy, palliative radiotherapy to control bleeding
Wertheim’s hysterectomy

Question 16

What chemotherapy is used in cervical cancer?

Answer 16

Cisplatin

Question 17

What are complications of treatment of cervical cancer?

Answer 17

Wertheim’s hysterectomy:
Bleeding, infection, VTE, ureteric fistula, bladder dysfunction, lymphedema

Radiotherapy:
Acute bladder and bowel dysfunction with tenesmus, mucositis, bleeding, ulceration, strictures and fistula formation

Question 18

What are risk factors for cervical cancer?

Answer 18

HPV 16, 18, 31, 33
Smoking
HIV
Early first intercourse
Many sexual partners
High parity
Lower SE status

Question 19

How does HPV cause cervical canes?

Answer 19

HPV 16 an 18 produce oncogenes E6 and E7 respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits the RB suppressor gene