DDx: Cervical Cancer Flashcards
Differential Diagnosis of Cervical Cancer:
Cervival Cancer
Dysplasia
Nabothian cysts
Cervicitis (see Sexually Transmitted Diseases)
Cervical ectopy
Cervical atrophy
Cervical polyp
Cervical cysts
Cervical Cancer
Cervical Cancer
Hx: Symptoms of cervical cancer may include postcoital bleeding, foul-smelling vaginal discharge, change in urinary or bowel habits, right upper quadrant abdominal pain, back pain, or leg swelling. The “terrible triad” of advanced cervical cancer is sciatic back pain, hydroureter, and leg swelling.
Px: Exophytic or ulcerative lesion on the cervix, foul-smelling vaginal discharge, firmness in the parametrium, leg swelling, and supraclavicular lymphadenopathy (Virchow node). Metastatic disease to the liver may present as tenderness or a mass in the right upper quadrant.
Dx: Pap anicolaou (PAP) smear screening has significantly decreased the risk of death from cervical cancer. Screening is initiated at age 21 years and is not recommended in younger females regardless of age at onset of vaginal intercourse. The screening interval is every 3 years starting at age 21 unless there is a history of diethylstilbestrol exposure or the patient is HIV-positive or immunocompromised. These high-risk women should undergo screening every 6 to 12 months.
Women at average risk aged >30 years can be screened with a combined Pap smear and HPV DNA testing (also referred to as cotesting). If both tests are negative, the screening interval can be increased to every 5 years. If the cytology is negative, but high-risk HPV DNA testing is positive, both tests should be repeated at 12 months. Screening for cervical cancer may be discontinued at age 65 years if the patient has been adequately screened, has had normal Pap smears, and has no other risk factors.
If the cytology result is atypical squamous cells of undetermined significance (ASC-US), the preferred management strategy is to order an HPV test when obtaining a Pap smear. Termed “reflex HPV testing,” an HPV test will be performed on any Pap smear that is reported as ASC-US. If results are positive for high-risk HPV, the patient should be referred for colposcopy. The colposcope is a low-powered magnification device that permits the identification of mucosal abnormalities characteristic of dysplasia or invasive cancer and guides selection of tissue for biopsy. If results are negative for high-risk subtypes, the Pap smear and HPV test are repeated in 3 years. Alternatively, if the HPV test was not performed, the cytology can be repeated in 1 year. If the repeat cytology is negative, the patient resumes routine screening in 3 years. If the repeat cytology is ASC-US or worse, the patient should be referred for colposcopy.
Women aged 21 to 24 years with ASC-US or low-grade squamous intraepithelial lesion (LSIL) are managed differently. The Pap test should be repeated in 12 months; if the result is negative, ASC-US, or LSIL, cytology is repeated again 12 months later. If a repeat test at 12 months is ASC-H (high-grade ASC-US) or worse, the patient should also be referred for colposcopy. If the cytology is negative × 2 or the initial reflex HPV test was negative, the patient can resume routine screening. If the cytology is ASC-US or greater at 24 months, the patient should be referred for colposcopy. The following cytology findings in pre- or postmenopausal women should be referred for colposcopy or further evaluation, even if HPV testing is negative: LSIL (unless aged 21 to 24), high-grade squamous intraepithelial lesion (HSIL), atypical squamous cells/cannot exclude HSIL (ASC-H), squamous cell cancer, adenocarcinoma, atypical glandular cells, or endometrial cells in women aged >40 years
Both bivalent and quadrivalent HPV vaccines are available. Both vaccines protect against high-risk HPV subtypes (HPV-16 and HPV-18) and the quadrivalent additionally protects against subtypes that cause genital warts (HPV-6 and HPV-11). Routine vaccination with either vaccine is recommended for girls aged 11 to 12 years but can be given as early as 9 years of age. Vaccination should be offered to females aged 13 to 26 years who have not previously received or completed the vaccine series.
Ddx:
Dysplasia: Abnormal Pap test result. Needs colposcopy and biopsy.
Nabothian cysts: Nabothian cysts are formed when glandular tissue is covered by squamous epithelium. Nabothian cysts are common and can become quite large. If diagnosis is questionable, needs biopsy.
Cervicitis: May cause postcoital bleeding. There are no discrete lesions on the cervix, but the cervix is red and inflamed. Needs biopsy if Pap smear result is abnormal.
Cervical ectopy: Presence of columnar epithelium on the ectocervix is a normal variant appearing as a red, beefy area; occasionally mistaken for cervicitis. Close inspection reveals the demarcation where the squamous epithelium begins.
Cervical atrophy: May cause postcoital bleeding. Vagina and cervix tend to be pale and atrophic. Obtain Pap smear.
Cervical polyp: Finger-like mass protruding from os. Needs biopsy or excision.
Cervical cysts: Tend to be well-circumscribed bubble-like lesions on the cervix. If diagnosis is questionable, needs biopsy.
Dysplasia
Abnormal Pap test result. Needs colposcopy and biopsy.
Nabothian cysts
Nabothian cysts are formed when glandular tissue is covered by squamous epithelium. Nabothian cysts are common and can become quite large. If diagnosis is questionable, needs biopsy.
Cervicitis (see Sexually Transmitted Diseases)
May cause postcoital bleeding. There are no discrete lesions on the cervix, but the cervix is red and inflamed. Needs biopsy if Pap smear result is abnormal.
Cervical ectopy
Presence of columnar epithelium on the ectocervix is a normal variant appearing as a red, beefy area; occasionally mistaken for cervicitis. Close inspection reveals the demarcation where the squamous epithelium begins.
Cervical atrophy
May cause postcoital bleeding. Vagina and cervix tend to be pale and atrophic. Obtain Pap smear.
Cervical polyp
Finger-like mass protruding from os. Needs biopsy or excision.
Cervical cysts
Tend to be well-circumscribed bubble-like lesions on the cervix. If diagnosis is questionable, needs biopsy.
