Dysplasia/Cervical Cancer

Question 1

Mx of HPV16/18/HSIL

Answer 1

• HPV cause CIN - precursor to SCC
• untreated CIN progress to cervical ca
• e.g. CIN3 30% reg 30% progress
• HPV16/18 = 90% of cervical ca
• Follow-up depends on bx
• LLETZ to confirm/treat - explain
• Address STI/Vax/smoke

Question 2

Mx of LSIL

Scenario 1 - 28yo P0 previous CIN3 + LLETZ, rpt CST -> LSIL

Answer 2

• Risk of progression to SCC low
• Colp +/- Bx
• LSIL or less -> repeat CST in 12/12
• Manage according to CC guideline
• address STI/Vax/smoke/comorbidity

Question 3

Mx of CIN in preg

Answer 3

• risk of progression to SCC low
• colp to exclude overt malignancy
• defer sampling/rx in preg
• only sample if suspect invasive d
• F/U 3mo PP w E if BF for colp+CST

Question 4

Mx of AIS

Answer 4

• cone bx to confirm
• risk = HPV - AIS - cervical adeno
• ref Tert - dysplasia MDT…
• mx depends on fertility
• if opt for fertility
  1. cyto surveillance - 6mo Colp
  2. conceive asap
• if not fertility -> hysterectomy
• annual co-test on vault for life

cone indication - Histo confirmed AIS, or Histo confirmed CIN3 with T3 TZ

Question 5

Mx of abn glandular cells on smear

Answer 5

• pelvic USS
• +/- Pipelle
• Colp+Bx+HDC

Question 6

Counsel re: risks for LLETZ + Cone

Answer 6

Surgical risks & Preg implications
- infection/pain/bleeding
- risk of transfus/hysterectomy w cone
- cervical insuff - future preg imp (PTB)
- cervical stenosis
- repeat treatment - +’ve margin

LLETZ PTB risks
- increased risk if any of the following
& need cervical surveillance if
1. >1 LLETZ
2. T3 excision
3. twins
4. short preg interval

CONE PTB risks
- increase risk of PTB 4-5% <34/40
- need cervical surveillance

Question 7

Mx of intra-op bleeding

Scenario 1 - LLETZ w sig bleeding

Answer 7

• risk of decompensation
• emergency
• inform team
• call for help
• simul resus/stabilize/rx
• MDI - gyn/ano +/- GONC
• Resus - Fluid/Txa/IDC
• FBE/UEC/LFT/Coag/G&S-x-match
• identify/pressure/pack till help arrives

Options
1. Ligate bleeding vessels (3 & 9 o’clock)
2. Hemostatic agent
3. Laparotomy (ligation ant div of UtA)
4. Embolisation
5. Hysterectomy

Post-op
- HDU admission
- repeat Hb +/- PRBC +/- iron infusion
- debrief/document - cx/mx/f/u
+/- rebook procedure if incomplete
- m&m/audit

Question 8

Mx of postop complications

Scenario 1 - 2/52 post cone bx p/w heavy bleeding

Answer 8

DDx
- infection endometritis/cervicitis
- arterial/venous bleeding
- menstruation

Immediate mx
- risk of sepsis/anemia/decompensat
- emergency
- call for help
- simultaneous resus/stabilise/rx
- ABC - O2/IVC - bloods includ x-match
- NBM/IDC/IVT
- identify - Monsel/Silver/Pack
- Txa + Broad abx
- inform con/ano/OT
- consent for EUA/cauterization +/- laparotomy +/- embolization
(risk of hysterectomy)

Intra-op
- senior +/- GONC
- lithotomy, good lighting, suction
- diathermy to cervix +/- suture
- fluid resus
- correct coagulopathy
+/- laparotomy +/- hysterectomy

Postop
- HDU
- anemia mx
- debrief/document
- M&M/Audit

Question 9

Mx of stage I cervical ca

Scenario 25yo P0, small invasive ca on LLETZ

Answer 9

• Risks of untreated ca progression
• Risks of treatment - fertility/preg imp

Pre-MDT ix
- FBE/UEC/LFT (anaemia/renal dysfunc)
- Renal tract USS (PSW involvement)
- MRI of pelvis (loco-regional disease)
- CXR/CTCAP (metastatic disease)

• Refer to Tertiary GONC unit
• MDT rv of ix/plan for mx
• likely need surgery - cone vs trachelect
• GONC F/U postop
• Cervical surveillance in future preg

PTB rate
- cone up to 5%
- trachelectomy up to 40%