Dysplastic and Malignant Disorders of Cervix Flashcards
What is the major etiologic agent of cervical pre-cancerous lesions
HPV
What are the two major factors associated with development of cervical intraepithelial neoplasia and cervical cancer
- HPV types
- Age and persistence
Low risk HPV types
6 and 11
High risk HPV types
16 (more prevalent) and 18
HPV 16 and 18 cause what type of cancer
- squamous cell carcinoma
- adenocarcinoma
The likelihood of HPV persistence is related to what
- older age
- duration of infection
- high oncogenic HPV subtype
What is the transformation zone
the border between the stratified squamous epithelium of the ectocervix and the columnar epithelium of the endocervix
Where does cervical neoplasia originate
the transformation zone (t-zone)
Three clinical scenarios that can follow an acute HPV infection
- latent infection
- active infection
- neoplastic transformation
Latent HPV infection
ifection without physical, cytologic of histologic manifestations
Active HPV infection
HPV undergoes replication but does not integrate into the host genome
Neoplastic transformation HPV infection
the virus persists into the cytoplasm and integrates into the host genome
What is an important factor in the early stages following HPV infection
susceptibility to oncogenic HPV types, determined by the host immune system
Other factors to that contribute to the pathogenesis of HPV
- immunosuppression
- cigarette smoking
- herpes/chlamydia
- OCP
Two types of testing for HPV
- HPV DNA testing
- HPV RNA testing
What does HPV RNA testing look for
expression of E6 and/or E7 RNA (oncoproteins)
What is ASC (2 types)
atypical squamous cells
- can be of undetermined significance (ASC-US)
- or cannot exclude high grade squamous intraepithelial lesions (ASC-H)
What are the two types of classification systems for cervical neoplasia
- LAST system
- Bethesda classification system
What can abnormal cytology findings be described as
- atypical squamous cells of undetermined significance
- low grade squamous intraepithelial lesions
- high grade squamous intraepithelial lesions
- atypical glandular cells of undetermined significance
- invasive cervical cancer
Histological terms for cervical intraepithelial neoplasia (CIN)
- CIN1 (low grade)
- CIN 2,3 (high grade)
- CIN 3 includes carcinoma in situ
What is cervical cancer screening co-testing
testing with both cervical cytology (pap) and HPV infection
What is reflex HPV testing
collecting a specimen for HPV testing when PAP is done but preforming the HPV test if cytology results are ASC-US
What is cervical intraepithelial neoplasia
premalignant condition of the uterine cervix
Risk factors for cervical cancer
- early onset of sexual activity
- multiple sexual partners
- high risk sexual partner
- hx of STI
- hx of vulvar or vaginal squamous intraepithelial neoplasia or cancer
- immunosuppression
What are the 4 major steps in cervical cancer development
- oncogenic HPV infection of the metaplastic epithelium at the cervical transformation
- persistance of HPV infection
- progression of a clone of epithelial cells from persistent viral infection to pre cancer
- development of carcinoma and invasion through the basement membrane
Direct extension of cervical cancer goes where?
- uterine corpus
- vagina
- peritoneal cavity
- bladder
- rectum
Clinical manifestations of cervical cancer
- irregular or heavy vaginal bleeding
- postcoital bleeding
Women with a visible cervical lesion, symptoms, abnormal cervical cytology should undergo what
colposcopy with directed biopsy
When is cervical conization necessary
if malignancy is suspected but is not found with directed cervical biopsies
Routine lab evaluations for cervical cancer
- CBC
- LFTs
- renal function test
- urine
FIGO system for cervical cancer staging is based mostly on ___
physical examination
FIGO system does not include ___
stage 0 (TNM does)
Primary CIN prevention
- pap screening
- HPV vaccination
If pregnant with ASC-US colposcopy can be deferred until ____
six weeks postpartum
If pregnant with ASC-H
colposcopy should be preformed and should not be deferred
What should not be done during pregnancy
endocervical curettage
At what ages should pap smear be done
21-65 years old
Location of pap smear
transformation zone
Types of equiptment to collect pap samples
- ayre spatula (conventional smears)
- cervix brush
- cytobrush (no ectocervical sample)
What is endocervical curettage
inseritng a small, sharp, scoop shaped instrument into the cervical canal to obtain tissue
When is endocervical curettage done
when endometrial or cervical cancer is suspected or needs to be ruled out
if 25 or older with HPV negative ASC-US—>
co testing in three years
If 25 years or older with HPV-positive ASC-US—>
colposcopy
If 21-24 w/ negative cytology, ASC-US or LSIL—>
repeat pap in 12 months for 2 years
If 21-24 w/ ASC-H, HISL or AGC—>
colposcopy
If 25 or older and no lesion or CIN1 on colposcopy—>
co-testing in 12 and 24 months
If 25 years or older and CIN 2,3 on colposcopy–>
treat! (LEEP)
Evaluation of ASC-H in females 21-24—>
cytology and colposcopy every 6 months for 12 months
What do you do next after evaluating a 21 to 24 year old with ASC-H
if cytology and colposcopy are neg—> co testing after 1 year
abnormality persists for 1 year–> repeat biopsy
abnormality persists for 2 years—> treat!
Cervical cancer treatments for women with microscopic disease
- extrafascial hysterectomy
- cone biopsy
What is an extrafascial hysterectomy
fascia of the cervix and lower uterine segment is removed along with the uterus
Candidates for radical hysterectomy
women with a tumor that is confined to the cervix, uterus or upper third of the vaginal with no lymph node metastasis
Candidates for chemo-radiation
women with local extension (low two thirds of the vagina or bladder) or lymph node metastasis
Candidates for full dose chemotherapy alone
women with widely metastatic disease
