Gynae: Cervical Cancer Flashcards
what age group is most commonly affected by cervical cancer?
younger women, of reproductive age
what is the most common type of cervical cancer?
most common (80%) is squamous cell next most common is adenocarcinoma
what virus are children aged 12-13 vaccinated against that is strongly associated with cervical cancer?
Human Papilloma Virus (HPV)
What cancers (other than cervical) is HPV associated with?
anal, vulval, vaginal, penis, mouth and throat
which strains of HPV are most commonly associated with cervical cancer?
type 16 and 18
explain the link between HPV type 16 and 18 and tumour suppressor genes?
HPV produces 2 proteins which target 2 tumour suppressor genes inhibiting their suppression therefore promoting the development of cancer
E6 inhibits P53
E7 inhibits pRb
What are the risk factors for cervical cancer? Think of increased risk of catching HPV, later detection and other risks
- Increased risk = early sexual activity, increased number of sexual partners, sexual partners who have had multiple partners, not using protection
- Non-engagement with cervical screening - many cases are preventable with early detection
- Others = smoking, HIV, COCP, increased number of full-term pregnancies, FHx, exposure to diethylstilbestrol during fetal development
What are the presenting symptoms of cervical cancer?
Usually asymptomatic
Abnormal vaginal bleeding
Vaginal discharge
Pelvic pain
Dyspareunia
what is NICE CKS 2017 guidance on smears in the context of cervical cancer?
Recommend against unscheduled cervical screening with a smear test
Also advise against using results of cervical screening to exclude cancer where it is suspected for another reason
for cervical cancer, symptoms are non-specific so a speculum examination is done. what may be seen on speculum exam that could indicate cervical cancer?
Ulceration
Inflammation
Bleeding
Visible tumour
when the appearance of the cervix is abnormal and suggestive of cervical cancer, what are patients urgently referred for and what is it?
colposcopy - using a colposcope to magnify the cervix allowing the epithelial lining to be examined in detail/ acetic acid and iodine solution can be used to differentiate abnormal areas. a punch biopsy or large loop excision of the transformation zone can be performed during colposcopy
what are the 2 stains used during colposcopy and what do they show?
- *acetic acid** - causes abnormal cells to appear white (described as acetowhite) occurs in cells with an increased nuclear to cytoplasmic ratio (cervical intraepithelial neoplasia and cervical cancer cells)
- *schiller’s iodine test** - uses iodine to stain healthy cells. unhealthy cells will not stain
what is CIN? And when is it diagnosed?
Cervical Intraepithelial Neoplasia
a grading system for the level of dysplasia in the cells of the cervix. diagnosed at colposcopy NOT cervical screening
what are the grades of CIN?
CIN I = mild dysplasia affecting 1/3 of the thickness of the epithelial layer - likely to return to normal without treatment
CIN II = moderate dysplasia affecting 2/3 of thickness of epithelial layer, likely to progress to cancer if untreated
CIN III = severe dysplasia very likely to progress to cancer if intreated
what is cervical screening?
way of picking up precancerous changes in epithelial cells of the cervix.
involves a smear test whereby cells are collected from the cervix with a small brush during a speculum exam.
cells transferred to preservation fluid and examined under microscope for precancerous changes called dyskaryosis
what happens before cervical cells are examined?
(incontext of screening/smears)
they are checked for high-risk HPV and if they are negative the cells are not examined further
who is involved in the cervical screening program?
women and transgender men who still have a cervix
every 3 years aged 25-49
every 5 years ages 50-64
what are the exceptions to the cervical screening program?
- Women with HIV screened annually
- Women > 65 may request a smear if they have not had one since aged 50
- Women with previous CIN may require additional tests (e.g. test of cure after treatment)
- Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
- Pregnant women due a routine smear should wait until 12 weeks post-partum
What are the cytology results for cervical screening?
- Inadequate
- Normal
- Borderline changes
- Low-grade dyskaryosis
- High-grade dyskaryosis (moderate)
- High-grade dyskaryosis (severe)
- Possible invasive squamous cell carcinoma
- Possible glandular neoplasia
what infections are commonly identified on smear tests?
bacterial vaginosis, candidiasis and trichomoniasis
what organisms are discovered on smear tests, in women with an intrauterine device and how are they managed?
actinomyces-like organisms
do not require treatment unless they are symptomatic (pelvic pain or abnormal bleeding)
may need to remove coil
management of smear results based on PHE guidelines from 2019
- Inadequate sample
- HPV negative
- HPV positive with normal cytology
- HPV positive with abnormal cytology
- Inadequate sample - repeat smear after at least 3 months
- HPV negative - continue routine screening
- HPV positive with normal cytology - repeat HPV test after 12 months
- HPV positive with abnormal cytology - refer for colposcopy
what is large loop excision of the transformation zone (LLETZ)
LARGE LOOP EXCISION OF THE TRANSFORMATION ZONE
aka loop biopsy
performed with local anaesthetic during colposcopy using a diathermy to remove abnormal epithelial tissue on the cervix
what are some consequences of LLETZ and some after advice
bleeding and abnormal discharge for several weeks
avoid intercourse and tampons to prevent infection
may increase risk of preterm labour
what is a cone biopsy?
cone biopsy is a treatment for cervical intraepithelial neoplasia and very early-stage cervical cancer
done under GA and surgeon removes a cone shaped piece of the cervix using a scalpel and the sample is sent for histology to assess for malignancy
what are the risks associated with cone biopsy?
- Pain
- Bleeding
- Infection
- Scar formation with stenosis of the cervix
- Increased risk of miscarriage and premature labour
how is cervical cancer staged?
International Federation of Gynaecology and Obstetrics
stage 1 = confined to cervix
stage 2 = invades the uterus or upper ⅔ of vagina
stage 3 = invades pelvic wall or lower ⅓ of vagina
stage 4 = invades bladder, rectum or beyond pelvis
how is cervical cancer managed?
- CIN and early-stage 1A: LLETZ or cone biopsy
- Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
- Stage 2B – 4A: Chemotherapy and radiotherapy
- Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
what is pelvic exenteration?
used in advanced cervical cancer and involves removing most or all of the pelvic organs (vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum)
what is bevacizumab (avastin)
monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer
it targets vascular endothelial growth factor A which is responsible for the development of new blood vessels
what is the name of the NHS vaccine which protects against HPV, what strains of HPV does it protect against and what do the strains typically cause?
Gardasil
- Strains 6 & 11 cause genital warts
- Strains 16 & 18 cause cervical cancer
