Gynae: PCB and cervical cancer Flashcards
What should you ask about when exploring HxPC for PCB?
- When and what happened? Has this happened before?
- How much? Is it still ongoing?
- Check it wasn’t first intercourse, that she wasn’t on her period, and that it was definitely PV
- Dyspareunia?
- Is there any chance you could be pregnant?
What other symptoms should you ask about when taking a history on PCB?
- Menstrual history
- LMP, regular, menorrhagia, “normal”?
- Bleeding at any other times
- Changes in periods à menorrhagia?
- Intermenstrual bleeding
- Pain? (including abdominal)
- Fever?
- Discharge?
- Bladder or bowel symptoms
- Systemic – tiredness, loss of weight, appetite
What background history should you ask about for PCB?
- Past obstetric history
- Past gynae history
- Any gynaecological problems or procedures in the past?
- Infections?
- Smears – up to date? –any abnormal, any treatment?
- Sexual history
- Past medical history
- Family history
- Drug history and contraception
- Smoking, alcohol, social history
What are some causes of PCB?
First intercourse
Cervix: cervical cancer, cervical eversion or ectropion, cervical polyps or cervicitis.
Vaginitis (eg atrophic)
PID/infection
Fibroids
What examinations and investigations should you perform for PCB?
Speculum examination with smear and triple swabs
Bi-manual and abdominal examination with special attention to external genital area to look for VIN/trauma/FGM
Sexual health screen
Bloods: FBC, TFT, clotting, Ca125
TV and abdominal US
Urine dip + MSU if positive
Describe some benign conditions of the cervix which may cause PCB
- Cervical ectropion*- red area around os= endocervix from eversion. Normally asymptomatic but can give PCB. Do colposcopy and smear to exclude carcinoma, then cryotherapy
- Acute cervicitis*- rare, due to STI.
Chronic cervicitis- chronic inflammation of ectropion, use cryotherapy+/-abx
- Cervical polyps*- benign tumours of endocervix. Most in women over 40, <1cm. If small, avulse and examine histologically
- Nabothian follicles*- get squamous epithelium over columnar after metaplasia, so secretions build up, giving white swelling on ectocervix.
Describe cervical cell anatomy
Endocervix= canal, lined by columnar glandular epithelium
Ectocervix= continuous with vagina, covered in squamous epithelium.
The 2 meet at squamocolumnar junction. In pregnancy and puberty, get partial cervix eversion. Lower pH of vagina gives metaplasia of columnar to squamous epithelium- ‘transformation zone’ Commonly forms origin of cervical carcinoma
What is CIN?
Presence of atypical cells in squamous epithelium. Histological diagnosis.
- Grade I= cells only in lower third
- Grade 2= cells in lower 2 thirds
- Grade III= full-thickness, carcinoma in situ. Get malignancy if they then invade through basement membrane
If untreated, 1 in 3 with CIN II/III will develop cervical cancer over 10 years. CIN often regresses
Peak incidence in 25-29 yr olds
Risk factors: HPV, OCP, smoking, immunocompromised
Describe the national screening programme for cervical cancer
- Aims to pick up CIN (asymptomatic and not visible on the cervix)
- Performed every 3 years from age 25-49, then 5-yearly between age 50 and 64.
- A speculum is inserted and a smear taken, and sent for liquid-based cytology. Identifies dyskaryosis which may be graded; it is suggestive of CIN with grade reflecting the severity, but colposcopy is required for true histological diagnosis of dysplasia.
How would you manage the different possible smear results?
Negative hrHPV: return to normal recall unless
- Test of cure pathway
- Untreated CIN1 pathway
- Follow-up for incompletely excised cervicial glandular intraepithelial neoplasia (CGIN)/stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
- Follow-up for borderline changes in endocervical cells
Positive hrHPV: sample examined cytologically
- If cytology is abnormal → colposcopy
- If the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
- If the repeat test is now hrHPV -ve → return to normal recall
- If the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later
- If hrHPV -ve at 24 months → return to normal recall
- If hrHPV +ve at 24 months → colposcopy
If sample is ‘inadequate’: Repeat the sample within 3 months
- If two consecutive inadequate samples then → colposcopy
What is HPV? Describe pathogenesis and vaccines available
- HPV is believed to be the cause of virtually all cervical cancer, as well as many vulval cancers.
- The HPV vaccine is a subunit vaccine (L1 virus-like particle) – Gardasil protects against HPV6/11/16/18, while Cervarix protects against HPV 16 and 18 only.
- HPV invades basal cells of stratified squamous epithelium and transcribes E6 and E7 proteins. E6 binds and disables p53 (tumour suppressor protein) and E7 binds to RB protein, causing uncontrolled cell replication.
Outline the pathology of cervical malignancies
90% squamous cell carcinomas
10% adenomcarcinomas from columnar epithelium. Worse prognosis.
CIN is pre-invasive stage
Describe some possible features of cervical carcinoma
- Hx- PCB, PMB, IMB and offensive vaginal discharge - cervical cancer presents early
- Visible cervical changes on speculum/colposcopy
- Later stages,:can get involvement of ureters, bladder, etc so haematuria, rectal bleeding and pain.
- May be no findings O/E
Briefly describe the treatment for cervical carcinoma
- Microinvasive disease can be treated with cone biopsy, as the risk of LN spread is negligible.
- All other stage 1 and 2a disease should be treated with radical abdominal hysterectomy, with pelvic LN clearance, removal of the parametrium and upper 1/3 of the vagina, and usually bilateral salpingo-oophorectomy.
- If LN are involved or excision margins are incomplete, radiotherapy +/- platinum-based chemotherapy are used.
- Stage 2b or worse should be treated with radiotherapy and platinum-based chemotherapy.
