Gynaecological cancers Flashcards
peak incidence of cervical cancer
25-29
80s second peak
cervical cancer type
70% SCC
15% adenocarcinoma
15% mixed
how long for CIN->cancer
10-20 years
human papilloma virus types that cause cancer
16 and 18
p53, pRB inhibition
risk factors for cervical cancer
smoking
other STIs
long-term COCP use (>8 years)
immunodeficiency (HIV)
3rd commonest gynae cancer
cervical
risk factors for HPV
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
Smoking
HIV (patients with HIV are offered yearly smear tests)
Combined contraceptive pill use for more than five years
Increased number of full-term pregnancies
Family history
Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)
Young age at first intercourse
Multiple sex partners
Exposure (no barrier contraception)
Immunosuppression/ HIV
Non-compliance with cervical screening
symptoms of cervical cancer
abnormal vaginal bleeding vaginal discharge dyspareunia pelvic pain and weight loss asymptomatic in early stages
advanced disease of cervical cancer
lower limb oedema loin pain rectal bleeding radiculopathy haematuria fistulae renal failure
examination in cervical cancer
Speculum examination – assess for evidence of bleeding, discharge and ulceration.
Bimanual examination – assess for pelvic masses.
GI examination – assess for hydronephrosis, hepatomegaly, rectal bleeding, mass on PR.
no smear test needed
grades of CIN
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated
DD cervical cancer:
abnormal vaginal bleeding
STI cervical ectropion polyp fibroids pregnancy-related bleeding endometrial carcinoma if post-menopausal
pre-menopausal investigation in cervical cancer
Pre-menopausal – test for chlamydia trachomatis infection
If positive; treat for chlamydia infection. If symptoms persist after treatment, refer for colposcopy and biopsy.
If negative; a colposcopy and biopsy is usually performed.
post-menopausal investigation in cervical cancer
urgent colposcopy and biopsy.
A colposcopy is where a colposcope (modified microscope) is used to produce a magnified view of the cervix. Acetic acid is used to stain dysplastic areas, and a biopsy is taken.
If the diagnosis of cervical cancer is confirmed, further investigations are required:
investigations in cervical cancer
chylamydia colposcopy and biopsy basic blood tests: FBC, LFT, U&E CT CAP further staging scans- MRI pelvis, PET \+/- examination under anaesthesia
principles of screening WHO
Condition should be an important health problem
Should be a treatment for the condition
Facilities for diagnosis and treatment should be available
Should be a latent stage of the disease
Should be a test or examination for the condition
Test should be acceptable to the population
Natural history of the disease should be adequately understood
Should be an agreed policy on who to treat
Total cost of finding a case should be economically balanced in relation to medical expenditure as a whole
exceptions to screening programme
Women with HIV are screened annually
Women over 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
smear result guidlines
Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy
stage 1 cervical cancer
Stage 1: Confined to the cervix:
A microinvasive
B clinical lesion
stage 2 cervical cancer
Stage 2: Invades the uterus or upper 2/3 of the vagina:
A upper 1/3 vagina
B parametrium
stage 3 cervical cancer
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina:
Lower 1/3 vagina, hydronephrosis
B extends to pelvic side wall, hydronephrosis
stage 4 cervical cancer
Stage 4: Invades the bladder, rectum or beyond the pelvis:
A invades adjacent organs (bladder/ bowel)
B distant sites
surgical options for cervical cancer stage 1a
Radical trachelectomy if fertility-preservation is a priority. (remove cervix and upper part of vagina)
Otherwise, a laparoscopic hysterectomy with pelvic lymphadenectomy is offered.
surgical options for cervical cancer stage 1b/2a
Radical (Wertheim’s) hysterectomy as a curative treatment modality.
Involves removal of the uterus, vagina and parametrial tissues up to the pelvic sidewall, plus lymphadenectomy.
surgical options for cervical cancer stage 4a or recurrent disease
Anterior/posterior/total pelvic extenteration.
Removal of all pelvic adnexae plus bladder (anterior)/rectum (posterior or both (total).
radiotherapy for stage 1b to 3 cervical cancer
Offered in conjunction with chemotherapy over a 5-8 week course.
Evidence suggests additional hysterectomy offers no benefits in terms of survival for these stages.
Therefore chemoradiation therapy is the gold standard.
chemotherapy for cervical cancer
Chemotherapy in cervical cancer is often cisplatin-based.
It can be given before treatment by surgery or radiotherapy (known as neoadjuvant chemotherapy), or after treatment (adjuvant chemotherapy).
It is also the mainstay of treatment in the palliative setting.
follow-up cervical cancer
Patients should be reviewed by a gynaecologist every 4 months after treatment has been completed for the first 2 years, and every 6-12 months for the subsequent 3 years.
All follow-ups should involve a physical examination of the vagina and cervix (if they haven’t been removed).
