Gynaecological Oncology Flashcards
What is the most common type of malignant cervical lesion? At what age is it usually diagnosed?
Squamous cell carcinoma (95%), followed by adenocarcinoma
50s
Where do the majority of cervical dysplasias and cancers arise?
The transformation zone of the cervix
What is the transformation zone and how does it arise?
- At birth, vagina lined with squamous epithelium - columnar epithelium lines only the endocervix and the central area of the ectocervix (original squamocolumnar junction)
- During puberty, oestrogen stimulates eversion of a single columnar layer –> exposed to acidic pH of vagina –> metaplasia (change from squamous to columnar) –> new squamocolumnar junction forms as a result
- TZ is the area located between the original and the current squamocolumnar junction
Describe the progression of cervical cancer.
Metaplasia –> HPV infection –> dysplasia –> carcinoma in situ –> invasion (growth by local extension) –> metastasis (occurs late)
With which HPV types is associated with a high risk cervical neoplasia?
16, 18
With which HPV types is associated with a low risk of cervical neoplasia?
6, 11
Describe the important aspects of the National HPV vaccine and the vaccination program (3)
- In Vic, free for Yr 7 boys and girls (12-13 yo) and Yr 9 boys (14-15 yo)
- Two types - Gardasil covers all four HPV types while Cervarix covers only two (16,18)
- 3 IM injections over a period of 6 months
When should the HPV vaccine ideally be administered?
Ideally, before onset of sexual activity HOWEVER vaccine is still indicated for sexually active females or those with a history of previous HPV infection or HPV-related disease
List 3 early and 3 late features of cervical cancer
Early: asymptomatic; discharge: initially watery, becoming brown or red; post-coital bleeding
Late: 80-90% present with bleeding (either post-coital, postmenopausal or irregular bleeding); pelvic or back pain (extension of tumour to pelvic walls); bladder/bowel symptoms
What are the cervical screening guidelines in the normal population of women?
In women over the age of 18 who have ever had sex, Pap smears required every 2 years even if they no longer have sex
(No advantages in doing more frequently, because cancer usually takes ~10 years to develop)
What are the cervical screening guidelines in those who’ve had a hysterectomy?
If total: vault smears
If partial: (i.e. cervix still there); Pap smear still required
When can regular cervical screening be stopped?
In those over the age of 70 and who’ve had two normal Pap smears in the last 5 years. They can still do so if they wish.
How is cervical cancer diagnosed? (2)
- Colposcopy - acetic acid wash applied to cervix dehydrates cells and reveals ‘acetowhite’ areas that correspond to increased nucleus-to-cytoplasm ratio (abnormal) - allows biopsy
- Cone biopsy or diagnostic excision (i.e. loop electrosurgical excision procedure)
How is cervical cancer treated?
Dependent on stage/size
Surgical - excision (cone, LEEP) or hysterectomy
Chemotherapy - for locally advanced or metastatic
Radiotherapy - for locally advanced disease
How are abnormal Pap tests managed in pregnancy? (3)
- Refer to colposcopy
- If diagnostic conization required, should be deferred until T2 to minimise risk of pregnancy loss
- Can deliver vaginally if invasive cancer ruled out
How is invasive cervical cancer managed in pregnancy? (In T1 vs T2/T3)
Depends on prognostic factors, degree of foetal maturity and patient wishes
General recommendations in T1: consider pregnancy termination, management with either radical surgery (hysterectomy vs. cervicectomy/trachelectomy)
In T2/T3 : delay of therapy until viable foetus and C/S for delivery with concurrent radical surgery or subsequent concurrent chemoradiation therapy
