Gynaecological Oncology & Screening - Cervical Cancer

Question 1

Histology of Cervix (3).

Answer 1

1. Endocervix : Columnar Epithelium.
2. Ectocervix : Squamous Epithelium.
3. Meeting : Squamous-Columnar Junction.

Question 2

What happens in the Cervix during Puberty and Pregnancy?

Answer 2

Hormonally-Induced Eversion : lower pH of the vagina results in the formation of a physiological Transformation Zone (TZ) - columnar epithelium undergoes physiological metaplasia to become squamous epithelium.

Question 3

Types of Cervical Cancer (2).

Answer 3

1. 80% - Invasive SCC (from CIN).

2. 20% - Adenocarcinoma (from CGIN - Glandular).

Question 4

Main Risk Factors of Cervical Cancer (3).

Answer 4

1. Increased Risk of Catching HPV.
2. Non-Engagement with Screening (Late Detection of Precancerous and Cancerous Changes).
3. Lifestyle Factors.

Question 5

What can cause an Increased Risk of Catching HPV? (4)

Answer 5

1. Early Sexual Activity.
2. Increased Number of Sexual Partners.
3. Sexual Partners With More Partners.
4. Not Using Condoms.

Question 6

Lifestyle Factors (6).

Answer 6

1. Smoking.
2. HIV.
3. COCP for 5+ Years.
4. Increased Number of Full-Term Pregnancies.
5. Family History.
6. Exposure to Diethylstilbestrol during Foetal Development (a drug used before 1971).

Question 7

Epidemiology of HPV.

Answer 7

1. Commonest Cause of Cervical Cancer.
2. 100+ Strains - Type 16 and 18 : Cervical Cancer.’
3. Resolve within 2 years spontaneously usually.

Question 8

Pathophysiology of HPV Infection and Cervical Cancer (2).

Answer 8

1. p53 and pRb are tumour suppressor genes.

2. HPV produces E6 and E7 proteins which inhibit these tumour suppressor genes (E6 - p53; E7 - pRb).

Question 9

HPV Vaccine (4).

Answer 9

1. Given to Boys and Girls BEFORE becoming sexually active.
2. Current NHS Vaccine : Gardasil.
3. 6 and 11 : Genital Warts.
4. 16 and 18 and 33 : Cervical Cancer.

Question 10

How do Infected Endocervical Cells appear under a microscope?

Answer 10

Koilocytes :

1. Enlarged Nucleus.
2. Irregular Nuclear Membrane Contour.
3. Hyperchromasia : Nucleus Stains Darker than Normal.
4. Perinuclear Halo.

Question 11

What is CIN?

Answer 11

Cervical Intrapeithelial Neoplasia - dysplasia (premalignant change) in the cells of the cervix - a diagnosis at colposcopy.

Question 12

Grading of CIN (3).

Answer 12

1. CIN I : Mild Dysplasia (1/3 of Thickness of Epithelial Layer - likely to return to normal without treatment).
2. CIN II : Moderate Dysplasia (2/3 of Thickness of Epithelial Layer - likely to progress to cancer without treatment).
3. CIN III (Cervical CIS) : Severe Dysplasia - very likely to progress to cancer without treatment.

Question 13

Management of CIN.

Answer 13

1. CIN I : Observation and Follow-Up.

2. CIN II/III - LLETZ.

Question 14

Clinical Presentation of Cervical Cancer (6).

Answer 14

1. Asymptomatic.
2. Abnormal Vaginal Bleeding - Intermenstrual, Postcoital, Postmenopausal.
3. Vaginal Discharge.
4. Pelvic Pain.
5. Dyspareunia.
6. Constitutional Symptoms.

Question 15

What is the Rule of Thumb with Cervical Cancer?

Answer 15

Post-Coital Bleeding is due to Cervical Cancer until proven otherwise.

Question 16

Examination of Cervical Cancer.

Answer 16

1. Swab - Infection.

2. Abnormal Appearance : Ulceration, Inflammation, Bleeding, Visible Tumour.

Question 17

Staging of Cervical Cancer (4).

Answer 17

FIGO System :

1. Confined to Cervix.
2. Invades Uterus/Upper 2/3 of Vagina.
3. Invades Pelvic Wall/Lower 1/3 of Vagina.
4. Invades Bladder, Rectum, Beyond Pelvis.

Question 18

Cervical Screening Recommendations.

Answer 18

1. Don’t use unscheduled cervical screening with a smear test.
2. Don’t use the result of cervical screening to exclude cervical cancer where it is suspected for another reason, even if the smear result was normal.

Question 19

Aim of Cervical Screening.

Answer 19

Pick up precancerous changes in the epithelial cells of the cervix.

Question 20

Method of Cervical Screening (2).

Answer 20

1. Cervical Smear Test - speculum examination and collection of cells from the cervix using a small brush.
2. The cells are deposited into preservation fluid and transported to a lab (liquid-based cytology) for microscopy to check for dyskaryosis.

Question 21

What are the Samples tested for? (2)

Answer 21

1. High-Risk HPV.

2. Cell Examination (only if HPV is Positive).

Question 22

Routine of Cervical Screening Program (7).

Answer 22

1. Every 3 Years Between 25-49.
2. Every 5 Years Between 50-64.
3. Annually - HIV.
4. 65+ Can Request Smear if None Since 50.
5. Additional Tests (e.g. Tests of Cure) if Previous CIN.
6. Additional Screening if Immunocompromised.
7. Routine Smear for Pregnancy - Wait 12 Weeks Post-Partum.

Question 23

Cytology Results (8).

Answer 23

1. Inadequate.
2. Normal.
3. Borderline Changes.
4. Low-Grade Dyskaryosis.
5. High-Grade (Moderate) Dyskaryosis.
6. High-Grade (Severe) Dyskaryosis.
7. Possible Invasive SCC.
8. Possible Glandular Neoplasia.

Question 24

Additional Findings in Cervical Smear Results (2).

Answer 24

1. Infections.

2. ALO - IUD Coil (only remove coil if symptomatic).

Question 25

Management of Smear Results (4).

Answer 25

PHE Guidelines : 1. Inadequate Sample - Repeat After at least 3 Months. If 2 Consecutive Inadequate Samples - Colposcopy. 2. HPV Negative - Continue Routine Screening. 3. HPV Positive + Normal Cytology - Repeat HPV Test after 12 Months. 4. HPV Positive + Abnormal Cytology - Refer for Colposcopy.

Question 26

When is the best time for a woman to take a cervical smear?

Answer 26

Mid-cycle.

Question 27

What is Colposcopy?

Answer 27

Insertion of a Speculum and Colposcope to magnify the cervix to examine the epithelial lining of the cervix.

Question 28

Stains in Colposcopy (2).

Answer 28

1. Acetic Acid : Acetowhite Appearance (White) in Cells with Increased Nuclear : Cytoplasmic Ratio e.g. CIN, Cancer. 2. Schiller's Iodine Test : Healthy cells stain brown; abnormal cells do not.

Question 29

Management of Cervical Cancer (6).

Answer 29

1. CIN/Early-Stage (1A) : LLETZ or Cone Biopsy. 2. 1B-2A : Radical Hysterectomy and Removal of Local Lymph Nodes with Chemotherapy and Radiotherapy. 3. 2B-4A : Chemotherapy and Radiotherapy. 4. 4B : Surgery, Radiotherapy, Chemotherapy and Palliative Care. 5. Pelvic Exenteration. 6. Bevacizumab (Avastin).

Question 30

What is LLETZ?

Answer 30

Large Loop Excision of the Transformation Zone (Loop Biopsy) with Local Anaesthetic during Colposcopy.

Question 31

What happens in LLETZ?

Answer 31

1. Loop of wire with electrical current (diathermy) is used to remove abnormal epithelial tissue on the cervix. 2. Diathermy cauterises the tissue and stops the bleeding.

Question 32

Post-LLETZ Considerations.

Answer 32

1. Bleeding and Abnormal Discharge can occur for several weeks following LLETZ. 2. Avoid intercourse and tampon use to reduce risk of infection. 3. Increased risk of preterm labour, based on depth of tissue removed.

Question 33

What is a Cone Biopsy?

Answer 33

A cone-shaped piece of the cervix is removed in surgery under general anaesthetic as treatment for CIN or early-stage Cervical Cancer to be sent for histology.

Question 34

Risks of Cone Biopsy (5).

Answer 34

1. Pain. 2. Infection. 3. Bleeding. 4. Scar Formation : Stenosis of Cervix. 5. Increased Risk of Miscarriage and Premature Labour.

Question 35

What is Pelvic Exenteration?

Answer 35

An operation in advanced cervical cancer, removing most/all pelvic organs.

Question 36

What is Bevacizumab/Avastin?

Answer 36

Monoclonal antibody to treat metastatic/recurrent cervical cancer by targeting VEGF-A.