Premalignant and malignant disease of the lower genital tract Flashcards
Cervical smear key features of focused Hx
LMP gynae Hx (IMB, PCB, discharge) Sexual Hx Contraception Obstetric and fertility desires Smoker? Immunosuppression?
If a smear is missed because of pregnancy?
Do 3mo after delivery
Smear procedure
Internal examination using small tube and brush Chaperone Gel warn before insertion 5 rotation clockwise and 10 dips in pot Label sample Dispose of brush and speculum Offer tissue allow to get dressed
Explanation of result
- Result within 2 weeks
- Screening catches (pre)cancerous changes
- Most of the time abnormal does not equal cancer but req. further Ix
What to do with cervical smear results
mild/borderline: HPV test and colposcopy
anything worse: urgent colposcopy referal
Inadequate: repeat (after 3 refer colposcopy)
Explanation of colposcopy
-Like a speculum but uses microscope to visualise the cervix better
- Liquid applied to identify abnormal areas +/- biopsy
- ?LLETZ
- Written result within 4wks if biopsy
Risk/Aftercare: bleeding/infection, no tampons or sex for 4 wks
Cervical Intraepithelial Neoplasia
Screening:
- CIN1 likely to resolve spontaneously (12m FU smear)
- CIN2/3/CGIN - removal
LLETZ
Large loop excision of transformation zone
Removal of abnormal cells w/heated loop
AKA loop diathermy
When can LLETZ be performed
At time of colposcopy
under LA as day case
Risks of LLETZ
Large/repeated risk midtrimester miscarriage and preterm delivery
Cone biopsy
used less frequently than LLETZ
Only if large area of tissue needs removal
under GA
Alternatives to cone and LLETZ
Laser
cyrotherapy
cold coagulation
Pts who undergo treatment for CIN FU
Test of cure after 6/12 - high risk HPV test and cyology - Negative: routine recall 3yrs irrespective of age, if >50 and last recall negative return to 5rly - Positive: repeat colposcopy to treat residual CIN
HPV vaccination
Boys and girls now 12-13
Quadrivalent = 6 13 16 18
Nonavalent covers other less common HPV
Cervical cancer Stages
1A - microscopic incidental
1B invasive confined to cervix
2+ beyond cervic
Cervical cancer Mx
1A - removal with clear margin, coexisting CIN removed
1B: Rad. hysterectomy w/bilat pelvic LN dissection (fertility sparing = radical trachelectomy)
in stage 1B radio is as effective
2+ radiotherapy mainstay
Surgical Mx of cervical cancer
1B - rad. hysterectomy w/pelvic LN diss. (ovaries spared in pre-men.)
- High cure rate
Pelvic LNs?
Obturator
Internal iliac
External iliac
Risk of surgical Mx of cervical cancer
Bladder dysfunction (atony)
- common may req. self cath immediately post op
Sexual dysfunction
Lymohoedema (LN removal)
Radiotherapy for Cervical cancer
- External beam: 4 wks, each session 10 mins
- Internal (brachytherapy); rods of radioactive Se inserted under anaesthetic (effective up to 5mm)
Risks of radiotherapy for cervical cancer
Lethargy Bowel/bladder erythema Radio induced menopause Fibrosis/steosis cystitis diarrhoea
Chemotherapy in cervical cancer?
Cisplatin as adjuvant w/radio
Vulvar cancer Mx
Radical surgery aim for 10mm margin
?neo-adjuvant chemo
Vulvar cancer other surgery required
sentinel lymph node biopsy (if positive then full groin LNectomy)
Full inguinofemoral lymphadenectomy if tumour >1mm
- very morbid procedure (VTE, chronic lymphoedema)
