Premalignant and malignant disease of the lower genital tract

Question 1

Cervical smear key features of focused Hx

Answer 1

LMP
gynae Hx (IMB, PCB, discharge)
Sexual Hx
Contraception
Obstetric and fertility desires
Smoker?
Immunosuppression?

Question 2

If a smear is missed because of pregnancy?

Answer 2

Do 3mo after delivery

Question 3

Smear procedure

Answer 3

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

Question 4

Explanation of result

Answer 4

• Result within 2 weeks
• Screening catches (pre)cancerous changes
• Most of the time abnormal does not equal cancer but req. further Ix

Question 5

What to do with cervical smear results

Answer 5

mild/borderline: HPV test and colposcopy
anything worse: urgent colposcopy referal
Inadequate: repeat (after 3 refer colposcopy)

Question 6

Explanation of colposcopy

Answer 6

-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

Question 7

Cervical Intraepithelial Neoplasia

Answer 7

Screening:

• CIN1 likely to resolve spontaneously (12m FU smear)
• CIN2/3/CGIN - removal

Question 8

LLETZ

Answer 8

Large loop excision of transformation zone
Removal of abnormal cells w/heated loop
AKA loop diathermy

Question 9

When can LLETZ be performed

Answer 9

At time of colposcopy

under LA as day case

Question 10

Risks of LLETZ

Answer 10

Large/repeated risk midtrimester miscarriage and preterm delivery

Question 11

Cone biopsy

Answer 11

used less frequently than LLETZ
Only if large area of tissue needs removal
under GA

Question 12

Alternatives to cone and LLETZ

Answer 12

Laser
cyrotherapy
cold coagulation

Question 13

Pts who undergo treatment for CIN FU

Answer 13

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

Question 14

HPV vaccination

Answer 14

Boys and girls now 12-13
Quadrivalent = 6 13 16 18
Nonavalent covers other less common HPV

Question 15

Cervical cancer Stages

Answer 15

1A - microscopic incidental
1B invasive confined to cervix
2+ beyond cervic

Question 16

Cervical cancer Mx

Answer 16

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

Question 17

Surgical Mx of cervical cancer

Answer 17

1B - rad. hysterectomy w/pelvic LN diss. (ovaries spared in pre-men.)
- High cure rate

Question 18

Pelvic LNs?

Answer 18

Obturator
Internal iliac
External iliac

Question 19

Risk of surgical Mx of cervical cancer

Answer 19

Bladder dysfunction (atony)
- common may req. self cath immediately post op
Sexual dysfunction
Lymohoedema (LN removal)

Question 20

Radiotherapy for Cervical cancer

Answer 20

• External beam: 4 wks, each session 10 mins

- Internal (brachytherapy); rods of radioactive Se inserted under anaesthetic (effective up to 5mm)

Question 21

Risks of radiotherapy for cervical cancer

Answer 21

Lethargy
Bowel/bladder
erythema
Radio induced menopause
Fibrosis/steosis
cystitis
diarrhoea

Question 22

Chemotherapy in cervical cancer?

Answer 22

Cisplatin as adjuvant w/radio

Question 23

Vulvar cancer Mx

Answer 23

Radical surgery aim for 10mm margin

?neo-adjuvant chemo

Question 24

Vulvar cancer other surgery required

Answer 24

sentinel lymph node biopsy (if positive then full groin LNectomy)
Full inguinofemoral lymphadenectomy if tumour >1mm
- very morbid procedure (VTE, chronic lymphoedema)

Question 25

Radiotherapy in vulvar cancer

Answer 25

adjuvant radio indicated if excision margins are close or in presence of 2+ groin node mets
Alternative if unfit for surg