RANZCOG questions Flashcards
State how cervical cancer is staged. (1 mark)
FIGO classification system Staging is clinical, using a combination of diagnostic tests to determine the local spread of cervical cancer during examination under anaesthesia
Outline the diagnostic tests which may be used to determine the stage using the International Federation of Gynaecology and Obstetrics (FIGO) staging system. (5 marks) (cervical ca)
• Colposcopy and biopsy- to assess the size of macroscopic tumours • Cone biopsy- to assess depth of invasion and size of microscopic tumours • EUA- examination of vulva, vagina and cervix under anaesthesia, bimanual and PR • Sigmoidoscopy- examination of invasion into the sigmoid colon • Cystoscopy- examination of invasion into the bladder • CXR- distant spread into the lungs • IVP- IV contrast given to image the renal tract and review if obstruction is present • Other modes of imaging- CT, MRI, PET CT are not part of formal FIGO staging but assist in surgical planning as they can help define node involvement
A 30 year old woman has a cervical biopsy showing cervical intraepithelial neoplasia Grade 3 (CIN 3). The histology of the large loop excision of the transformation zone (LLETZ) specimen is reported as “squamous cell carcinoma with invasion 6 mm deep and lateral spread of 9 mm”. Her last Pap smear, 5 years ago, was normal. She has no other significant past history and has one child delivered vaginally. After full assessment, diagnosis of cervical carcinoma Stage IB1 is made. b. Treatment options include surgery or chemoradiation. What factors influence the choice of treatment for this woman? (2 marks)
Patient factors • Current pregnancy status • Future plans for childbearing and fertility • Preference Tumour factors • If tumour is fully resectable • Any evidence of spread
Comprehensively outline the late complications of radiotherapy that could occur in this woman. (7 marks) (1b1 cervical ca)
- Vaginal stenosis: Can occur with external beam and brachytherapy, Dyspareunia and interference with coitus- dilator therapy can help 2. Infertility and early menopause: Prevents further childbearing and if falls pregnancy high-risk pregnancy. Radiation to the ovaries raises the risk of early menopause and thus menopausal symptoms (VVA, VMS etc) and risks associated with early menopause (CVD, osteoporosis) 3. Bladder: Urinary incontinence and recurrent UTI 4. Chronic proctitis: Symptoms include rectal and abdominal pain, tenesmus, diarrhoea, rectal bleeding and dyschezia 5. Ileitis: Symptoms include severe abdominal pain, chronic constipation or diarrhoea, chronic PR bleeding Can result in stricture formation and bowel perforation 6. Fistula: Vesico-vaginal, ureterovaginal and rectovaginal fistula can all occur and be dehibilitating for women 7. Lymphoedema: Causes constant aching, difficulty with mobilising, predisposes to leg infections 8. Femoral head necrosis: Hip pain and immobility, necessitates hip replacement when severe 9. Pelvic malignancy: Risk of spontaneous pelvic malignancy increase eg leiomyosarcoma 10. Psychological symptoms: Anxiety, depression
In both Australia and New Zealand, indigenous populations have significantly higher incidence of, and mortality from, cervical malignancy than non-indigenous populations. a. Identify five (5) epidemiological factors which may account for this. (5 marks)
Increased incidence of smoking Lower age at commencing sexual intercourse Risker sexual behaviour ie multiple partners, less likely to use barrier contraception Barriers to cervical screening and colposcopy Barriers to appropriate medical care and follow up eg financial, psychosocial, transport issues Barriers to education regarding the importance of cervical screening, immunisation and treatment of CIN Lower Gardasil immunisation uptake Cultural barriers
A 32 year old woman is diagnosed with cervical carcinoma Stage 1B. b. According to the FIGO Staging system, list all the examinations and investigations that could have been included to establish the diagnosis and the stage of her cancer. (4 marks)
Physical examination- speculum, bimanual and rectovaginal examination for palpation and inspection of the primary tumour, uterus, vagina and parametria. Palpation of groin and supraclavicular LN to exclude metastatic cancer. Cystoscopy, Proctosigmoidoscopy EUA, hysteroscopy, endocervical curettage Colposcopic assessment- Colposcopy with directed cervical biopsy for visible cervical abnormalities/ lesion +/-Endocervical curettage, cone biopsy CXR Intravenous pyelogram (IVP) – Evaluation for urinary tract obstruction Imaging not part of FIGO staging but to help guide management: CT or MRI abdomen and pelvis to evaluate extra peritoneal or lymph node spread PET Barium enema
Her tumour is a squamous cell carcinoma which is 2cm in size. Imaging studies do not suggest lymph node involvement. (You may wish to use a table to answer the following.) c. i) List her three (3) treatment options. (1½ marks) ii) Outline one (1) indication for each treatment option. (1½ marks) iii) List two (2) long-term complications associated with each treatment option. (Use different complications for each treatment option). (3 marks)
- Modified radical hysterectomy and lymph node dissection. Indication: Complete staging procedure- able to o provide histological specimen and information regarding lymph node spread Has completed famiy Other uterine pathology present- firboid Complication: Lymphadema, Chronic pelvic pain, Damage to bladder/ bowel, Pelvic floor prolapse, Sexual dysfuction, Haematoma 2. Trachelectomy Indication: Fertility sparing option for women in childbearing age Complication: Cervical incompetence Preterm birth Requires cervical suture and ELLSCS Stenosis/ impair fertility 3. Primary radiotherapy Indication: Reserved as primary treatment for women who are not candidates for surgery due to medical comorbidities or poor functional status/ declined surgery Complication: Ovarian failure, Vaginal stenosis, Radiation cystitis, Bladder dysfunction, Dyspareunia Bowel stenosis 4. Hysterectomy with ovarian conservation Indication: Provide treatment wihout casuing premature menopause Complication: Risk of disease spread to the adnexa or parametria Risk of lymphovascular invasion, 2-8%
What is CIN? What is metaplasia?
Cancer precursors Lack the features of invasive cancer (no invasion of the basement membrane) Severity of lesion is in thirds from the bottom (basement membrane) upwards. How does metaplasia occur? - rise in oestrogen at puberty - promotes growth of lactobacilli - lowers pH - exposure of low pH to columnar epithelium stimulates metaplasia squamous - metaplasia most active during adolescence and pregnancy
Likelihood of developing cancer for CIN 1,2 and 3:
CIN1 = 1% proceed to cancer CIN2 = 5% CIN3 = 12+ % Only a third of CIN3 will regress.
Sensitivity and specificity of smear?
- 55-80% sensitivity for a single test. However very high specificity (98%) - Never evaluated in an RCT however countries using it in screening programmes have noted a dramatic decline in cervical cancer
How to take a smear?
Taking a pap smear - avoid menstruation or intercourse 48h prior. - Document date of last period, pregnancy or not, hormone use, IUCDs, menopausal status, past smear history Now Liquid based cytology used - put brush in a liquid transport medium - processed to produce a monolayer of cells on a glass slide. - Blood, mucus and cell overlap eliminated - Most of all collected cell material is available on glass slide - ? lower unsatisfactory smear rate however ? lower positive predictive value.
Colposcopy
- magnification 3 to 40 fold - high intensity light - green (red free) filter - normal saline- helps remove mucus - acetic acid (clumps nuclear chromatin) - Lugol (iodine) normal oestrogenised cells stain dark due to glycogen content. Dysplastic cells have lower glycogen content Reid Colposcopic index (each scored 0-2) - peripheral margin (feathery, smooth, rolled) - colour to ACW (shiney translucent, duller white, dull white/ gray) - vascular patterns (fine, absent, coarsed) - lugol solution (positive, partial, negative) Other things to note about abnormal vessels - punctuation (fine coarse) - mosaicism (mosaic tiles with central punctuation = CIS) - atypical vessels o graded on o vessel calibre o intercapillary distance o uniformity
Advantages and disadvantages of LLETZ:
Advantages - can be done in clinic under local - ease of procedure - safety profile - low cost - good tissue specimen Disadvantages - training - bleeding - infection - cervical insufficiency - preterm birth - cervical stenosis
Mary Smith is a 54-year old woman presenting with recent onset of vaginal bleeding. Her last period was four years earlier. Mary is obese (BMI 33). She is otherwise well and has not been taking any medication or over-the-counter therapies. Bimanual pelvic examination is normal. Her last Pap smear was 18 months ago and was normal. a) Mary is concerned that she has cancer. What are you going to advise her in the outpatient setting? (3 marks)
• Cancer is not the most common cause of her symptoms (only 10%) but it is an important one to investigate • Potential cancers could include endometrial, cervical, vaginal, vulvar or ovarian (atypical presentation but possible) • Other potential causes for her PMB are: o Atrophy o Polyps o Hyperplasia o Infection • Suggest further investigation with imaging (TV USS) and endometrial biopsy.
Mary Smith is a 54-year old woman presenting with recent onset of vaginal bleeding. Her last period was four years earlier. Mary is obese (BMI 33). She is otherwise well and has not been taking any medication or over-the-counter therapies. Bimanual pelvic examination is normal. Her last Pap smear was 18 months ago and was normal. List and briefly compare three modalities of ultrasound evaluation of the endometrium in relation to this presentation. (3 marks)
• Grayscale USS – acceptable, cheap, TV gives best definition but TA may be more acceptable to some women • Sonohysterography – best for assessment of endometrial abnormalities e.g. polyps. More expensive • Doppler USS – helpful for assessing vascularity e.g. polyp. No additional cost (standard setting on most machines)
Briefly compare and contrast the role of outpatient endometrial sampling (such as Pipelle) versus formal hysteroscopy, dilatation and curettage with reference to the differential diagnosis of endometrial carcinoma in this presentation. (4 marks)
- Pipelle*
- Hyst D&C*
Cost
Cheap
Expensive
Need for GA
No
Sometimes
Outpatient procedure
Yes
Sometimes office
Targetted biopsy
No
Yes
Visualise endometrial cavity
No
Yes
Can ‘see and treat’
No
Yes e.g. polyp, submucous fibroid
Risk perforation
No
Possible
Need for cervical dilation
No
Possible
Sensitivity for cancer
High
High
False negative
Possible (10%) – may miss polyp or may miss cancer if small area
Less likely
