SM_218b: Vulvar and Cervical Malignancy Flashcards
Describe common risk factors for cervical cancer and its precursor lesions
Common risk factors for cervical cancer and its precursor lesions
- Early age at first coitus
- Infection with high-risk HPV
- Early age at first pregnancy
- Lack of routine cytologic screening
Pap smear is ____ and allows for ____
Pap smear is liquid-based and allows for reflex testing (HPV)
- Sensitivity: > 95%
Describe cervical cytology terminology
Cervical cytology terminology
- NILM: no intraepithelial lesions or malignancy
- ASC-US: atypical squamous cells of unknown significance
- LSIL: low-grade squamous intraepithelial neoplasia
- HSIL: high-grade squamous intraepithelial neoplasia
- ASC-H: atypical squamous cells, cannot exclude high-grade lesion
- AGC: atypical glandular cells
Describe benchmarking for risk in cervical cancer screening
Benchmarking for risk in cervical cancer screening
- NILM: routine screening every 3 years
- ASC-US: short interval screening
- LSIL: immediate colposcopy
- HSIL: immediate colposcopy
- ASC-H: immediate colposcopy
- AGC: immediate colposcopy with EMB
Low-grade HPV is ____ and ____
Low-grade HPV is 6 and 11
(genital warts)
High grade HPV is ___ and ___
High grade HPV is 16 and 18
(high grade dysplasia / cancer)
Circular dsDNA, non-enveloped, icosahedral capsid is ____
Circular dsDNA, non-enveloped, icosahedral capsid is HPV
- Sexual, skin-to-skin contact
- Persistent HPV infection increases risk of dysplasia or cancer: 80-90% cleared by 18 months
- HPV infection is common
Describe the use of HPV testing
Use of HPV testing
- Better sensitivity for CIN2 and CIN3 and better reproducibility than cytology
- Diagnostic uses: triage of ASCUS pap and more sensitive for detecting HGSIL, triage of postmenopausal LGSIL, post treatment screening
- Co-testing: HPV testing + cytology: increased detection of CIN3, improves detection of cervical cancer, enhances detection of adenocarcinoma
Describe the algorithm for cervical cytology / HPV testing
Algorithm for cervical cytology / HPV testing
In colposcopy, focus on the ____
In colposcopy, focus on the transformation zone
(area between normal columnar epithelium and mature squamous epithelium)
Describe indications for conization (loop electrosurgical excision) indications
Conization (loop electrosurgical excision) indications
CIN 2 and CIN 3 are more likely to ___ than CIN 1
CIN 2 and CIN 3 are more likely to progress / persist than CIN 1
Describe what makes the pap smear a successful screening tool for cervical cancer
Pap smear is a successful screening tool for cervical cancer
- Cervical cancer is common
- Untreated CIN3 has a 30 year risk of progression to invasive CA of 30% compared to < 1% for treated CIN3
- Dysplastic lesions can be detected for 5-10 years prior to progression
- Pap smear has sensitivity > 95% for detecting squamous lesions ≥ CIN2
- Pap smear requires a pelvic examination and a pathologist trained in its interpretation
Describe symptoms of cervical cancer
Cervical cancer symptoms
- Commonly: abnormal vaginal bleeding, post-coital bleeding, vaginal discharge
- Advanced disease: pelvic pain, difficulty urinating / defecating
- Metastatic: back pain, one sided leg swelling
Describe physical exam findings of cervical cancer
Cervical cancer physical exam findings
- Visiaully: necrotic, friable lesion on cervix
- Staging is clinical
- Biopsy confirmation
Describe treatment recommendations for cervical dysplasia and cancer
Treatment recommendations for cervical dysplasia and cancer
- Low grade dysplasia: surveillance vs non-excisional treatment
- High grade dysplasia: excisional (cervical conization or hysterectomy)
- Cervical cancer diagnosed on biopsy: surgery for microscopic disease, radical surgery for small tumor (< 2-4 cm) confined to uterus, radiation with sensitizing chemo for locally advanced tumor, chemo for distant metastatic disease
Care must be taken to avoid injuring the ____, ____, and ____ when performing pelvic lymphadenectomy for cervical cancer
Care must be taken to avoid injuring the common iliac artery, obturator nerve, and ureter when performing pelvic lymphadenectomy for cervical cancer
As FIGO stage of cervical cancer increases, survival ____
As FIGO stage of cervical cancer increases, survival decreases
Most common cervical cancer risk factor is ____
Most common cervical cancer risk factor is a lack of cervical cancer screening
- HPV vaccines are effective in the prevention of cervical dysplasia
Compare HPV and non-HPV associated vulvar cancer
HPV and non-HPV associated vulvar cancer
- HPV-associated: HSIL (VIN-2/3), younger age (< 55 yo), smoking, low SES, high risk sexual behaviors, HIV
- Non-HPV associated: chronic inflammatory disease (lichen sclerosis)
Lichen sclerosis is a ____
Lichen sclerosis is a complex chronic inflammatory skin condition
- Considered autoimmune
Severe pruritis, vulvar irritation, pain, and dyspareunia is ____
Severe pruritis, vulvar irritation, pain, and dyspareunia is lichen sclerosis
Describe appearance of lichen sclerosis on physical exam
Lichen sclerosis on physical exam
- Porcelain white (hypopigmentation) papules and plaques, often with areas of ecchymosis, purpura, and excoriation
- Shiny, waxy, thinned, whitened, and crinkling (cigarette paper)
- CHanges in vulva: loss of labial contours and fusion of labia minoria into labial fat pad
This is ___
This is vulvar / perianal condyloma (LSIL)
Describe treatment of vulvar cancer
Vulvar cancer treatment
- Current surgical management: triple incision vulvectomy / wide local excision
- Radical vulvectomy: depth of the perineal membrane / periosteum of pubic symphysis
- Radical vulvectomy: butterfly vs longhorn
- For advanced disease: neoadjuvant chemoradiation
- Inguino-femoral lymph node dissection performed in all stages except IA
Postmenopausal Caucasian woman with eczematoid red weeping area on vulva has ____
Postmenopausal Caucasian woman with eczematoid red weeping area on vulva has Paget’s disease
- 15% have underlying vulvar adenocarcinoma
- 20-30% will develop metastatic disease
- Treatment: WLE
