The cervix and its disorders Flashcards
Histology and process of transformation zone
Endocervix (canal) = columnar (glandular) epithelium
Ectocervix (continuous with vagina) = squamous epithelium
both meet at squamocolumanr junction
Puberty and pregnancy = partial eversion of cervix → lower vagina pH causes exposed area of columnar epithelium to undergo metaplasia to squamous epithelium → transformation zone at squamocolumnar junction
- these metaplastic cells vulnerable to agents that induce neoplastic change → cervical carcinoma
Blood supply and lymph drainage (rel. cervical carcinoma)
Upper vaginal branches and the uterine artery (from the hypogastric artery)
lymph drainage to obturator and external and internal iliac nodes to common iliac and the para-aortic nodes
- cervical carcinoma spreads through his or locally by direct invasion into the uterus, vagina, bladder and rectum
Cervical ectropion
columnar eversion to so more columnar than squamous (red area around os on cervix surface) → prone to INFECTION
RFs = pregnant, taking the pill aka COCP.
- COCP as oestrogen makes cervix os open
mostly asymptotic OR
- PCB
- vaginal discharge
Ix:
- smear FIRST
- colposcopy EXCLUDE CARCINOMA
Tx:
- cryotherapy w/o anaesthetic
Cervical polyp
benign tumours of endocervical epithelium
<1cm mostly
RFs = >40 y/o
asymptomatic/IMB/PCB
Ix = histologically
Tx = small polyps avulsed w/o anaesthetic
Cervical Intreaepithelial Neoplasia (CIN): definitions and grading, if left untreated
Atypical (dyskaryotic = larger nuclei, frequent mitoses) cells in squamous epithelium.
I-III histological grading:
- I (mild dysplasia) = atypical cells in lower third of epithelium
- II (moderate dysplasia) = atypical cells in lower two thirds of epithelium
- III (severe dysplasia) = atypical cells full thickness of epithelium (CARCINOMA IN SITU), cells similar to those in malignant lesions w/o invasion, malignancy when they invade through basement membrane
If untreated = ⅓ women with CIN II/III will develop cervical cancer over the next 10 years
Natural history of CIN
CIN I least malignant potential, can progress to II/III but commonly regresses spontaneously
CIN epidemiology
<45 y/o
peak incidence 25-29 y/o
RFs for CIN
Number of sexual contacts (almost unknown in virgins)
- HPV infection, 16/18/31/33 most frequently associated with cervical cancer
- 16 + 18 UK Vaccination programme types (responsible for 75% cervical cancer cases in UK)
- Human papilloma viruses 6 and 11 are non-carcinogenic and associated with genital warts
Vaccination against individual viruses reduces incidence of cervical cancer (prophylactic effect so given to <13 y/o)
- to males? = also prophylactic for penile cancer and reduce HPV transmission rate to unvaccinated women
Screening for cervical cancer: cervical smears (programme and method)
25-49 y/o = every 3 years
50-64 y/o = every 5 years
65+ = those not screened or have had recent abnormal tests
method:
- Cusco speculum + brush around external os of cervix
- break brush tips into preservative fluid → lab → centrifuge → slide for microscopy (LBC, liquid-based cytology) and can test for HPV
Results:
- identifies cellular abnormalities (→ dyskaryosib)
- classified as borderline, low grade, high grade
- high grade is likely to be CIN III histologically
cervical smears: result interpretation and follow-up
The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
Negative hrHPV
- return to normal recall, unless
- the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
- the untreated CIN1 pathway
- follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
- follow-up for borderline changes in endocervical cells
Positive hrHPV
- samples are examined cytologically
- if the cytology is abnormal → colposcopy
- this includes the following results:
- borderline changes in squamous or endocervical cells.
- low-grade dyskaryosis.
- high-grade dyskaryosis (moderate).
- high-grade dyskaryosis (severe).
- invasive squamous cell carcinoma.
- glandular neoplasia
-
if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
- if the repeat test is now hrHPV -ve → return to normal recall
- if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
- If hrHPV -ve at 24 months → return to normal recall
- if hrHPV +ve at 24 months → colposcopy
If the sample is ‘inadequate’
- repeat the sample within 3 months
- if two consecutive inadequate samples then → colposcopy
If HIV:
- annual cervical screening
If pregnant:
- normal cytology = 3 months post party
- abnormal cytology (low-grade) = wait until post-delivery
- abnormal cytology (high-grade) = colposcopy (later first or early second trimester)
The follow-up of patients who’ve previously had CIN is complicated but as a first step, individuals who’ve been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community.
Human papilloma viruses 6 and 11 are non-carcinogenic and associated with genital warts so if HPV+ve → return to normal 3-yearly screening, and discuss safe-sex practices
Colposcopy
cervix inspected via speculum using an operating microscope with magnification 10-20 fold
3 ways to prevent cervical cancer
- HPV vaccination
- Prevent CIN = sexual and barrier contraceptive education
- Identification and treatment of CIN = cervical smear programmes
CIN tx
Colposcopy (examination of the cervix) biopsy can be taken. If there are moderate to severe abnormalities can excise or ablate the region. Excision – LLETZ (large loop excision of the transformation zone). Involves removal of abnormal cells using a thin wire loop that is heated by electric current.
Risk = Large excision or repeat excisions are associated with an increased risk of midtrimester miscarriage and preterm delivery.
Cone biopsy can also be done (less common).
Requires a test of cure 6mo later
CIN PACES Counselling
CIN III = advise that without treatment, she has around 30% chance of developing cancer over 8-15 years
HOWEVER, colposcopic treatment is straightforward and successful
Cervical cancers ranking with other GYN cancers
- uterine
- ovarian
- cervical
most common cancer in females <35 y/o
cervical cancer pathology
90% SCC
10% AC = worse prognosis
cervical cancer aetiology
same as CIN = HPV vaccination, immunosuppression (e.g. HIV/steroids), not familial
cervical cancer clinical features: occult and clinical carcinoma
occult
- asymptomatic, but diagnosis by biopsy or LLETZ
clinical carcinoma
- History = PCB, offensive vaginal discharge/PMB, pain not an early feature. Later stages → involvement of ureters, bladder, rectum, nerves → uraemia, heamaturia, rectal bleeding and pain
- examination = ulcer/mass may be visible or palpable on cervix. Early disease → cervix may appear normal on naked eye
cervical cancer: spread
Spread = locally to parametric and vagina, then pelvic side wall. Lymphatic spread an early feature. Ovarian spread rare with SCC. Blood-borne spread occurs late.
FIGO cervical cancer staging
FIGO cervical staging and mx
Management of stage IA tumours
- Gold standard of treatment is hysterectomy +/- lymph node clearance
- Nodal clearance for A2 tumours
- For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed
- Close follow-up of these patients is advised
- For A2 tumours, node evaluation must be performed
- Radical trachelectomy is also an option for A2
Management of stage IB tumours
- For B1 tumours: radiotherapy with concurrent chemotherapy is advised
- Radiotherapy may either be bachytherapy or external beam radiotherapy
- Cisplatin is the commonly used chemotherapeutic agent
- For B2 tumours: radical hysterectomy with pelvic lymph node dissection
Management of stage II and III tumours
- Radiation with concurrent chemotherapy
- See above for choice of chemotherapy and radiotherapy
- If hydronephrosis, nephrostomy should be considered
Management of stage IV tumours
- Radiation and/or chemotherapy is the treatment of choice
- Palliative chemotherapy may be best option for stage IVB
Management of recurrent disease
- Primary surgical treatment: offer chemoradiation or radiotherapy
- Primary radiation treatment: offer surgical therapy
if presence of sx (PCB/IMB), abnormal exam findings (cervix looks abnormal on speculum) → what should you do
cervical cancer must be excluded → refer urgently to GYN team via urgent 2ww referral
Cervical cancer Ix
confirm diagnosis = tumour biopsy
staging = vaginal + rectal exam to assess size of lesion and parametrical or rectal invasion
exam under anaesthetic (EUA)
assess pt fitness for surgery = CXR, FBX, U+E
- cross-match blood before surgery
cervical cancer prognosis
Indications for chemo-radiotherapy for cervical carcinoma
carcinoma of the cervix at a glance
CIN at a glance
