Cervical cancer

Question 1

Cervical cancer, percentage of total female cancers

Answer 1

13% of gyn cancers

4% when including breast cancer

Question 2

Risk factors for cervical disease

Answer 2

1. Sexual activity (includes HPV infection)
2. Immune deficiency (HIV, steroids, smoking)
3. Poor screening

Question 3

Usual presentation of early cervical cancer

Answer 3

Abnormal screening

Question 4

Progression of squamocolumnar junction over time

Answer 4

Recedes into endocervix

Question 5

Endocervix cell types

Answer 5

Columnar

Question 6

Ectocervix cell types

Answer 6

Squamous

Question 7

Alternative HPV testing guideline for paps

Answer 7

HPV alone every 5 years starting at 25 y/o

Question 8

When to discontinue pap screening

Answer 8

65 y/o IF no hx of CIN2-3 in last 20 years, no hx of cervix cancer, no DES

Question 9

Koilocytosis is pathognomonic for ___

Answer 9

LSIL

Question 10

Proportion of cervical cancer caused by HPV 16/18

Answer 10

70%

Question 11

Low-risk HPV associated with condyloma and CIN1

Answer 11

HPV 6/11

Question 12

Duration of HPV infection

Answer 12

Median 8 mos
70% resolve by 12 mos
>90% resolve by 24 mos

Question 13

Progression of HPV to invasive cancer takes how long?

Answer 13

10-20 yrs

Question 14

Advantage to HPV primary screening

Answer 14

Sensitive (good NPV), improve detection of glandular cell abnormalities

Question 15

Disadvantage to HPV primary screening

Answer 15

Low specificity (low PPV), increased referrals for colpo

Question 16

Trial that made HPV primary testing more acceptable

Answer 16

ATHENA

Question 17

Acetowhite epithelium is ___

Answer 17

Intracellular keratin

Question 18

How Lugol’s works

Answer 18

Stains glycogen brown in normal cells

Question 19

What Lugol’s shows better

Answer 19

Vessels

Question 20

Dysplasia development histologically

Answer 20

Starts at the basement membrane and makes its way to the epithelial surface (CIN1 is one layer at membrane and CIN is almost to surface (CIS includes epithelium)

Question 21

Indications for ECC

Answer 21

Inadequate colpo, concern for endocervical extension

Question 22

Cure rate of conization (LEEP, CKC, laser cone)

Answer 22

95%

Question 23

When not to do laser ablation or cryotherapy

Answer 23

If colpo unsatisfactory

Question 24

When to do conization

Answer 24

CIN 2-3 or high-grade screen with low-grade histology

Question 25

Outcomes from positive margins following excision

Answer 25

67% resolve spontaneously

Question 26

Management for positive margins following excision

Answer 26

Pap + ECC in 6 mos (then repeat excision if CIN 2-3) OR just repeat excision in 6 wks (preferred only for AIS)

Question 27

What if CIN1 persists beyond 2 yrs?

Answer 27

Continue follow-up vs excision

Question 28

At what age does endometrial cells on pap matter?

Answer 28

40 y/o

Question 29

What to do if premenopausal with endometrial cells on pap?

Answer 29

Asymptomatic > routine follow-up | Symptomatic > endometrial sampling

Question 30

What to do if postmenopausal with endometrial cells on pap?

Answer 30

Endometrial sampling regardless of symptoms

Question 31

What to do for AGC

Answer 31

HPV test, colpo, and ECC; add endometrial sampling if >35 y/o or risk factors

Question 32

What to do for atypical endometrial cells

Answer 32

HPV test, colpo, ECC, endometrial sampling

Question 33

What to do if AGC or AIS and no e/o invasive disease

Answer 33

Excisional procedure

Question 34

What to do if AIS on excisional procedure

Answer 34

Hysterectomy vs cautious observation if fertility desired

Question 35

LEEP during pregnancy?

Answer 35

Acceptable for CIN3 vs waiting till 6 wks postpartum

Question 36

When to start screening for HIV pos

Answer 36

Within one year of starting sexual activity

Question 37

When to stop screening for HIV pos

Answer 37

Never

Question 38

What is more common in HIV with CD4<500?

Answer 38

Glandular cell abnormalities

Question 39

Conization should be done before hysterectomy in setting of CIN IF...

Answer 39

Unsatisfactory colpo Suspicion for cancer ECC w/ CIN2-3 Evidence of high-grade glandular neoplasia

Question 40

Proportions of squamous vs adenocarcinoma of cervix

Answer 40

Squamous 70% | Adeno 20-25%

Question 41

Tools for FIGO staging of cervical cancer

Answer 41

EUA, cystoscopy, proctoscopy, IVP, CXR (or may substitute CT or PET)

Question 42

Mnemonic for cervical cancer staging

Answer 42

Down and out

Question 43

FIGO stage I-IV locations

Answer 43

I - cervix II - uterus / upper vagina III - lower vagina / pelvic sidewall IV - outside of pelvis

Question 44

Survival rates by staging

Answer 44

I - 90% II - 70% III - 40% IV - 15%

Question 45

Stage I divisions

Answer 45

``` IA1 - <3 mm IA2 <5 mm IB1 >5 mm and <2 cm wide IB2 >5 mm and 2-4 cm wide IB3 >5 mm and > 4 cm wide ```

Question 46

Stage II divisions

Answer 46

IIA1 - upper 2/3 vagina, <4 cm IIA2 - upper 2/3 vagina, >4 cm IIB - parametrial involvement

Question 47

Stage III divisions

Answer 47

IIIA - lower 1/3 of vagina IIIB - pelvic sidewall IIIC1 - pelvic LN IIIC2 - paraortic LN

Question 48

Stage IV divisions

Answer 48

IVA - adjacent organs | IVB - distant spread

Question 49

Treatment for IA1

Answer 49

Hysterectomy

Question 50

Treatment for IA2

Answer 50

Modified radical hysterectomy + PLND

Question 51

Treatment for IB1

Answer 51

Rad hysterectomy + PLND

Question 52

Treatment for IB2 and above

Answer 52

Chemo-RT + brachytherapy

Question 53

Most common early complications of radical hysterectomy

Answer 53

UTI, ileus, fever, DVT

Question 54

Most common late complications of radical hysterectomy

Answer 54

Urinary retention, lymphedema, sexual dysfunction

Question 55

When to use radiation as adjuvant therapy

Answer 55

Positive LN at time of surgery, risk factors like large tumor, deep invasion, parametrial extension, positive margins

Question 56

How chemoradiation works

Answer 56

Low-dose chemo sensitizes cells to radiation

Question 57

Management of acute bleeding in cervical cancer

Answer 57

Vaginal packing with Monsel's Embolization "Hot shot" or traditional brachytherapy

Question 58

How to treat cervical cancer at 24 wga or above

Answer 58

Consider neoadjuvant chemotherapy | Deliver by Classical C/S

Question 59

How to treat cervical cancer <24 wks and no desire to continue pregnancy

Answer 59

Stage I-IIA: rad hyst + LND | Stage IIB - IVA: pelvic chemo-RT, SAB vs D&E, brachytherapy

Question 60

Surveillance post-treatment for cervical cancer

Answer 60

Every 3 months x 2 yrs Every 6 mo to 5 yrs Annually after that

Question 61

What to do for vaginal bleeding after radiation treatment for cervical cancer

Answer 61

Colpo, pack with Monsel's, embolization, hysterectomy (last resort because risk for complications)

Question 62

Treatment for central recurrence

Answer 62

``` Radiation (if s/p rad hyst) Pelvic exenteration (if s/p radiation) ```

Question 63

Treatment for lateralized pelvic recurrence

Answer 63

Chemo-RT (if s/p rad hyst) | Chemo (if s/p radiation)

Question 64

Treatment for distant recurrence

Answer 64

Systemic chemo