Cervical cancer

Question 1

Types of cervical cancer

Answer 1

squamous carcinoma ~75%

adenocarcinomas

Question 2

Cervical cancer oncogenesis

Answer 2

Viral transformation of surface epithelial cells by high risk HPV 16, 18, 31
2 viral gene products (E6, E7) interact with p53 and pRB –> affect control mechanism of cell cycle

Question 3

Natural history of cervical cancer

Answer 3

Dysplasia - mild/moderate/severe
Carcinoma in situ
micro-invasive carcinoma

Question 4

Risk factors of cervical cancer

Answer 4

HPV, smoking
squamous cell requires sexual intercourse
Early sex (

Question 5

Spread of cervical cancer

Answer 5

local extension

lymphatics

Question 6

SSx of cervical cancer

Answer 6

bleeding

discharge

Question 7

Diagnosis of cervical cancer

Answer 7

Biopsy: suspicious lesions regardless of cytology
Colposcopy: magnifying instrument
Cone biopsy: suspicious or + cytology and no lesion found

Question 8

Staging of cervical cancer

Answer 8

clinical

Question 9

Tx cervical cancer - early

Answer 9

cryotherapy
laser therapy
electrosurgical loop excision

Question 10

Tx cervical cancer, Stage

Answer 10

cone biopsy

hysterectomy + nodes

Question 11

Tx cervical cancer, late >Ib2 (locally advanced)

Answer 11

radiation +/- chemo

Question 12

Followup cervical cancer

Answer 12

adjuvant radiotherapy if pelvic nodes are involved
extension outside cervix
close margins

Question 13

Squamocolumnar junction development until puberty

Answer 13

originally situated in region of external os
Before puberty: pH is alkaline; afterwards, breakdown of glycogen in vaginal/cervical squamous epithelium –> acidic pH
Puberty: endocervical epithelium extends distally into acid environment of vagina, forms ectropion
Transformational zone forms as squamous epithelium regrows over ectropion
penings of crypts may be obliterated in process and result in formation of mucus-filled Nabothian follicles

Question 14

Transformation zone of the cervix

Answer 14

Zone of metaplastic squamous epithelium that extends from original squamocolumnar jxn to current squamocolumnar jxn –> new squamous epithelium in area previously columnar
Increasing age: squamocolumnar jxn moves superiorly as metaplastic squamous epithelium replaces endocervical glandular epithelium (jxn higher up in cervix)

Question 15

Pap smear sampling

Answer 15

Do not use lubricant
If squamocolumnar jxn is visible: rotate spatula through 360, fixation not necessary
If not visible: spatula for exocervix. Cytobrush 180 degrees for endocervix; smear and fix

Question 16

Pap smear cautions/clinical notes

Answer 16

Cytobrush not recommended in pregnant patients
If clinically suspicious specimen seen - biopsy immediately
reschedule if menstruation/infection present
Irregular bleeding may be a symptom of gynecological malignancy –> do a pelvic examination + appropriate investigations

Question 17

Ideal patient conditions for screening

Answer 17

Patient has not douched vagina for 48 h before screening
Patient has avoided use of contraceptive creams/jellies for 48 h
Smears not recommended during menstruation
mid-cycle optimal
Patient should be informed that date of LMP is required

Question 18

Cervical cancer screening recommendations - starting

Answer 18

Onset of sexual activity/soon after (21, or +3 after onset of sexual activity)
Smear q12 mo until 3 consecutive normal, then continue q24 mo

Question 19

Cervical cancer screening recommendations - abnormal cytology

Answer 19

Mild dyskaryosis: repeat 6 mo. Colopscopy recomm if mild atypia persists for 2 y
Moderate/higher dyskaryosis: colposcopic exam recommended

Question 20

Cervical cancer screening recommendations - older

Answer 20

> 69 y:
stop screening if >=3 normal smears in the last 10 y and no history of previous significant abnormality (moderate atypia or higher)

Question 21

Cervical cancer screening recommendations - special populations

Answer 21

Pregnant women:

• if no history of previous Pap, do Pap
• otherwise follow guidelines of normal popn

HIV positive:

• repeat smear in 6 mo until 2 consecutive normal smears
• then continue q12 mo

Question 22

Dysplasia

Answer 22

Histological finding

need biopsy for structure

Question 23

Dyskaryosis

Answer 23

Cytological abnormality

result from Pap smear

Question 24

Mild squamous dyskaryosis/mild endocervical glandular atypia management

Answer 24

Repeat smear q6mo
if abnormal cytology persists for 2 y, refer to colposcopy

If mild dysplasia (CIN1) confirmed at colposcopy, follow with repeat Pap in 6 mo

Question 25

Low grade epithelial abnormalities from Pap

Answer 25

mild squamous dyskaryosis | mild endocervical glandular atypia

Question 26

High grade epithelial abnormalities from Pap

Answer 26

``` moderate squamous dyskaryosis marked squamous dyskaryosis Suspicious for squamous cell carcinoma in situ malignant squamous cells moderate endocervical glandular atypia marked endocervical glandular atypia cells suspicious for endocervical carcinoma seen malignant glandular cells seen ```

Question 27

High grade epithelial abnormality (Pap) management

Answer 27

Refer to colposcopy and directed biopsy If moderate dysplasia/severe dysplasia/carcinoma in situ (CIN2-3) confirmed, tx by gynecologist If microinvasion present, refer to gyne/gyne oncologist If frank invasion present, refer to gynecologic oncologist

Question 28

Cervical ca Stage I

Answer 28

confined to cervix

Question 29

Cervical ca stage II

Answer 29

beyond uterus but not to the pelvic wall/lower 1/3 of vagina

Question 30

Cervical ca stage III

Answer 30

extends to pelvic wall, and/or involves lower 1/3 of vagina and/or causes hydronephrosis or non-functioning kidney

Question 31

Cervical ca stage IV

Answer 31

carcinoma has extended beyond true pelvis or has involved (biopsy proven) the mucosa of the bladder/rectum

Question 32

LSIL

Answer 32

low grade squamous intraepithelial lesion - possible cervical dysplasia - usually associated with CIN-1 on biopsy - likely caused by HPV infection - watchful waiting - can do colposcopy if HPV +ve, or repeat cytology in 6 mo - low risk of invasive cancer

Question 33

HSIL

Answer 33

high-grade squamous intraepithelial lesion possible cervical dysplasia associated with CIN2, 3, or carcinoma-in-situ follow up with colposcopy and biopsy tx usually LEEP/cryotherapy/laser ablation 2% associated with current invasive cancer 20% will proceed to invasive ca without treatment

Question 34

CIN1

Answer 34

corresponds to LSIL cytology mild dysplasia and abnormal cell growth (minimal) confined to basal 1/3 of epithelium corresponds with HPV infection - can be transient/cleared by immune activity If not cleared, can progress to CIN-2

Question 35

CIN-2

Answer 35

moderate dysplasia spans more than 2/3 of epithelium or up to full thickness can sometimes be called cervical carcinoma in-situ can progressive to invasive cancer

Question 36

HPV vaccine efficacy

Answer 36

bivalent/quadrivalent prevent 70% of cervical cancers | but difficult to get everyone to have 3 doses, so lower efficacy irl

Question 37

Spontaneous clearing of HPV infection

Answer 37

majority cleared within 24 mo