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Flashcards in Cervical cancer Deck (37):
1

Types of cervical cancer

squamous carcinoma ~75%
adenocarcinomas

2

Cervical cancer oncogenesis

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

3

Natural history of cervical cancer

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

4

Risk factors of cervical cancer

HPV, smoking
squamous cell requires sexual intercourse
Early sex (

5

Spread of cervical cancer

local extension
lymphatics

6

SSx of cervical cancer

bleeding
discharge

7

Diagnosis of cervical cancer

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

8

Staging of cervical cancer

clinical

9

Tx cervical cancer - early

cryotherapy
laser therapy
electrosurgical loop excision

10

Tx cervical cancer, Stage

cone biopsy
hysterectomy + nodes

11

Tx cervical cancer, late >Ib2 (locally advanced)

radiation +/- chemo

12

Followup cervical cancer

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

13

Squamocolumnar junction development until puberty

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

14

Transformation zone of the cervix

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)

15

Pap smear sampling

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

16

Pap smear cautions/clinical notes

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

17

Ideal patient conditions for screening

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

18

Cervical cancer screening recommendations - starting

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

19

Cervical cancer screening recommendations - abnormal cytology

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

20

Cervical cancer screening recommendations - older

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

21

Cervical cancer screening recommendations - special populations

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

22

Dysplasia

Histological finding
need biopsy for structure

23

Dyskaryosis

Cytological abnormality
result from Pap smear

24

Mild squamous dyskaryosis/mild endocervical glandular atypia management

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

25

Low grade epithelial abnormalities from Pap

mild squamous dyskaryosis
mild endocervical glandular atypia

26

High grade epithelial abnormalities from Pap

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

27

High grade epithelial abnormality (Pap) management

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

28

Cervical ca Stage I

confined to cervix

29

Cervical ca stage II

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

30

Cervical ca stage III

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

31

Cervical ca stage IV

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

32

LSIL

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

33

HSIL

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

34

CIN1

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

35

CIN-2

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

36

HPV vaccine efficacy

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

37

Spontaneous clearing of HPV infection

majority cleared within 24 mo