Cervical Disease

Question 1

Around 50% of cases of cervical cancer occur in women under the age of 45 years

Answer 1

true

Question 2

cervical cancer in the UK are highest in people aged

Answer 2

25-29 years

Question 3

Types of cervical cancer

Answer 3

squamous cell cancer (80%)

adenocarcinoma (20%)

Question 4

Features of cervical cancer

Answer 4

may be detected during routine cervical cancer screening
abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
vaginal discharge

Question 5

Which virus is commonest for cervical cancer?

Answer 5

Human papillomavirus (HPV), particularly serotypes 16,18 & 33

Question 6

Rx factors cervical cancer?

Answer 6

smoking
human immunodeficiency virus
early first intercourse, many sexual partners
high parity
lower socioeconomic status
combined oral contraceptive pill*

Question 7

Mechanism of HPV causing cervical cancer

Answer 7

HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene

Question 8

The UK has a well established cervical cancer screening program which is estimated to prevent 1,000-4,000 deaths per year.

Answer 8

true

Question 9

The main aim of cervical screening

Answer 9

detect pre-malignant changes rather than to detect cancer

Question 10

cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening

Answer 10

true

Question 11

Who is screened and how often? A smear test is offered to all women between the ages of

Answer 11

25-64 years

Question 12

Cervical cancer screening 25-49 years:

Answer 12

3-yearly screening

Question 13

Cervical cancer screening 50-64 years:

Answer 13

5-yearly screening

Question 14

cervical screening cannot be offered to women over 64

Answer 14

true

Question 15

cervical screening in pregnancy

Answer 15

usually delayed until 3 months post-partum unless missed screening o

Question 16

women who have never been sexually active have very low risk of developing cervical cancer therefore they may wish to opt-out of screening

Answer 16

True

Question 17

Cervical screening - How is performed?

Answer 17

There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid.

It is said that the best time to take a cervical smear is around mid-cycle. Whilst there is limited evidence to support this it is still the current advice given out by the NHS.

Question 18

Advantages of LBC includes

Answer 18

reduced rate of inadequate smears

increased sensitivity and specificity

Question 19

management is based solely on the degree of dyskaryosis

Answer 19

false

The introduction of HPV testing allowed patients with mild dyskaryosis to be further risk-stratified

Question 20

HPV is such a strong risk factor patients who were HPV negative could be treated as having normal results.

Answer 20

true

Question 21

The NHS has now moved to an HPV first system what does this mean

Answer 21

sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.

Question 22

Management of results - negative hrHPV

Answer 22

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

Question 23

Management of results - positive hrHPV

Answer 23

samples are examined cytologically

different mx based on cytology abnormal/normal

Question 24

Management of results - positive hrHPV if the cytology is abnormal

Answer 24

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 abnormal → colposcopy

Question 25

Management of results - positive hrHPV if the cytology is normal

Answer 25

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

Question 26

Management of results - positive hrHPV | If the sample is 'inadequate'

Answer 26

repeat the sample within 3 months | if two consecutive inadequate samples then → colposcopy

Question 27

The follow-up of patients who've previously had CIN is complicated but as a first step,

Answer 27

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.

Question 28

The management of cervical cancer is determined by the

Answer 28

FIGO staging and the wishes of the patient to maintain fertility.

Question 29

FIGO Stage IA

Answer 29

Confined to cervix, only visible by microscopy and less than 7 mm wide: A1 = < 3 mm deep A2 = 3-5 mm deep

Question 30

FIGO Stage IB

Answer 30

Confined to cervix, clinically visible or larger than 7 mm wide: B1 = < 4 cm diameter B2 = > 4 cm diameter

Question 31

FIGO Stage II

Answer 31

Extension of tumour beyond cervix but not to the pelvic wall A = upper two thirds of vagina B = parametrial involvement

Question 32

FIGO Stage III

Answer 32

Extension of tumour beyond the cervix and to the pelvic wall A = lower third of vagina B = pelvic side wall NB: Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III

Question 33

FIGO Stage IV

Answer 33

Extension of tumour beyond the pelvis or involvement of bladder or rectum A = involvement of bladder or rectum B = involvement of distant sites outside the pelvis

Question 34

Management of stage IA tumours

Answer 34

Gold standard of treatment is hysterectomy +/- lymph node clearance - nodal clearance for A2 tumours For patients wanting to maintain fertilit: 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

Question 35

Management of stage IB tumours

Answer 35

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

Question 36

Management of stage II and III tumours

Answer 36

Radiation with concurrent chemotherapy If hydronephrosis, nephrostomy should be considered

Question 37

Management of stage IV tumours

Answer 37

Radiation and/or chemotherapy is the treatment of choice | Palliative chemotherapy may be best option for stage IVB

Question 38

Management of recurrent disease

Answer 38

Primary surgical treatment: offer chemoradiation or radiotherapy Primary radiation treatment: offer surgical therapy

Question 39

The prognosis of cervical cancer is dependant on the FIGO staging:

Answer 39

I 1yr 99% 5yr96% II 1yr85% 5yr54% III 1yr74% 5yr38% IV 1yr35% 5yr5%

Question 40

Cervical cancer - Complications of surgery

Answer 40

Standard complications (e.g. bleeding, damage to local structures, infection, anaesthetic risk) Cone biopsies and radical trachelectomy may increase risk of preterm birth in future pregnancies Radical hysterectomy may result in a ureteral fistula

Question 41

Cervical cancer - Complications of radiotherapy

Answer 41

Short-term: diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness Long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema

Question 42

What is a Cervical Ectropion

Answer 42

Elevated oestrogen levels result in larger area of columnar epithelium being present on the ectocervix

Question 43

What is in the transformation zone?

Answer 43

On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal.

Question 44

What can elevate oestrogen levels

Answer 44

ovulatory phase, pregnancy, combined oral contraceptive pill use

Question 45

Features of cervical etropion?

Answer 45

vaginal discharge | post-coital bleeding

Question 46

Mx cervical ectropion

Answer 46

Ablative treatment (for example 'cold coagulation') is only used for troublesome symptoms