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O&G > Cervical Disorders > Flashcards

Cervical Disorders Flashcards

1
Q

Explain the anatomy of the cervix, in relation to cellular composition

A

Endocervix (canal)
- Lined by columnar (glandular) cells

Ectocervix (continuous with vagina)
- Lined by squamous epithelium

Squamocolumnar junction (region of transformation zone)
- Where the two types of cells meet
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2
Q

Describe how the transformation zone is formed, and the significance of this area

A
  • During puberty and pregnancy, partial eversion of the cervix occurs
  • This exposes the columnar cells to the low pH of the vagina –> metaplasia to squamous epithelium
  • This area of new cells is the transformation zone
  • This is where cells are most vulnerable to neoplastic change
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3
Q

Define ectropion and outline in which women it is usually found in

A

When columnar epithelium of the endocervix is visible as a red area around the os on the surface of the cervix, this is due to eversion

3Ps
- Commonly found in pregnant women, those taking the pill and during puberty

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4
Q

Outline the clinical presentation of ectropion

A
  • Can be asymptomatic
  • Post-coital bleeding (most common cause of PCB)
  • Vaginal discharge
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5
Q

Describe the investigations and management of cervical ectropion

A

Investigations:

  • Smear
  • Possible colposcopy depending on smear results
  • Cervical and upper vaginal swabs to test for STIs

Management (if causing functional problems)

  • Switch from oestrogen based contraception
  • Cervical ablation (cryocautery)
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6
Q

Define, outline the risk factors, clinical presentation and management for cervical polyps

A

Benign tumours arising from the endocervical epithelium

Symptoms:
- Asymptomatic, PCB, IMB

Managment:
- Removed with avulsion

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7
Q

Define and outline the treatment for cervical nabothian follicles

A

Occur when squamous epithelium forms over the columnar epithelium of the transformation zone. The underlying columnar secretions are trapped, forming cysts which appear as white or opaque swellings

Management: nil (unless very large and symptomatic)

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8
Q

Define CIN (cervical intraepithelial neoplasia)

A

Presence of atypical cells within the squamous epithelium. These atypical cells are dyskaryotic:

  • Exhibiting larger nuclei
  • Frequent mitoses

This makes CIN a histological diagnosis

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9
Q

Explain the 3 different grades of CIN

A

• CIN I (mild dysplasia): Atypical cells are found only
in the lower third of the epithelium.

• CIN II (moderate dysplasia): Atypical cells are found
in the lower two-thirds of the epithelium.

• CIN III (severe dysplasia): Atypical cells occupy
the full thickness of the epithelium. (No invasion of basement membrane, if this occurs there is malignancy)

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10
Q

Explain how HPV increases the risk of developing CIN

A
  • Incorporation of viral DNA into host cell DNA, in the TZ
  • Viral proteins inactive tumour suppressor genes
  • -> more mutations –> dysplasia –> carcinoma
  • Virus also induce changes to hide infected cell from immune system
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11
Q

Outline the different screening procedures for cervical pre-malignant & malignant conditions

A
  • Cervical smear (cytology)

- Colposcopy (+ biopsy)

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12
Q

Which strains of HPV does the childhood vaccine protect against?

A

6, 11, 16 & 18

  • 16 & 18 responsible for most cases of cervical cancer
  • 6 & 11 can cause genital warts
  • Given to 12 to 13yr olds (Year 8)
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13
Q

At what ages and how frequently are smears taken in the cervical cancer screening programme

A
  • 25-49 every 3 years

- 50-64 every 5 years

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14
Q

Explain what can be seen on cervical smear samples

A
  • Identifies cellular NOT histological abnormalities
  • Can detect and grade dyskaryosis (borderline, low, high grade)
  • This suggests the presence of CIN
  • Can detect cervical glandular intraepithelial neoplasia: CGIN (abnormal columnar cells)
  • Also tests for HPV
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15
Q

Outline the clinical presentation of CIN

A
  • Generally asymptomatic

* Speculum – cervix often unremarkable

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16
Q

Outline the next steps in investigation for the following smear results:
normal, borderline OR low grade dyskaryosis, high grade dyskaryosis, CGIN

A

Normal: return to routine cervical screening

Borderline or low grade dyskaryosis:

  • If HPV -ve: return to routine recall
  • If HPV +ve: colposcopy

High grade dyskaryosis: colposcopy

CGIN: colposcopy (if no abnormality, then hysteroscopy)
- Want to exclude adenocarcinoma of the cervix or endometrium

17
Q

Give some risk factors for developing CIN

A

Multiple sexual partners, early age of first intercourse, smoking, low socioeconomic status, HIV

18
Q

Give the management for CIN

A

CIN II/III:

  • LLETZ (large loop excision of transformation zone)
  • Resulting specimen is further tested histologically
19
Q

What are some complications of LLETZ?

A
  • Postoperative haemorrhage (uncommon)

- Risk of subsequent preterm delivery

20
Q

Outline the pathology of cervical cancers

A
  • 90% squamous cell carcinoma
  • 10% adenocarcinoma

CIN is the pre-invasive stage for SCC

21
Q

Give some risk factors for cervical cancer

A
  • CIN
  • Rest same as RF for CIN: smoking, early first intercourse,
    multiple sexual partners, lower, socioeconomic status, HIV

NOT hereditary

22
Q

Describe the clinical presentation of cervical cancer on history and examination

A

History:

  • PCB, IMB
  • Offensive vaginal discharge
  • Often missed smears
  • Later stages of disease: uraemia, haematuria, rectal bleeding, pain (ureter, bladder, rectum and nerve involvement)

Examination

  • Palpable or visible cervical ulcer/mass
  • Abdominal mass (pelvic spread)
23
Q

Outline some investigations for cervical cancer

A
  • Tissue dx – colposcopy and biopsy
  • Bloods – FBC (anaemia), U&E (obstruction), LFT (mets), clotting (if abnormal LFT), GS (surgical prep)
  • Imaging – CXR, CT (radiological staging), MRI (increased accuracy, can assess) lymph nodes
  • Other – cystoscopy
24
Q

Describe the FIGO staging of cervical cancer (stages 1,2,3,4)

A

Stage 1: confined to cervix

1a: only seen under microscope, 1b: clinically visible
- 1a(i): max horizontal dimension = 7mm and depth of invasion = <3mm
- 1a(ii): max horizontal dimension = 7mm, depth of invasion = 3-5mm
- 1b(i): lesions greater than 1a(ii), no greater than 4cm in size in greatest dimension
- 1b(ii): clinically visible, greatest dimension >4cm

Stage 2: invasion into vagina (upper 2/3rds only), but not pelvic side wall

  • 2a: involves vagina
  • 2b: involves parametrium

Stage 3: invasion of lower vagina and/or pelvic wall

  • 3a: lower 1/3rd of vagina
  • 3b: pelvic wall: hydronephrosis due to ureteric obstruction

Stage 4: involves bladder, rectal mucosa or extends beyond the true pelvis (distant spread)

25
Q

Outline the management for cervical cancer

A

Surgical:
1a(i)
- Cone biopsy
- Or simple hysterectomy (older women)
1a(ii)
- Simple hysterectomy with pelvic lymphadenopathy
1b
- May be suitable for trachelectomy (radical excision of
cervix) to conserve fertility
1b or 2a
- Radical hysterectomy and pelvic lymphadenopathy

Chemoradiation
- Can be used for 1a(ii) - 2a, if LN are involved, as alternative to surgery
2b and worse, or positive LN:
- Radiotherapy and chemotherapy (platinum) alone

Recurrence:
- Consider radiation if not already given, or pelvic exenteration (removal of uterus, cervix, bladder and/or rectum)

26
Q

Outline the difference between: simple hysterectomy, radical hysterectomy, trachelectomy

A

Simple hysterectomy
- Uterus and cervix removed

Radical hysterectomy

  • Hysterectomy: uterus, ovaries
  • Pelvic node clearance
  • Removal of parameterium and upper 1/3rd of vagina

Trachelectomy

  • Laparoscopic lymphadenectomy first
  • If nodes +ve: use chemo-radiotherapy, if nodes -ve, then progress to trachelectomy
  • -> Removal of 80% of cervix and the upper vagina
27
Q

Outline the prognosis for cervical cancer, in the following stages: I,II,II,IV

A

Five year survival:

Stage I, II, II, IV → 90-95%, 65%, 35%, 10-30%

O&G (6 decks)

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