Cervical Pathology

Question 1

What is cervical ectropion?

Answer 1

Exposure of endocervical columnar epithelium to acidic vaginal environment resulting in squamous metaplasia in a circular area around the external os

Question 2

Is cervical ectropion a pathological or physiological change, and why?

Answer 2

Physiological

Transitional bone changes position during reproductive life

Question 3

What factors exacerbate cervical ectropion?

Answer 3

Increased oestrogen - COCP, pregnancy

Question 4

What is the presentation of cervical ectropion?

Answer 4

Clear non-smelling vaginal discharge

Abnormal bleeding - post-coital, intermenstrual

Question 5

What is the management of cervical ectropion?

Answer 5

Cautery with silver nitrate

Ablation with cold coagulation

Question 6

What complications can cervical ectropion cause?

Answer 6

Ante/post-partum haemorrhage

Vasa praevia

Question 7

What is a cervical polyp?

Answer 7

Benign growth of endocervix

Question 8

What is the presentation of a cervical polyp?

Answer 8

Asymptomatic
Clear non-smelling vaginal discharge
Abnormal bleeding - post-coital, intermenstrual

Question 9

What is the management of a cervical polyp?

Answer 9

Avulsion

Question 10

What is a complication of cervical polyps?

Answer 10

Antepartum haemorrhage

Question 11

What is the pre-invasive phase of squamous cervical carcinoma?

Answer 11

Cervical intraepithelial neoplasia

Question 12

Has cervical intraepithelial neoplasia breached the epithelium?

Answer 12

No

Question 13

What are risk factors for cervical intraepithelial neoplasia?

Answer 13

HPV 16 and 18
Higher number of sexual partners
No condom use
Long term use of COCP
Smoking

Question 14

What is cervical glandular intraepithelial neoplasia?

Answer 14

Pre-invasive phase of cervical adenocarcinoma

Question 15

Who are screened for cervical neoplasia?

Answer 15

Patients with cervixes aged 25-64

Question 16

What is done in cervical screening?

Answer 16

Speculum examination and sample of cells from transformational zone

Question 17

What does cervical screening test for?

Answer 17

HPV

Question 18

If a cervical screening test is HPV negative, what does this mean, and what is done next?

Answer 18

Low risk of developing cervical cancer in the next 5 years - so next appointment in 5 years

Question 19

What is done if a cervical screening test is HPV positive?

Answer 19

Cytology will be carried out

Question 20

What is the transformational zone?

Answer 20

Where the columnar epithelium of the endocervix transitions to the squamous epithelium of the ectocervix

Question 21

Where is the cervical screening sample taken from?

Answer 21

Transitional zone

Question 22

What is done if HPV is positive but then cytology is negative?

Answer 22

HPV test in 12 months

Question 23

What is done is HPV is positive, cytology is negative, then the next HPV is negative?

Answer 23

Return for next screening in 5 years

Question 24

What is done is HPV is positive, cytology is negative, then the next HPV is positive?

Answer 24

Perform cytology again

Question 25

What is done is HPV is positive, cytology is negative, then the next HPV is positive but cytology is still negative?

Answer 25

Test HPV again (3rd time) in 12 months - if negative again return in 5 years

Question 26

What is done if cytology is positive?

Answer 26

Colposcopy

Question 27

What is done if high grade dyskaryosis is found on cytology?

Answer 27

Urgent 2 week colposcopy and biopsy

Question 28

What is the grading system of cervical intraepithelial neoplasia?

Answer 28

CIN I = abnormal cells occupying a third of the basal epithelium CIN II - abnormal cells have spread to the middle third CIN III - abnormal cells span the full thickness of the epithelium

Question 29

What is the purpose of colposcopy?

Answer 29

Detailed examination of the cervix | Visualise squamocolumnar junction

Question 30

What is the next step in management of a patient with symptoms suggest of cervical cancer?

Answer 30

Urgent colposcopy and biopsy

Question 31

What are the options for what happens next in cervical intraepithelial neoplasia?

Answer 31

Regression (CIN I 60%, CIN III, 32%) | Progression to cancer (CIN I 1%, CIN III 12%)

Question 32

How long does CIN take to progress to cervical cancer?

Answer 32

Years - CIN III can take 5-20 years

Question 33

What is the management of CIN I?

Answer 33

Repeat biopsy in 6 months

Question 34

What is the management of CIN II or III?

Answer 34

Excision at time of colposcopy or after a biopsy Laser ablation Cryotherapy

Question 35

What management is done post-treatment of CIN?

Answer 35

Smear and HPV est at 6 months If both negative - back to routine screening If either positive - refer to colposcopy

Question 36

What is the presentation of cervical cancer?

Answer 36

``` Abnormal bleeding (post-coital, intermenstrual, menorrhagia) Offensive vaginal discharge (brownish, blood stained) Pelvic pain ```

Question 37

What are the symptoms of advanced cervical cancer?

Answer 37

``` Backache Leg pain Haematuria Weight loss Anaemia Changes in bowel habit ```

Question 38

What is the most common type of cervical cancer?

Answer 38

Squamous

Question 39

What are the subtypes of squamous cervical cancer, and which is most common?

Answer 39

Keratinising (most common) Large cell Non-keratinising Small cell

Question 40

What is the spread of cervical cancer?

Answer 40

``` Adjacent structures - prametrium - upper vagina - pelvic side wall - bladder - rectum Draining lymphatics - pelvic nodes - para-aortic nodes ```

Question 41

How is cervical cancer staged?

Answer 41

Stage 1 - depth up to 5mm, width up to 7mm, confined to the cervix Stage 2 - spread to adjacent organs Stage 3 - involvement of pelvic wall Stage 4 - distant metastases or involvement of rectum or bladder

Question 42

What is the management of stage 1 cervical cancer?

Answer 42

Local excisioon | Can do simple hysterectomy and pelvic lymphadenopathy

Question 43

What is the management of stage 2 cervical cancer?

Answer 43

Radical hysterectomy and pelvic lymphadenopathy | Or radical radiotherapy, can be combined with chemotherapy

Question 44

When is chemoradiotherapy preferred over radical hysterectomy in stage 1-2 cervical cancer?

Answer 44

If extension past the cervix

Question 45

What is the management of stage 3-4 cervical cancer?

Answer 45

Radical radiotherapy plus chemotherapy

Question 46

What is the recurrence risk of cervical ceancer?

Answer 46

12 months