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Gynae > Cervix > Flashcards

Cervix Flashcards

1
Q

What ligaments attach to the cervix?

A

Posteriorly - uterosacral ligaments

Laterally - cardinal ligaments

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2
Q

Where are the uterine vessels and utreters contained?

A

Parametrium - lies lateral to cervix.

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3
Q

Histologically describe the cervix:

A
  • Endocervix (canal) -> columnar glandular epithelium
  • Ectocervix (vaginal) -> squamous epithelium
Squamocolumnar junction (SCJ) - where the epithelia meet. During pregnancy and puberty, partial eversion of the cervix occurs - > some columnar epithelium gets exposed on the vaginal aspect and the decreased pH of the vagina causes it to undergo squamous metaplasia = 'transformation zone'.
The cells undergoing metaplasia are vulnerable to agents inducing neoplastic change (=cervical carcinoma).
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4
Q

Describe the blood supply of the cervix:

A
  • Uterine arteries (from internal iliac artery)

- Upper vaginal arteries’ branches (also from IIA)

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5
Q

What is the lymphatic drainage of the cervix?

A

Internal and external iliac nodes -> common iliac nodes ->para-aortic nodes

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6
Q

Where does cervical carcinoma typically spread and why?

A
  • Local spread - uterus, vagina, bladder, rectum.

- Lymph spread

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7
Q

List 5 benign cervical pathologies:

A
  • Cervical ectropion
  • Acute cervicitis
  • Chronic cervicitis
  • Cervical polyps
  • Nabothian follicles
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8
Q

What is cervical ectropion? When is it found?

A

When columnar epithelium of the endocervix is visible as a red area around the OS on the surface of the cervix ->eversion.

Found in pregancy, puberty, when on the pill.

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9
Q

What are the signs/symptoms of cervical ectropion? What are the Rx?

A 
S&S:
- Usually asymptomatic
- PCB (post-coital bleeding)
Rx - 
- Smear + colposcopy to rule out carcinoma
- cryotherapy w/o anaesthesia
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10
Q

What can cause acute cervicitis?

A

STIs. Rare.

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11
Q

What is chronic cervicitis associated with? what are the S&S? What is the typical treatment?

A

It is chronic inflammation & infection. Associated with ectropion.

S&S:

  • vaginal discharge
  • Inflammatory spear (^WBC)

Rx:
- Cryotherapy +/- Abx

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12
Q

What are benign tumour so the endocervical epithelium known as? What age of people do they usually affect?

A

Cervical polyps. ~40yrs.

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13
Q

What are the s&s of cervical polyps? Rx?

A

S&S:
- Asymptomatic
- IMB/PCB
Rx:
- Polyps avulsed (to tear off) w/o anaesthetics
- Subsequent histological examination of resected polyps

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14
Q

What are Nabothian follicles?

A

Squamous epithelium forming within columnar endocervix (metaplasia).
Causes retention of columnar secretions = cyst formation on ectocervix (opaque swellings)

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15
Q

What is the Rx for Nabothian follicles?

A

Rarely symptomatic. No Rx.

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16
Q

What does CIN stand for? What is it considered in relation to cervical carcinoma?

A

Cervical Intraepithelial Neoplasia.

Pre-malignant.

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17
Q

What is CIN?

A

Also known as cervical dysplasia. Formation of atypical dyskaryotic (large pale nuclei, ^mitosis) cells within squamous epithelium (no BM breaching)

18
Q

What are the histological stages of CIN?

A
  • CIN I (mild dysplasia) - atypical cells confined to lower 1/3 of epithelium
  • CIN II - (moderate dysplasia) - atypical cells confined to lower 2/3 of the epithelium
  • CIN III (severe dysplasia) - atypical cells occupy full thickness of the epithelium: CARCINOMA IN SITU
19
Q

Outline the likely progression from each of the stages of CIN:

A
  • CIN I - can progress to CIN II/III (esp. if decreased immunity) but usually regresses spontaneously
  • CIN II/III -> 30% women will develop cervical cancer in 10 years
20
Q

What causes change from cervical columnar -> squamous epithelium?

A

Low vaginal pH. Called metaplasia.

21
Q

What causes change from squamous to CIN/dyskaryotic epithelium?

A

Viral agents (HPV 16/18/31). Called dysplasia

22
Q

What causes change from CIN I -> CIN II -> CIN III?

A

Poor host immunity.

23
Q

What ages of women are normally affected by CIN? What is done to prevent this progressing?

A

Peak at age 25-29yrs, 95% cases in those <45 years old.

Cervical screening:

  • 25-49 (every 3years)
  • 50-64 (every 5 years)
24
Q

Why is cervical screening not performed on those <25yrs?

A

They tend to have abnormal cervical change anyways.

25
Q

What is the common cause of CIN? And how was this attempted to be reduced?

A

HPV 16 and 18 (31 and 33).

National vaccination program against HPV 16/18 in adolescent girls.

26
Q

Give 3 risk factors for CIN:

A
  • Oral contraceptives
  • Smoking
  • Immunocompromised patients (HIV, long-term steroids)-> quicker progression
27
Q

How does HPV cause CIN?

A

Exposure of squamous epithelium to HPV = incorporation of viral DNA into cell DNA.
Viral proteins inactivate key cell tumour suppressor genes & push cell into an endless cell cycle

28
Q

How does CIN present?

A

CIN is ASYMPTOMATIC. Only invasive carcinoma will cause PCB or IMB but that would be too late.

Therefore it is important to identify CIN of screening to prevent its invasive progression!

29
Q

How is CIN diagnosed?

A

1) Cervical screening -
- Cuscos speculum - loose cells collected from transformation zone -> liquid + cell centriguged (LBC).
- If dyskaryotic cell found -> smear for HPV. - If +ve for HPV -> colposcopy.
- If -ve for HPV or only normal cells found then ask to return in 3-5 years.

2) Colposcopy -
- Indications: low-grade dyskaryosis & HPV +ve, high-grade dyskaryosis, CGIN (cervical glandular intraepithelial neoplasia - any grade)
- Cervix inspected via speculum & operating microscope -> biopsy -> 5% acetic acid staining (to establish grade) and invasion through BM.

30
Q

What type of CIN is treated and how is this done?

A
  • CIN II/III - LLETZ (large loop excision of transformation zone) Under local.
  • Then histological examination of excised tissue (malignancy?)
31
Q

What is the prevalence of cervical cancer?

A
  • 3rd most common gynae cancer (after Uterine and Ovarian)
  • most common cancer in females <35yo
  • Peaks in incidence in 30’s and 80’s
32
Q

By what degree has screening decreased cervical cancer?

A

Down 50% since 1988.

Overall prognosis 65% survival.

33
Q

What kind of cervical epithelium is typically affected in those with cervical cancer?

A
  • Squamous (90%) cell carcinoma

- Columnar (10%) (clear cell) carcinoma -> worse prognosis

34
Q

What is the inheritance pattern for cervical cancer?

A

Not familial.

35
Q

What are the features of cervical carcinoma?

A

Occult:
- No symptoms -> discovered on screening (biopsy or LLETZ for supposed CIN II/III)

Clinical carcinoma -

  • PCB, IMB, offensive vaginal discharge
  • PMB (in older women -> less common)
  • Invasion of local structures: haematuria, uraemia, adjacent nerve involvement
  • O/E - ulcer or mass seen on the cervix
36
Q

Where does/doesn’t cervical cancer typically spread?

A

Local spread:

  • Parametrium, vagina
  • NOT ovaries however

Lymphatics:
- Pelvic lymph nodes(internal &external iliac nodes)

37
Q

Outline cervical carcinoma staging:

A

Stage 1 - cervix only:

  • Cone biopsy or simple hysterectomy (1a :diagnosed with microscope)
  • Lymphadenectomy + radical trachelectomy (1b: if clinically visible lesion)
  • 5yr prognosis 95% or 80% respectively

Stage 2 - Cervix and vagina:

  • Radical hysterectomy (without parametrium and -ve LN involvement)
  • Chemo-radiotherapy alone (if parametrium/LN involvement)

Stage 3 - cervix + vagina + pelvic side wall:
- Chemo-radiotherapy alone

Stage 4 - Bladder/rectal/ extra-pelvic involvement:
- Chemo-radiotherapy alone

38
Q

Outline the investigations performed in those with suspected cervical carcinoma:

A
  • Tumours biopsy (confirms diagnosis)
  • EUA (Examination under anaesthetic) -> vaginal/rectal/bladder examination + MRI -> staging the disease (incl. LN involvement)
  • Fitness for surgery -
    • CXR, FBC, U&E
    • Cross match blood prior to surgery
39
Q

What is the treatment for those with stage 1a cervical cancer?

A
  • cone biopsy (preserves fertility for younger women)

- Simple hysterectomy (for older women)

40
Q

What is the Rx for those with stage 1b-2a cervical cancer (without parametrium involvement)?

A
  • Radical hysterectomy
  • Radical trachelectomy

If LN +ve, chemo-radiotherapy (not-surgery)

41
Q

What is the Rx for those with stage 2b and worse cervical cancer?

A

(parametrium involved/lymph nodes +ve)

  • Chemotherapy - platinum agents: decrease recurrence, ^ survival
  • Radiotherapy: to shrink the tumour and slow-down the spread
42
Q

What is the Rx for those with recurrent tumours originating from cervical cancer?

A
  • Chemo-radiotherapy
  • MRI & PET -> looking for distal mets
  • Pelvic exenteration: Vagina + uterus + cerix + bladder +/- rectum -> all removed.

Gynae (8 decks)

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