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Reproduction > Cervix & cervical screening, Vulval cancer > Flashcards

Cervix & cervical screening, Vulval cancer Flashcards

1
Q

What percentage of cervical cancers are caused by HPV?

A

> 99%

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2
Q

Does cervical cancer have a good cure rate?

A

Good cure rate if detected early BUT major cause of death in in women in low income countries

Despite cervical screening & despite HPV immunisation some women will still develop cancer either because they are not vaccinated or the have cancer which is attributed to non vax high risk HPV types or because they have a cancer that is not related to HPV such as neuroendocrine tumours

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3
Q

What is the peak age for cervical cancer?

A

Peak age 45-55 years

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4
Q

What types of HPV are related to cervical cancer?

A

HPV related (16 & 18)

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5
Q

What predisposes people to cervical cancer?

A

Multiple sexual partners
Early age at first intercourse
Older age of partner
Cigarette smoking

Young age of onset of sexual activity likely relates to the immaturity of the cervix & the TZ is more susceptible to HPV infections

Older partner is more likely to have acquired HPV infection & persistent infection themselves

Smoking-effects cell mediated immunity & nicotine is detected within cervical mucous

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6
Q

For whom is cervical smear test for?

A

Asymptomatic population

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7
Q

What are the symptoms of cervical cancer?

A

Abnormal vaginal bleeding
Post coital bleeding
Intermenstrual bleeding/PMB
Discharge
(Pain)

Sometimes women describe bleeding as discharge as is brown and has got a smell to it – but could be that they have a very offensive discharge if they have a large necrotic tumour

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8
Q

When is pain associated with cervical cancer?

A

Pain is associated with very advanced cancer that has spread to sidewalls of pelvis so have neuropathic pain or else got obstruction of the ureters and so getting back pain from hydronephrosis

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9
Q

How is cervical cancer diagnosed?

A

Clinical
Screen detected
BIOPSY needed for diagnosis as it is a pathological diagnosis

Remember screening aims to detect pre-cancerous disease NOT cancer

Screen detected=as a result of attending screening programme

Screening is for the detection of precancerous asymptomatic changes

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10
Q

What are the histological types of cervical cancer?

A

Tumour cells from epithelium invade into underlying stroma

Majority squamous carcinoma (80%)

Adenocarcinoma (endocervical) rising in relative incidence
Adenocarcinomas-developing in endocervical glandular epithelium

Can see combo of squamous adenocarcinomas

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11
Q

Where does cervical cancer spread to?

A

Metastases:

Lymphatic – pelvic nodes- Spreads out laterally within pelvis to the parametrium to pelvic LNs

Blood – liver, lungs, bone

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12
Q

How is cervical cancer staged?

A

PET-CT

MRI

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13
Q

How is cervical cancer staged?

A

PET-CT

MRI

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14
Q

What are the treatment options for cervical cancer?

A

Excision of the cervical TZ or hysterectomy
Radical hysterectomy
Chemo-radiotherapy

Cervical cancer is very radiosensitive

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15
Q

How is radical hysterectomy done?

A

Exploration of pelvic and para-aortic space

Removal of:
Uterus, cervix, upper vagina
Parametria
Pelvic nodes
Ovaries conserved-in premenopausal women

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16
Q

What are the therapy option ways to treat cervical cancer?

A

Radiotherapy- External Beam

Chemotherapy- once weekly during radiotherapy

Brachytherapy - Caesium Insertion (24 hours)- to boost the treatment to the site of the tumour in the cervix

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17
Q

What is screening for in cervical cancer?

A

Screening detects pre-invasive changes which are asymptomatic

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18
Q

What is the single most important cause of cervical cancer?

A

HPV

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19
Q

Cervical cancer causes abnormal vaginal bleeding. There is effective cure for early stage disease, what are they?

A

Surgery or combined chemoradiation

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20
Q

12% of human cancers are caused by viruses. Which viruses are implicated?

A

HBV
HIV
EBV
HPV

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21
Q

HPV is a very stable virus, what does this mean?

A

Very stable virus so does not mutate or change

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22
Q

How common is a HPV infection?

A

Peak prevalence 15-25yrs
prevalence declines with age

~30% prevalence in young women
lifetime risk of exposure 80% from serological studies

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23
Q

How is HPV infection in the cervix transmitted?

A

Transmitted by close intimate contact usually by penetrative sex

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24
Q

How can HPV infection & cervical disease be prevented?

A

Prevention by preventing HPV infection and by detecting precancerous changes and treating them to avoid progression

25
Q

What does vaccinating against HPV 6 & 11 prevent against?

A

Genital warts

26
Q

Most HPV infections are cleared by what?

A

The immune system

HPV very rarely causes cancer

27
Q

Who is vaccinated for HPV in the UK?

A

In UK, 12 year olds are immunised against HPV16/18 to reduce the risk of cervical cancer

28
Q

What is used for cervical smears?

A

LBC=Liquid based cytology

Sample transformation zone

29
Q

When are people invited for a smear test?

A

CHI identifies she is female and age 25

First registered on SCCRS when become age 25

30
Q

What is the presentation of vulva cancer?

A

Age 74 (27-97)
75% diagnosed over age 60

Presentation:
pain
itch
bleeding
lump/ulcer

(Older women with pain/ulcer/lump)
(Younger women with VIN)

31
Q

What are the risk factors for vulva cancer?

A

Intraepithelial neoplasia or cancer at other lower genital tract site
Lichen sclerosus
Smoking
Immunosuppression

32
Q

What is lichen sclerosis (risk factor for vulva cancer)?

A

Chronic dermatoses which is believed to be autoimmune in origin & it is not related to HPV

33
Q

How is the staging of vulva cancer done?

A

Staging surgical-pathological

Size of lesion

Lymph node involvement
- inguinal & upper femoral
- pelvic

34
Q

What is the difference between HPV and non HPV related vulva cancer?

A

HPV:
Usual type VIN
Younger women
Multifocal
Multizonal
Immunosuppression
Past history of intra-epithelial neoplasia

Non-HPV:
Differentiated VIN
Older women
Lichen Sclerosus
Often presents as cancer at first diagnosis

35
Q

What staging is used for vulva cancer?

A

Like other gynaecological cancers use FIGO staging

Stage 3= risk of affecting the inguinal lymph nodes

36
Q

Histopath for vulva cancer: what are the possible diagnosis?

A

Punch biopsy or excisional biopsy
Small piece of tissue which we process and look at under the microscope

Possible diagnosis?
Inflammatory, including lichen sclerosus
Dysplasia- VIN
Malignant- squamous cell carcinoma

37
Q

What is vulvar intraepithelial neoplasia?

A

Abnormal proliferation of squamous epithelium; can progress to carcinoma

Usual type (aka classical / warty)
- Associated with HPV infection

Differentiated type
- In older women, not HPV related
- always high grade

38
Q

Describe vulva cancer - squamous cell carcinoma?

A

Malignant tumour of squamous cells
Ability to invade adjacent tissues and spread to distant sites (metastasis)

On a biopsy very important to measure depth of invasion

Grade on how differentiated it is

Depth of invasion affects the staging and the management of the patient

39
Q

How can vulva cancer be treated?

A

Surgery
- individualised surgery
- Local excision
- Unilateral or bilateral node dissection

Radiotherapy/Chemotherapy-may be sole treatment or may be used to downstage the disease and reduce it before surgery for any residual disease

Also plan whether to remove LNs or not – depends on location of lesion & size – may use sentinel node involvement

40
Q

With what morbidity is groin node dissection associated with?

A

Inguinal and upper femoral nodes

Separate node incisions

Staging and remove nodal disease

Associated with significant morbidity
Wound infection
Lymphocysts
Nerve damage

41
Q

When is the peak prevalence of HPV infection?

A

Peak prevalence 15-25yrs

Prevalence declines with age

42
Q

Does smoking put you at higher risk of cervical cancer?

A

YES

Cigarette smoking alters cell mediated immunity – nicotine secreted in cervical mucous

43
Q

Who is invited for a smear test and screened for cervical cancer and how is this done?

A

Person with a cervix aged 25-64 years

5 yearly smears

Liquid Based Cytology (LBC)

Test for high risk HPV

If hrHPV positive; triage with cytology

44
Q

Why do we test for HPV in cervical screening?

A

HPV testing is more sensitive than cytology for high grade abnormalities

As more HPV-immunised women enter the screened population, cervical disease will decrease and will be more difficult to detect by cytology. HPV will be more effective test for the future.

If the HPV test is negative, the woman’s chance of developing cervical cancer in the next 5 years is very small, allowing a 5 year screening interval for all women regardless of age.

45
Q

When is a cervical cytology sample done?

A

Only if high risk HPV +ve

  • Microscopic assessment of cells scraped from the transformation zone
  • Look for abnormal cells (dyskaryosis)
  • Indicate that woman may have underlying cervical intraepithelial neoplasia - CIN
46
Q

Graded low or high grade dyskaryosis reflects what?

A

Reflects degree of underlying CIN

Low grade (+ borderline)

High grade

Borderline = not definite dyskaryosis but there are changes so cant report as negative

47
Q

What do Koilocytes reflect?

A

HPV infection

(Cells with a perinuclear halo)

48
Q

What happens if negative for hrHPV compared to if positive?

A

Negative for hrHPV – routine recall 5 years

Positive for hrHPV:
- Cytology normal; repeat test 1 year
- Dyskaryosis: refer to colposcopy

49
Q

What should be done if cervix looks abnormal?

A

Refer to gynae for urgent assessment – not managed through screening programme

50
Q

How is a colposcopy done?

A

Magnification and light to see cervix

Exclude obvious malignancy

Use of acetic acid +/- Iodene:
- Identify limits of lesion
- Select biopsy site
- Define area to treat

51
Q

What are the options for management?

A

Punch biopsy to make a diagnosis

Return for Treatment if CIN2/3

“See and treat” at first visit
- See and treat if have hrHPV +ve, high grade CIN & colposcopy features suggesting high grade

52
Q

What are the low risk types of HPV?

A

E.g. 6 & 11

  • Genital warts & low grade CIN
  • Often transient & resolve
53
Q

What are the high risk types of HPV?

A

E.g. 16 & 17

  • Persistent infection increases risk of developing
  • High grade CIN & more rarely cancer
54
Q

CIN is invisible to the naked eye: what are the grades of CIN?

A

CIN 1: low grade dysplasia–will regress

CIN 2: moderate dysplasia – may regress

CIN 3: severe dysplasia – unlikely to regress

Precursor of invasive cancer

(CIN 1 – consider to be a HPV infection & CIN 2 in young women or those who haven’t completed their families-manage conservatively)

55
Q

How is CIN 2/3 treated?

A

Excise TZ of cervix
- LLETZ = Large loop excision of the transformation zone

Ablate TZ of cervix
- Thermal Ablation
- Laser ablation

56
Q

What follow up is done after treatment of CIN?

A

To confirm that treatment was effective = Residual disease with in 2 years

To prevent invasive cancer
- Recurrent disease 5% after 3-5 years
- Detect occasional cancer

To reassure the woman that her treatment has worked

Follow-up LBC at 6 months for cytology and high risk HPV
- Both negative – return to 3? year recall
- Either positive – return to colposcopy

57
Q

What is the aim of cervical screening?

A

Reduce the risk of cervical cancer

58
Q

How is protection against cervical cancer maximised?

A

HPV vaccination + cervical screening to maximise protection

Even if immunised, anyone with a cervix still needs to be offered cervical screening

Reproduction (17 decks)

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