Gynacological Cancers Flashcards
What is the histology of the cervix?
- Endocervix is lined with columnar epithelium
- Ectocervix is lined with squamous epithelium
- The 2 cell types meet at the squamocolumnar junction
What histological changes occur to the cervix during puberty and pregnancy?
- Hormonally induced eversion of the cervix
- The lower pH of the vagina results in the formation of a physiological transformation zone
- The columnar epithelium undergoes physiological metaplasia to tougher and more resistant squamous epithelium
What is the metaplasia-dysplasia-carcinoma sequence that occurs in the cervix?
- The lower pH of the vagina causes the columnar mucosa to undergo a metaplastic change to form metaplastic squamous mucosa
- Persistent HPV infection causes a change from the metaplastic squamous mucosa to Cervical Intraepithelial Neoplasia (CIN) - a pre cancer
- Left untreated, CIN can develop into squamous cell carcinoma
What is the major risk factor of the development of CIN to Squamous Cell Carcinoma?
Persistent HPV infection
=> Other risk factor which alongside HPV further increase likelihood of cancer development:
- Smoking
- Immunosuppression
What are the different subtypes of HPV?
- HPV types 16 and 18 are high risk subtypes with a strong link to cervical cancer
- HPV types 6 and 11 are low risk subtypes linked with anogenital warts, but not CIN or cancer
What is the pathophysiology of Cervical Cancer?
- HPV viral DNA integrates into host DNA
- Virus preferentially infects cells in the transformation zone
- Viral proteins E6 and E7 are produced, which inhibit tumour suppressor gene products p53 and Retinoblastoma protein
- These proteins usually control the cell cycle, without them uncontrolled cell proliferation occurs
What is the main clinical presentation of Cervical Cancer?
- Post coital bleeding
- May be offensive vaginal discharge
=> Post coital bleeding is due to cervical cancer until proven otherwise
What are the 2 main types of cancer Cervical cancer can be?
- Invasive squamous cell carcinoma
- Adenocarcinoma, possible but less likely. Precursor lesion to this is Cervical glandular intraepithelial neoplasia (CGIN)
What is the NHS Cervical Screening Programme?
- Used to detect and treat premalignant lesions before they develop into cancer
=> Women between the ages of 25-49 are screened every 3 years
=> Women between the ages of 50-64 are screened every 5 years
SMEAR = SCREENING
What is Dyskaryosis?
Refers to abnormalities in the nucleus of the cell and is a term used to describe what you seen in a cervical smear
- A smear showing dyskaryosis is a good predictor of the presence of CIN in the cervix
=> Low grade (mild) dyskaryosis predicts presence of CIN 1
=> High grade (moderate) dyskaryosis predicts presence of CIN 2
=> High grade (severe) dyskaryosis predicts presence of CIN 3
What is meant by Borderline nuclear change?
Term used in smear tests when it is uncertain whether the smear is normal or shows dyskaryosis
What is the management of abnormal Cervical smears?
Upon finding dyskaryosis on smear (screening), refer for a cervical biopsy (gold standard)
=> High grade dyskaryosis is referred to colposcopy
=> Low grade dyakaryosis require HPV testing via PCR:
- HPV +ve: refer to colposcopy
- HPV -ve: routine recall
=> Borderline changes are managed in the same way as low grade dyskaryosis
What is the management of CIN?
=> CIN 1 - observation and regular follow up smears
=> CIN 2 and 3 - excision of transformation zone under local anaesthetic, known as large loop excision of the trasnformation zone (LLETZ)
=> Patients who undergo a LLETZ are offered a repeat smear and high risk HPV test 6 months later
What is endometrial hyperplasia?
Increase in the number of endometrial glands relative to the endometrial stroma, resulting in thickening of the endometrium
What is the clinical presentation of endometrial hyperplasia?
Abnormal vaginal bleeding
