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Cervical Cancer and Pre-Invasive Disease - Coggle Diagram
Cervical Cancer and Pre-Invasive Disease
Overview / Epidemiology
Epidemiology
Cervical cancer 8th most common cancer in women in IRE
300 cases a year IRE
85% occur sin develping countries - mjor global health problem
Estimate risk 1:123 - less than 1% for females up to 74y/o in IRE
HPV
99.7% cervical cancers attributed to HPV
70% of cervical cancer caused by 2 high risk subtypes
HPV16
HPV18
HPV
Transmission
Intimate skin to skin contact
20 types affect genital tract
Risk
Lifetime risk of infection up to 80% in exposed individuals
Prevalence
Declines with age
Increases with increased number of sexual partnres
Infection
Most asymptomatic and self limiting
9/10 people clear of HPB in 2 years
Low Risk / High Risk types
High risk
HPV16
HPV18
Risk Factors
HPV infection
Multiple sexual partners
Tobacco use
Parity +3
Weakened immune system
Prolonged use of birth control pills
Diet low in fruit and veg
Fhx
HPV Vaccine
Gardasil 9 vaccine
Nonavalent
HPV 6, 11, 16, 18, 31, 33, 45, 52, 58
Protects against 9 / 10 cervical cancers
Timing
1st year of secondary school
Girls since 2010
Boys since 2019
Global Strategy to Eliminate Cervical Cancer
90-70-90 Target
Vaccination: 90% girls full vaccinated with HPV vaccine by age 15
Screening: 70% of women screening using a high performance test by age 35, and again by age 45
Treatment: 90% of women with pre-cancer treated and 90% of women with invasive cancer managed
Each country to meet 90-70-90 target by 2030 to eliminte cervical cancer in next century
Anatomy
Cervical Transformation zone
Area at risk from HPB
Pre-pubery
Squamous epithelium - outside
Columnar epithelium - inside
Original squamoolumnar junction (SCJ)
Puberty
Eversion of cervical canal exposing colmnar epithelium
Early reproductive age
Squamous metaplasia - Squamous epithelium grows over columnar epithelium
Transformation zone is between original and new squamocolomnar junctions
Cervical Pre-Invasive Disease
Cervical Screening
National cervical screening programme CervicalCheck
HPV triage
More sensitive for high grade cell changes
Higher NPV - longer recall intervention
Timing
Every 3 years from 25-29 y/o
Every 5 years 30+ y/o
Method
Cytobrush obtains sample of cells from cervix
Insert into external os and rotate 350 x5 to pick up loose cells from transformation zone
Transfer to ThinPrep pot by dabbing cytobrush on bottom of pot 10x
Check expirary on pot
Pot closed until black lines on lid match up
Labelled and sent to lab for HPV testing +/- cytological analysis
Potential Results
HPV not found
HPV found with no abnormal cells
HPV found with abnormal cells
4 Inadequate or unsatisfactory sample
Colposcopy Referral Criteria
Pts with
one positive HPV test and a cytological abnormality
Pt with
2 positive HPV tests
and any cytology
Pt with
suspicious appearing cervix
Colposcopy
Definition
Use of microscope (colposcope) to assess cervic
Tests
5% Acetic acid application
MOA
Coagulated cellular protein and turns lesion white (acetowhite)
Positive Test
Acetowhite
Lugol's Iodine Application (Shiller's Test)
MOA
Dysplastic cells will not absorb solution due to lower levels of glycogen
Postive Test
Non staining
Top normal
Bottom abnormal
Punch Biopsy
Taken of abnormalities
Mutiple biopsies if diffuse changes
Cervical Intraepithelial neoplasia (CIN) is a
histological
diagnosis
Cervical Intraepithelial Neoplasia (CIN) Biopsy interpretation
Treatment
Excisional
LLETZ Large loop excision of transformation zone
Procedure: Removal of transformation zone using an electro-diathermy loop
Setting: Local anaesthetic in colposcopy
Excision: Small specimen usuall 8-15 mm
Conisation / Cone Biopsy
Procedure: Removal of transformational zone and cervix to deeper level
Setting; GA in operating theatre
Excision: Larger 2-2.5 cm
Ablative
Cold coagulation
Procedure: Tissue boiled by applying probe heated to 100-120 ° C
Setting: LA in colposcopy
Most common
Indication: Pre-treatment low grade histology result
Cervical preserving treatment
Radical Electodiathermy
Procedure: Burning the transformational zone
Setting: GA
Cryocautery
Procedure: Freezing the tissue
Setting: LA
Post Treatment Complications
Infection
Bleeding
Visceral injury (exisional only)
Cervical incompetence (exisional only) - relates to depth of tissue removed in one / repeat procedures
Cervical stenosis - due to fibrosis / scaring
Cervical Cancer
Types
Squamous cell carinoma
Adenocarinoma
Adenosquamous cell carinoma
Small cell carcinoma
Rarer types
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Referral Pathways
Screening - Asymptomatic
Symptomatic
Symptoms
PCB
Post menopausal bleeding
Intramenstrual bleeding
PV discharge
Blood tained discharge with strong odour
Pelvic pain
Dyspareunia
Pain in back and legs
Systemic
Anorexia
Fatigue
Unexplaiend weight loss
Staging
Clinical Assessment
General Exam
Pelvic Exam
Roughened hard cervix
Loss of fornix
Fixed cervix
Cervical lesions
Bleeding
MRI Pelvic
Assess local involvement
Parametrium
Bladder
Bowel
Ureters
PET CT Scan
Assess nodal involvement and mets
MDT
Gynae oncology
Radiology
Histopathology
Surgical / medical / radiation oncology
Palliative care
Cancer nurse specialist
FIGO Staging
Stage 1 – limited to the cervix
Stage 2 – local spread beyond the uterus to the parametria or upper vagina
Stage 3 – extension to the pelvic sidewall and/or the lower third of the vagina
Stage 4 – extension beyond the pelvis, or involvement of the bladder or bowel mucosa, or distant metastases
Stage at diagnosis
Management
Surgical
Cervical cone
Tumour seize: Microscopic <3mm
FIGO Stage 1A1
Radical hysterectomy / Lymph nodes
FIGO Stage 1A2 - 1B2
Fetility sparing option if <2cm
Tumour size: 3mm-4cm
Removal of uterus , cervix, parametium, upper vaginal cuff
Lymph node assessmenrt
Radical Trechelectomy / Lymph nodes
Removal of cervix, parametrium, upper vagina
Lymph node assessment
Chemoradiation
Indication: Tumour >4cm or Tumour outside the cervix
External Beam Radiotherapy (EBRT) intra-cavity (internal) Brachytherapy (BT) and concomitant chemotherapy
Regimen
Radiotherapy 5 days a week for 5 weeks
Chemotherapy weekly for 5 weeks
Follow up
Radical Hysterectomy / Chemoradiation
5 Years in GO clinic
Cone biopsy
10 years annually in colposcopy
Radical Trachelectomy
10 years colposcopy / Gynae Onc clinic
Survivorship
Urological Effects
Frequency
Urgency
Incontinence
Dysuria
Haematuria
Contracture
Spasm
Reduced flow
Fistula
Ulceration
Necrosis
GI Effects
Frequency
Urgency
Tenesmus
Rectal bleeding
Incontinence
Diarrhoea
Steatorrhoea
Mucous stool
Bloating / wind
Malabsorption
Weight loss
Fistula
Ulceration
Necrosis
Sexual Morbidity
Vaginal atrophy
Loss of libido
Vaginal stenosis
Dyspareunia
Vaginal Dryness
Painful / lack of orgasm
Bone
Pain
Insufficincy
Fractures
