Cervical Cancer

Question 1

What is ectropion?

Why does it occur?

Answer 1

• during puberty, rising levels of oestrogen cause the cervix to evert
• the columnar tissue lining the cervical canal is everted onto the surface of the cervix
• the area of columnar tissue in the centre of the cervix is known as ectopy / ectropion

Question 2

What is the transformation zone?

How is it related to ectropion?

Answer 2

• the columnar cells on the surface of the cervix undergo squamous metaplasia
• this is a normal process caused by acidic conditions in the vagina
• the point where the columnar cells transform into squamous cells is the transformation zone

Question 3

How might cervical intraepithelial neoplasia (CIN) develop?

Answer 3

• CIN can develop if oncogenic HPV affects the transformation zone
• CIN forms instead of normal squamous tissue

Question 4

Where are samples taken from in cervical screening?

When can this be difficult?

Answer 4

• samples are taken from the transformation zone of the cervix
• this is more difficult in postmenopausal women
• the transformation zone is not visible with a speculum as it retracts

Question 5

What is the most common cause of cervical cancer?

Answer 5

human papilloma virus (HPV)

• this is a sexually transmitted infection
• types 16 and 18 are responsible for 70% cervical cancers
• most cases of HPV resolve spontaneously within 2 years

it is also associated with anal, vulval, vaginal, penis, mouth + throat cancers

Question 6

What is the vaccination schedule against HPV?

Answer 6

• 12- and 13- year old girls are offered a bivalent vaccine against HPV 16 + 18
• this prevents 90% genital warts and 60-70% CIN

Question 7

What are the risk factors for cervical cancer associated with increased risk of catching HPV?

Answer 7

• unprotected sex
• sexually active from a young age
• multiple sexual partners
• sexual partners who have had more partners

Question 8

What is the biggest risk factor for cervical cancer?

Answer 8

non-engagement with cervical screening

• many cases of cancer are preventable with early detection + treatment of precancerous changes

Question 9

What are the other risk factors associated with cervical cancer?

Answer 9

• smoking
• HIV (immunosuppression)
• COCP use for > 5 years
• increased number of full term pregnancies
• family history
• exposure to diethylstilbestrol during fetal development (used prior to 1971)

people with HIV are offered yearly smear tests due to increased risk

Question 10

What are the presenting symptoms that may be associated with cervical cancer?

Answer 10

• abnormal vaginal discharge (persistent, offensive, blood-stained)
• abnormal bleeding (PCB, PMB or IMB)
• dyspareunia
• pelvic pain (late disease)

many of these symptoms are non-specific and NOT caused by cancer

PCB = post-coital bleeding
IMB = intermenstrual bleeding
PMB = post-menopausal bleeding

Question 11

If someone presents with cancer-associated symptoms, what should be done?

Answer 11

speculum examination

• this allows visualisation of the cervix
• swabs can be taken to exclude infection

this should be followed by bimanual and PR examination

Question 12

What signs on speculum examination are red flags?

Answer 12

• ulceration
• inflammation
• bleeding
• visible tumour
• if any of these are seen, an urgent 2WW referral for colposcopy should be made

Question 13

What is involved in a cervical smear test?

Answer 13

• a speculum is inserted and a small brush is used to collect cells from the transformation zone of the cervix
• this aims to pick up precancerous changes (CIN) in the cervical epithelial cells
• the cells are deposited in preservation fluid
• they are examined under a microscope for dyskaryosis

Question 14

Before the cells from the smear test are examined microscopically, what is done?

Answer 14

• the cells are initially tested for high-risk HPV
• if this is negative, the cells are not examined
• the woman is returned to the routine screening programme

Question 15

Who is offered cervical screening?

Answer 15

• every 3 years aged 25-49
• every 5 years aged 50-65
• women > 65 can request a smear test

Question 16

How is dyskaryosis assessed?

Answer 16

• nuclear enlargement
• variation in size / shape of the nuclei
• hyperchromasia
• reduction in cytoplasm, altering the nuclear:cytoplasmic ratio

"clustering / layering up" of the cells can be seen

hyperchromasia - the nuclei appear dark / smudged / opaque when stained

Question 17

What else may be detected / reported on the smear result?

Answer 17

• trichomonas
• candidiasis
• bacterial vaginosis
• actinomyces-like organisms in women with an intrauterine device

Question 18

What are the 4 different potential outcomes of a smear test?

Answer 18

inadequate sample:

• repeat smear after at least 3 months

HPV negative:

• continue routine screening

HPV positive with normal cytology:

• repeat HPV test in 12 months

HPV positive with abnormal cytology:

• refer for colposcopy

Question 19

What is cervical intraepithelial neoplasia?

Answer 19

• a grading system for the level of dysplasia (premalignant change) in the cells of the cervix
• this is diagnosed at colposcopy, and not on screening

• dysplasia is found during colposcopy
• dyskaryosis is found on cervical smear test

Question 20

What is meant by CIN I?

Answer 20

mild dysplasia

• this affects 1/3 thickness of the epithelial layer
• likely to return to normal without treatment

• when confined to the epithelial layer, this is a pre-invasive change
• it becomes cancer when it invades below the epithelial layer

Question 21

What is meant by CIN II?

Answer 21

moderate dysplasia

• this affects 2/3 thickenss of the epithelial layer
• likely to progress to cancer if not treated

Question 22

What is meant by CIN III?

Answer 22

severe dysplasia

• this affects the whole epithelial layer
• very likely to progress to cancer
• sometimes called cervical carcinoma in situ

Question 23

What is involved in colposcopy?

Answer 23

• a speculum is inserted and a colposcope is used to magnify the cervix
• the whole transformation zone is examined
• stains - aceitic acid and iodine solution - are used to differentiate abnormal areas

Question 24

Why is acetic acid used and what is a positive result?

Answer 24

• abnormal cells will stain white (acetowhite)
• this occurs in cells with increased nuclear-to-cytoplasmic ratio
• e.g. CIN / cervical cancer

Question 25

What is involved in Schiller's iodine test?

Answer 25

* an iodine solution is used to stain the cervix * **healthy cells** will stain **brown** * **abnormal areas** will **not stain**

Question 26

How is a biopsy taken during colposcopy?

Answer 26

* a ***punch biopsy*** * or a ***large loop excision of the transformational zone*** (LLETZ)

Question 27

What is involved in a large loop excision of the transformational zone (LLETZ)?

Answer 27

* **local anaesthetic** is given during colposcopy * a **loop of diathermy wire** is used to remove abnormal epithelial cells * the electrical current **cauterises** the tissue to **prevent bleeding**

Question 28

What advice is given to women following a LLETZ procedure?

Answer 28

* **bleeding / abnormal discharge** can occur for several weeks following the procedure * **avoid tampon use / sexual intercourse** due to increased infection risk * increased risk of **preterm labour**

Question 29

What is involved in a cone biopsy?

Answer 29

* a **cone-shaped piece** of the cervix is removed using a scalpel * the sample is sent for **histology** to assess for malignancy ## Footnote * this can lead to pain, bleeding and infection * scar formation can lead to stenosis of the cervix * increased risk of miscarriage / preterm labour

Question 30

How common is cervical cancer and what is the survival like?

Answer 30

* 12th most common cancer in women * most common in women under 35 * 67% 5-year survival * 90% survival in women < 40 ## Footnote uterine and ovarian cancers are more common

Question 31

What other organs does cervical cancer tend to spread to?

Answer 31

**direct / local spread:** * vagina * bladder * parametrium * bowel **bloodborne spread:** * lungs + liver

Question 32

What lymph nodes does cervical cancer tend to spread to?

Answer 32

* parametrial nodes * internal, external + common iliac nodes * obturator nodes * pre-sacral nodes * para-aortic nodes

Question 33

What staging system is used for cervical cancer?

Answer 33

international federation of gynaecology and obstetrics **(FIGO) staging system**

Question 34

What are the 4 stages of cervical cancer according to FIGO?

Answer 34

**stage 0:** * carcinoma in-situ / CIN **stage I:** * confined to the cervix **stage II:** * invades upper 2/3 of vagina or uterus **stage III:** * invades pelvic wall or lower 1/3 of vagina **stage IV:** * invades bladder, bowel or beyond the pelvis

Question 35

What is the management for early stage cervical cancer?

Answer 35

* **radical hysterectomy** with **removal of local lymph nodes** * this is followed with chemotherapy + radiotherapy * if women require future fertility, **cone biopsy** can be repeated with **pelvic node dissection**

Question 36

What is the current vaccination programme for HPV?

Answer 36

* it is given to all girls and boys around the **age of 12-13** * this is before they become sexually active * strains **6 and 11** cause **genital warts** * strains **16 and 18** cause **cervical cancer**