cervical screening

Question 1

What virus is associated with cervical cancer?

Answer 1

HPV

Question 2

What is the incidence of HPV?

Answer 2

peak prevalence 15-25yrs

• prevalence declines with age
• 10% overall
• ~30% prevalence in young women
• lifetime risk of exposure up to 80% from serological studies

Question 3

What cancers does HPV have an association with?

Answer 3

• Cervical
• Anus
• Penis
• Vulva/vagina
• Oropharynx
• Mouth

Question 4

What is a squamous intraepithelial lesion?

Answer 4

An abnormal growth of squamous cells detectable on smear

Question 5

What are abnormal cells in the cervix detected by biopsy and histological examination classified as?

Answer 5

cervical intraepithelial neoplasia (CIN)

graded 1-3

Question 6

What types of HPV is associated with cervical cancer in Europe?

Answer 6

Types 16 and 18

Question 7

What are the possible outcomes of CIN1?

Answer 7

• regression
• remain unchanged
• progression to CIN2, CIN 3 or cervical cancer

Question 8

What is the UK HPV immunisation programme?

Answer 8

• introduced in September 2008
• offered to girls born after 1 September 1990
• currently a 2 dose regime

Question 9

What are the steps in the Scottish Cervical Call Recall System?

Answer 9

• smear taker enters request details onto SCCRS database
• vials sent to lab receipt logged on SCCRS
• patient details received from SCCRS, vials processed, slides stained and screened
• cytology lab results put on SCCRS database
• woman and GP receive results

Question 10

What is the cervical screening programme in Scotland?

Answer 10

• women aged 25-64 years
• 5 yearly smears
• liquid based cytology
• test for high risk HPV
• if positive, triage with cytology

Question 11

What is an HPV test?

Answer 11

molecular test on cells sampled from cervix

• identifies high risk type HPV viral DNA or RNA
• any high risk type leads to type specific genotyping

Question 12

What is cervical cytology?

Answer 12

microscopic assessment of cells scraped from the transformation zone

Question 13

What type of epithelium is found in the endocervix?

Answer 13

Columnar epithelium

Question 14

What type of epithelium is found in the ectocervix?

Answer 14

Stratified squamous epithelium

Question 15

What type of epithelium is find at the transformation zone of the cervix?

Answer 15

Squamo-columnar junction

Question 16

How are cervix cells stained?

Answer 16

Stained by Papinicolaou method

Question 17

What is dyskaryosis?

Answer 17

Abnormal cells showing the earliest signs of malignancy in its nucleus whilst retaining relatively normal cytoplasm

Question 18

What are the nuclear features of dyskaryosis?

Answer 18

• Increased size and nuclear:cytoplasmic ratio
• Variation in size, shape and outline
• Coarse irregular chromatin
• Nucleoli

Question 19

How is dyskaryosis graded?

Answer 19

reflects degree of underlying CIN

• Low grade (+ borderline)
• High grade

Question 20

What do koilocytes reflect?

Answer 20

HPV infection

Question 21

What does HPV test identify?

Answer 21

HPV infection (could be transient or CIN associated)

Question 22

What does cytology identify?

Answer 22

Cellular changes

• Low grade (persisting infection/CIN1)
• High grade (CIN2/3)

Question 23

What happens if a cervical smear is hrHPV is negative?

Answer 23

Routine recall in 5 years

Question 24

What happens if a cervical smear is hrHPV is positive?

Answer 24

• Cytology normal; repeat test 1 year

- Dyskaryosis: refer to colposcopy

Question 25

What is colposcopy?

Answer 25

- magnification and light to see cervix - exclude obvious malignancy use of acetic acid =/- Iodine: to identify lesion limits, select biopsy site and define area to treat

Question 26

What are the options for management of dyskaryosis?

Answer 26

- punch biopsy to make a diagnosis and can return for Treatment if CIN2/3 - or “See and treat” at first visit

Question 27

What HPV related pathology can affect the transformation zone of the cervix?

Answer 27

- HPV infection - precancerous changes cervical intraepithelial neoplasia (CIN) - cervical carcinoma

Question 28

How does HPV infection affect the transformation zone of the cervix?

Answer 28

- infects basal layer cells - utilises host for replication - as host cell matures, different viral genes expressed

Question 29

What does the E7 protein product do?

Answer 29

Prevents cell cycle arrest

Question 30

What does the E6 protein product do?

Answer 30

Inhibits cell death

Question 31

What is koilocytosis?

Answer 31

cells with wrinkled nucleus and perinuclear halo multinucleation

Question 32

What are the low risk types of HPV?

Answer 32

6, 11, 42, 44, others genital warts and low grade CIN often transient and resolve

Question 33

What are the high risk types of HPV?

Answer 33

16, 18, 31, 45, others persistent infection increases risk of developing high grade CIN and (more rarely) cancer

Question 34

How does HPV cause high grade CIN?

Answer 34

persistent infection - viral DNA integrates into host cell genome - overexpression of viral E6 and E7 proteins - deregulation of host cell cycle

Question 35

How does CIN present histologically?

Answer 35

- disorganised proliferation of abnormal cells in squamous epithelium (dysplasia) - lack of maturation - variation in cellular size and shape - nuclear enlargement - irregularity - hyperchromasia - cellular disarray

Question 36

What is CIN a precursor of?

Answer 36

Invasive cancer

Question 37

How is CIN treated?

Answer 37

excise of transformation zone of cervix - LLETZ ablate transformation zone of cervix - thermal ablation - laser ablation

Question 38

Why is CIN followed up after treatment?

Answer 38

to confirm treatment was effective to prevent invasive cancer to reassure woman treatment has worked

Question 39

How is CIN followed up after treatment?

Answer 39

follow-up LBC at 6 months for cytology and high risk HPV - both negative – return to 3 year recall - either positive – return to colposcopy

Question 40

What is the incidence of cervical cancer?

Answer 40

- 2500 cases per year in UK - 1200 deaths - 10th commonest cancer in women in Scotland - Good cure rate if detected early - BUT major cause of death in in women in developing countries

Question 41

What are the risk factors for cervical cancer?

Answer 41

- peak age 45-55 years - HPV related (16&18) - multiple sexual partners - early age at first intercourse - older age of partner - cigarette smoking

Question 42

What are the symptoms of cervical cancer?

Answer 42

- abnormal vaginal bleeding - post coital bleeding - intermenstrual bleeding/PMB - discharge - (pain)

Question 43

How is cervical cancer diagnosed?

Answer 43

- clinical - screen detected - biopsy

Question 44

What is the histology of cervical cancer?

Answer 44

tumour cells from epithelium invade into underlying stroma - majority squamous carcinoma (80%) - adenocarcinoma (endocervical) rising in relative incidence

Question 45

What is stage 1A cervical cancer?

Answer 45

Invasive cancer identified only microscopically

Question 46

What is stage 1B cervical cancer?

Answer 46

Clinical tumours confined to the cervix

Question 47

How can cervical cancer spread?

Answer 47

Local - Stage 2: Vagina (upper 2/3), - Stage 3: lower vagina, pelvis, - Stage 4 bladder, rectum Metastases - Lymphatic: pelvic nodes - Blood: liver, lungs, bone

Question 48

How is cervical cancer staged?

Answer 48

- PET-CT | - MRI

Question 49

How is cervical cancer treated?

Answer 49

- excision of cervical TZ - radical hysterectomy - chemo-radiotherapy

Question 50

What is a radical hysterectomy?

Answer 50

removal of - uterus, cervix, upper vagina - parametria - pelvic nodes ovaries conserved in pre-menopausal women