Cin & Cervical Cancer

CIN & Cervical Cancer Endocervix lined by columnar epithelium, ectocervix by squamous Oestrogen à endocervix everts à exposes columnar to pH of vagina à change to squamous by metaplasia Area of metaplasia is where CIN develops Common cervical pathology Polyps Ectocervical, core of connective tissue lined with squamous epithelium (columnar if endocercial) Can cause PCB, IMB No malignant risk, can be left if asymptomatic (mainly to prevent re-referral) Remove under local in clinic by twisting & snapping stalk Ectropions (“erosions”) Columnar epithelium on the ectocervix (due to oestrogen stimulus) Can cause PCB, IMB, excess brown or normal discharge Very common in pregnancy & on COCP. Not seen post menopausally Only treat if symptomatic (cauterise epithelium so it grows back as squamous) Ebothian follicle Squamous epithelium seals off a gland from the columnar layer --> cystic bubble Not pathological Seen as white domed areas on colposcopy Smears Screen programme starts at 25 (3 yearly) and continues until 65 (not required if not sexually active) 60-65% pickup of cervical carcinoma on a single smear (3 --> 95% pickup rate) Samples the transformation zone (squamocolumnar junction) Assess cytology (loose cells). Look for dyskaryosis (mild/mod/severe). Can also detect infections 2 mild smears, or one moderate / severe smear should be referred for colposcopy Colposcopy Application of acetic acid causes abnormal epithelium to turn “aceto-white” due to protein coagulation (or use iodine – abnormal cells don’t take up as much). Biopsy such areas May be a mosaic or punctuate pattern of blood vessels through the white area. The greater the intervessel distance the more severe the lesion Bizarre branching with coarse puctuation (vessels seen end on) indicated invasion. Best treatment in LLETZ to remove all abnormal tissue (doesn’t cure HPV) HPV Mainly HPV 16 & 18 Linked to CIN (responsible for 90% of cervical tumours), VIN, VAIN (vaginal) and AIN (anus) Produces E6 which interferes with P53 and E7 which affects Rb proteins (cell cycle & replication rate) CIN Cervical intraepithelial neoplasia = squamous (CGIN = cervical glandular --> adenocarcinoma) Pre cancerous state, grade 1-3 (relates to proportion of abnormal cells) Treatment of CIN Low grade disease is NOT treated (esp in under 25) Large loop excision or biopsy to confirm stage and then treat accordingly 3 or more loops --> increased risk of pregnancy problems Follow up Any CIN (treated or not) has risk of developing to cancer. (1/3 of CIN III --> Ca in 20yrs) Repeat smears & colposcopy regularly (6 months-1 yr) Cervical Cancer 60% squamous (arises from areas of untreated CIN III), 40% adenocarcinoma Linked with HPV (serotypes 16 & 18), oral contraceptive pill (allows unprotected sex), & smoking Presentation – Often only after abnormal smear. PCB, IMB, menorrhagia & offensive vaginal discharge. Advanced disease can present with backache, referred leg pain, leg oedema, haematuria, altered bowel habit. Clinical appearance Exophytic lesion (on ectocervix) à large polyploid mass which bleeds easily or in endocervical canal à barrel shape Infiltrating tumour showing little ulceration à hard indurated cervix Ulcerative tumour which erodes a portion of cervix & vaginal vault à crater with local infection & seropurulent discharge Grading – based on depth from basement membrane & size across I - confined to cervix (A = upto 5mm deep by 7mm diameter, B = upto 4cm) IIA – upper vagina IIB – parametrium (treat with platinum radiotherapy bec too close to ureters) IIIA – pelvic sidewall IIIB – fixed to pelvic sidewall Pathology – mostly squamous, can also be adeno Spread – spreads by direct extension into adjacent structures (vagina, parametrium, pelvic sidewall, bladder & rectum) & via lymphatics (no predictable pattern of spread although usually iliac & obturator nodes). Blood borne is rare. Treatment – IA1 – IA2 – simple excision (cone biopsy or hysterectomy) (<1% met changes, 100% prognosis @ 5yr) IB – IIA – radical radiotherapy or radical hysterectomy IIB – IV – radical radiotherapy & platinum based chemo Recurrence – most recurrence has 1 yr survival of 10-15% & suitable for palliative care only