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Gynecology

[CERVICAL CANCER]

Intro and Etiology


Cervical cancer is caused by the Human Papilloma Virus. Its
carried in asymptomatic males and infects a woman during sex.
While not all cervical cancer is HPV related, for our purposes its
ok to assume it is. Therefore, it occurs in sexually active females.
HPV causes an infection of the cervical mucosa, transforming the
cells of the cervix through inflammation. The cells with a nucleus
are located at the basement membrane; this is where cells will be
first transformed (CIN I). As cancerous cells grow and fill the
epithelial layer (Carcinoma In Situ) they eventually penetrate
the basement membrane and become full blown cancer. HPV
causes cancer (subtypes 16, 18, 30s) and genital warts (subtypes
6, 11). Risk factors are number of sexual partners and history of
STDs.
Symptoms and Patient Presentation
Hopefully, shell get screened with Pap Smears and avoid
symptoms altogether. In any patient who has post-coital
bleeding, consider cervical cancer. Do a pelvic and stage. In a
post-menopausal woman its likely secondary to vaginal atrophy,
but all women who bleed after sex deserve a pelvic, and soon.
Diagnosis and Treatment
If a mass is identified on exam the diagnosis is made by biopsy
of that mass. The patient must then be staged. Cervical cancer is
the only cancer that is clinically staged rather than surgically.
The further down the vagina the higher the grade. B
classification denotes involvement of the cardinal ligament or the
pelvic sidewall. Involvement of the bowel, bladder, or distant
mets makes it stage 4. In addition to the physical a CT scan can
be used to stage. Cancers that are IIa or better are cured
surgically. Cancers that are IIb or worse are treated with
debulking and chemo.
Screening
The most high-yield topic for cervical cancer is screening. A
woman should receive a pap q3y starting at 21 years old
(regardless of if/when she began having sex). If theres ever an
abnormal pap (other than ASCUS) do a reflexive colposcopy.
From the colpo we get a sampling of two things: ectocervical
biopsy and endocervical curettage. If Ecto and Endo the
problem is on the outside of the cervix and a local destruction
can be done: LEEP, Cryo or laser. If the Ecto and the Endo
or couldnt be sampled, it must be assumed its in the endocervix;
a cone biopsy is required. Both local destruction and cone biopsy
are curative. If the original pap showed ASCUS, dont do a colpo.
Either repeat the pap q3month to watch for resolution or do an
HPV DNA to confirm its high risk HPV. If the patient is
pregnant a cone biopsy may harm the pregnancy - it can be
deferred until after delivery. Remember, it takes 3-7 years to
develop cancer from precancer, so 9 months of pregnancy wont
make a huge difference.
Prevention
Everyone (including males) should get the HPV vaccine.

Reproductive Aged
51
Virus stays with her,
risk never ends

11
Menses + Sex

CIN I
Dysplasia

Endocervical
Carcinoma

CIN III
Carcinoma In situ

Ectocervical Carcinoma

HPV 16,18,30

Dysplasia/CIS

Squamous Cell

h/o sex partners


other STDs

pap smear q1y

surgery or
chemo

Stage IV
a- Bowel/Bladder
b- Distant Mets

III b

IIb

Stage I

Stage II a
Stage III a
Asx Screen
ASCUS

Anything but ASCUS


or a normal pap

Pap Smear

ASCUS

Abnormal
Colpo

HPV DNA

Repeat 3
months
Ectocervix
Only

Endocervix
+ Ecto

Local
Destruction
(LEEP, Cryo)

Cone Bx

OnlineMedEd. http://www.onlinemeded.org